Treatment of seizures in children

Patient information: Treatment of seizures in children

Author
Angus Wilfong, MD
Section Editors
Douglas R Nordli, Jr, MD
Timothy A Pedley, MD
Deputy Editor
Janet L Wilterdink, MD

Disclosures

SEIZURES OVERVIEW — This article discusses common medications and treatments used to treat children with seizures.

An article about the various types of seizures and the methods used to diagnose seizures is also available. (See “Patient information: Seizures in children”.) A discussion of febrile seizures and treatment is also available (see “Patient information: Febrile seizures”).

WHEN TO TREAT SEIZURES — Seizures are treated if they recur or appear likely to recur. Not all children will require treatment for seizures, especially if the child only has one seizure and the EEG and MRI (or other imaging test) are normal.

Even when treatment is necessary, the long-term impact of seizures is small for most children, especially if there are no underlying abnormalities in the brain. (See “Treatment of seizures and epileptic syndromes in children”.)

GENERAL INFORMATION ABOUT MEDICATIONS — Medications used to prevent seizure are called antiepileptic drugs (AEDs).

Most medications are started at a low dose and slowly increased until seizures no longer occur.
The dose of the medication may be adjusted as the child grows and weight increases or as new medications are added for other problems (eg, asthma).
A second AED may be added or substituted if the first drug was only partially effective in stopping seizures, or if there were significant side effects with the first drug.
Interactions with other medications — Many AEDs can interact with other medications; parents should be sure that their child’s healthcare providers and pharmacist are aware of all prescription and nonprescription medications taken by the child.

Monitoring during treatment — Occasional blood testing is recommended with some drugs to monitor the level of the drug in the body. Testing may be done on a regular basis and when the doses changes.

Allergic reaction — All drugs have the potential to cause an allergic reaction. The first sign of a drug allergy is often a rash; parents who notice this should call their healthcare provider immediately. Rashes can be caused by many different things, including some common viruses, but the provider will evaluate the situation to decide whether or not the rash is related to the AED. Do not stop giving the antiepileptic medication unless the child’s doctor says so because some medications should not be stopped suddenly.

Risk of suicide — An expert review suggested that antiepileptic drugs can slightly increase the risk of suicidal thoughts in children over the age of five [1]. In considering whether or not to use AEDs to treat seizures, the parent(s) and physician must balance the small increased risk of suicidal thoughts against the risk of continued seizures if the child is not adequately treated. Any mention of suicidal thoughts or feelings should be taken seriously and reported to the child’s physician. (See “Patient information: Depression in adolescents”, section on ‘Preventing suicide’.)

Dealing with side effects — AEDs often have side effects, some of which can be bothersome and interfere with a child’s ability to function (table 1). Side effects can sometimes be managed by lowering the medication’s dose or changing the dosing schedule.

Parents should not assume that a side effect is caused by medication; it is possible that the child’s seizure disorder or another condition is responsible. Parents should discuss any concerns about side effects with their child’s healthcare provider, and should never stop their child’s AED without first discussing it with their child’s provider.

Stopping antiepileptic drugs — Most children who are treated with AEDs continue taking them until there have been no seizures for two years. After two years of being seizure-free, the chance of having another seizure is reduced to 30 to 40 percent. This is true for all types of seizures, although children with other neurologic problems (eg, cerebral palsy) have a slightly higher risk of having another seizure after the AED is stopped.

AEDs should be tapered slowly rather than stopped suddenly. This may mean that the dose is reduced on a weekly basis over several months. Parents should discuss the tapering schedule with the child’s healthcare provider.

Specific antiepileptic drugs — There are a number of anti-seizure medications available. A table that briefly describes these medications is available here (table 1). (See “Pharmacology of antiepileptic drugs”.)

OTHER TREATMENTS

Dietary treatment — A special diet, known as the ketogenic diet, has been used as a treatment for children with some types of seizures that do not respond to AEDs. The diet consists of high fat, relatively low carbohydrate and adequate protein. The diet does not usually “cure” the seizures, but it lowers the likelihood of seizures by at least 50 percent in approximately 40 percent of patients, particularly those between one and 10 years of age.

Parents should not attempt to start their child on a ketogenic diet alone; it should be supervised by a well-trained dietitian in an Epilepsy Center with experience managing the diet. The diet is usually started in a hospital setting, although some experts are able to manage patients at home. The child must be closely monitored to ensure he or she is growing and getting all the necessary nutrients. The diet is often continued for at least two years in children who improve significantly.

The restriction on eating carbohydrates may be difficult for some children, especially those who are reluctant to try new foods. Parents, teachers, relatives, and friends need to understand that even one bite or taste of a restricted food can lead to a seizure. The diet may significantly change experiences like birthday parties and holidays, which frequently include high carbohydrate foods. Talking to other parents of children who have used the diet may be helpful in deciding whether to attempt it.

Vagus nerve stimulation (VNS) — The vagus nerve is a large nerve located in the neck. Stimulating the left vagus nerve intermittently with electrical pulses can reduce the frequency of seizures in some people. This requires surgically implanting a small device or pacemaker, called a stimulator, under the skin in the left upper chest, which is attached to a wire secured in the neck.

Often, many months of VNS are needed before benefit is seen. Studies show that VNS reduces seizure frequency by about 50 percent in 30 to 40 percent of individuals. VNS is approved for children over age 12 years, although it has been used in younger children.

Brain surgery — Children whose seizures do not respond to medications may be candidates for brain surgery. Surgical treatments may be considered for children who have persistent, frequent seizures that are not controlled after a trial of at least three anti-seizure medications.

Most epilepsy surgeries involve removal of the area of the brain causing the seizures. This area may be as small as the tip of a finger or as large as an entire lobe of the brain or even the entire half of the brain.

The area causing seizures is often found to be a scar, an area of abnormal brain growth, or rarely, a tumor. Many of these abnormalities can be seen on MRI scans, but not all. Some children will require other specialized tests in order to localize the exact spot where the seizures are arising. The risk and benefits of epilepsy surgery must be discussed in detail with an epilepsy team, including a neurosurgeon and/or neurologist prior to proceeding.

CARE DURING SEIZURES — If you witness your child’s seizure, it is important to prevent the child from harming him or herself.

Place the child on their side to keep the throat clear and allow secretions (saliva or vomit) to drain. Do not try to stop the child’s movements or convulsions. Do not put anything in the child’s mouth, and do not try to hold the tongue. It is not possible to swallow the tongue, although some children may bite their tongue during a seizure, which can cause bleeding. If this happens, it usually does not cause serious harm.
Keep an eye on a clock or watch. Seizures that last for more than five minutes require immediate treatment.
Move the child away from potential hazards, such as a stove, furniture, stairs, or traffic.
Stay with the child until the seizure ends. Allow the child to sleep after the seizure if he/she is tired. Explain what happened and reassure the child that they are safe when they awaken.
Discuss a post-seizure plan of care with your child’s healthcare provider to determine if and when to call the doctor or go to the emergency room and when to give additional anti-seizure medicine after a seizure.
When to call for help — Call for an ambulance in the following situations:

If the seizure lasts for more than five minutes, one person should stay with the child while another person calls for emergency medical assistance, available by dialing 911 in the United States and Canada
If the child is seriously injured during the seizure (eg, falls and hits head)
If the child is having difficulty breathing and/or the skin is blue after the seizure
If another seizure occurs immediately or if the child cannot be aroused after the seizure
Status epilepticus — Status epilepticus is the name for a prolonged seizure (greater than 10 minutes) or clusters of seizures in which the child does not awaken between seizures. Status epilepticus requires emergency medical attention to stop seizures and prevent them from recurring. You should not attempt to drive a child with status epilepticus to the hospital; an ambulance should be called.

If your child has a history of status epilepticus, you should develop a plan for future episodes with your child’s healthcare provider; this may include having emergency treatment available at home. Home treatment usually involves giving one dose of diazepam gel (Diastat®) into the rectum if a child’s seizure lasts more than five minutes. (See “Management of status epilepticus in children”.)

LIVING WITH SEIZURES — Children with epilepsy often need to make lifestyle changes to minimize the frequency of seizures and possible dangers associated with seizures. However, you must balance your concerns about your child’s health so that the child can have as full and independent a life as possible.

Reducing and avoiding harm — There are many things that parents of a child with epilepsy need to know about decreasing the risk of harm due to seizures and seizure treatment. A few tips are listed here.

Parents should teach their child to avoid biking, skating, and skateboarding on streets with heavy traffic. All children need to wear protective gear, including a helmet, during these activities.
Activities at heights (eg, climbing a tree or rope) should be avoided to prevent serious falls if the child has a seizure while climbing.
Always supervise the child around water, including bathtubs, at the beach, and near wading pools. Showers may be unsupervised, but swimming should be closely supervised at all times by someone who is aware of their condition. If seizures are poorly controlled, a life jacket should be worn when they are in the water.
Parents should talk to their child’s teachers and other parents about their child’s condition and what to do in case a seizure occurs.
Children with epilepsy should wear a medical identification bracelet or necklace at all times. If a seizure occurs and the child is unable to explain their condition, this will help responders give the proper care as quickly as possible. The identification device should include the child’s condition, a list of known allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert® (www.medicalert.org), provides a toll-free number that emergency medical workers can call to find out a person’s medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
Encourage the child to sleep well and take medications on time.
Driving restrictions for people with seizures vary from state to state and country to country. Some people with seizures are not allowed to drive at all, while others can drive with restrictions (eg, unless a seizure has occurred recently or medication type or dose is changing).
Teens with epilepsy need counseling about the effects of seizures and seizure medications on sexual activity. All medications have the potential to cause birth defects if taken during pregnancy, although some may be riskier than others. Also, birth control pills may not be effective in preventing pregnancy when used with some anti-seizure medications.
Parents of teens should also discuss the increased risk of seizures due to drinking alcohol or using recreational drugs. Alcohol and drugs (prescription, over-the-counter, and recreational) can interact with anti-seizure medications, making them less effective and increasing the risk of seizure. Also, the effects of alcohol and the side effects of anti-seizure medications can be enhanced when combined.
School and seizures — Children with epilepsy are often fearful of having a seizure while at school. Seizures can be an embarrassing and frightening event, but advance planning can help a child to feel more confident. Parents should be sure that their child’s teacher, school nurse, and other faculty are aware of the child’s condition, need for treatment, and what to do in case the child has a seizure (see ‘Where to get more information’ below). Local epilepsy groups often have information that parents can give to school personnel that describes what epilepsy is and how it is treated. Meeting to discuss an individual child’s needs is often helpful.

Children with epilepsy sometimes have difficulty keeping up academically with peers as a result of missing school for appointments or tests. While intelligence is not usually affected by epilepsy, seizures and the side effects of anti-seizure medications can affect a child’s ability to perform well on tests and remember detailed information. The child’s neurologist or other healthcare provider can be helpful in providing guidance to parents and children about difficulties with school performance.

WHERE TO GET MORE INFORMATION — Your child’s healthcare provider is the best source of information for questions and concerns related to your child’s medical problem.

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Seizures in children
Patient information: Febrile seizures
Patient information: Depression in adolescents

Professional Level Information:

Clinical and laboratory diagnosis of seizures in infants and children
Clinical features and complications of status epilepticus in children
Clinical features and diagnosis of infantile spasms
Clinical features and electrodiagnosis of neonatal seizures
Epilepsy syndromes in children
Etiology and prognosis of neonatal seizures
Febrile seizures
Management and prognosis of infantile spasms
Management of status epilepticus in children
Neonatal epileptic syndromes
Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy
Pharmacology of antiepileptic drugs
Treatment of neonatal seizures
Treatment of seizures and epileptic syndromes in children

The following organizations also provide reliable health information.

The Epilepsy Foundation
(www.epilepsyfoundation.org/)

National Institute of Neurological Disorders and Stroke
(www.ninds.nih.gov/disorders/epilepsy/detail_epilepsy.htm)

National Library of Medicine
(www.nlm.nih.gov/medlineplus/epilepsy.html)

Epilepsy Therapy Development Project
(www.epilepsy.com)

International League Against Epilepsy and the International Bureau for Epilepsy
(www.epilepsy.org)

REFERENCES
www.fda.gov/cder/drug/InfoSheets/HCP/antiepilepticsHCP.htm; accessed January 31, 2008.
Sillanpää M, Schmidt D. Natural history of treated childhood-onset epilepsy: prospective, long-term population-based study. Brain 2006; 129:617.
American Academy of Pediatrics. Behavioral and cognitive effects of anticonvulsant therapy. Committee on Drugs. Pediatrics 1985; 76:644.
Hirtz D, Berg A, Bettis D, et al. Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2003; 60:166.
Sillanpää M, Schmidt D. Prognosis of seizure recurrence after stopping antiepileptic drugs in seizure-free patients: A long-term population-based study of childhood-onset epilepsy. Epilepsy Behav 2006; 8:713.
Vining EP, Freeman JM, Ballaban-Gil K, et al. A multicenter study of the efficacy of the ketogenic diet. Arch Neurol 1998; 55:1433.