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Seizure Control in Kids
While living with the likelihood you will have a seizure is challenging for anyone, it is particularly difficult for children and teenagers. And yet many kids cope with this reality. According to the Epilepsy Foundation, approximately 45,000 children under 14 are diagnosed annually with epilepsy, a neurological disorder that causes seizures.
Educating parents and kids, as well as teachers and fellow students, about epilepsy can help ensure children's safety and comfort level. Below, Trevor Resnick, MD, discusses different kinds of seizures children may experience, including seizures triggered by fever that are not considered part of epilepsy. Dr. Resnick also addresses when treatment is necessary and what it involves.
What is epilepsy?
Epilepsy really is a term that is used for adults or children who have recurrent seizures. An individual seizure is the result of an abnormal electrical discharge in the brain.
When in life does epilepsy usually occur?
The incidence of epilepsy is very high in infancy, drops down in the first decade to be relatively low through into the 40s and 50s, and then grows again in late adulthood and old age.
What are some of the things that can cause epilepsy in children?
There are very many different causes of epilepsy. Some people have a genetic predisposition for seizures. We don't know the cause of genetic seizures, but we've begun to identify specific genes that are responsible for causing seizures. And then there's the second group of seizures, where there's an identifiable cause, such as a stroke, or a scar or tumor in the brain, or something the child has been born with. In these children, there is a specific area in the brain where the cells are either not aligned normally or are malformed. That can cause abnormal electrical discharges in that area that can set up seizures.
What kinds of seizures can children have?
There are seizures that are partial. "Partial" implies that they begin in a specific area of the brain, and that those seizures are unassociated with a change in consciousness. So for example, a child may be jerking the left arm and be able to say, "What's wrong with me? My left arm is jerking."
The most common form of partial seizures is called benign rolandic epilepsy. And those seizures usually occur at night and are characterized by gagging or drooling. The seizures are usually very well controlled by medication, and sometimes you don't even need to treat them. And almost always, as the child grows older and into adolescence, the seizures go away.
Partial complex seizures are seizures that start in a particular area of the brain, but then spread in a fashion that renders a change in consciousness where they're not entirely with it. And then with generalized seizures, the abnormal electrical discharge spreads to involve the entire brain. Depending upon the spread of the epileptic discharge, the child may have a seizure that's characterized by a just blank stare or by generalized body stiffening or both.
In a form of seizures called petit mal, or absence seizures, children may be involved in an activity and suddenly will stop and stare blankly ahead for a few seconds, and then continue with their regular activities.
What can trigger a seizure?
There are a number of common environmental triggers. The most well-recognized is fever, and very common in children, especially between about one and five years of age, a high fever can trigger a seizure. Under those circumstances it is called a febrile seizure. Almost all children with febrile seizures grow out of it, and they do not need treatment.
Other types of seizures can also be provoked by sleep deprivation, flashing lights, and, in older children, alcohol.
How do you diagnose epilepsy?
The most important aspect of diagnosing epilepsy is to take a good history from the family or the patient. The backbone diagnostic test for a patient with seizures or epilepsy is an EEG, which is a brain wave test. The EEG will provide more evidence, telling us what kind of seizure the patient is having, maybe where in the brain the seizure is coming from, and will also assist in deciding what kind of treatment would be best for that child.
What is the goal in managing epilepsy in children?
The primary goal is to completely control the seizures with medication. Based upon the clinical history and the kind of seizures that the patient has, in some patients, it's likely that you will have very good control of seizures, and in a period of time—two years, four years—and you will be able to stop the medication.
And then there is the group of patients who have seizures that are not easy to control with medication, due to the cause of the seizures, such as a scar in the brain. When you have a hard time controlling the seizures and they are coming from an identifiable area in the brain, there are alternative forms of treatment that may result in seizure cure. For example, you may be able render the patient seizure-free surgically.
What medications are available to treat epilepsy?
There really has been a dramatic change in the treatment of epilepsy over the last five to ten years with the advent of new medications. The older group of medications consists of very effective antiepileptic drugs, but they have a host of side effects. Whenever you use a medication for a problem in the brain, it's going to have the potential to affect other brain functions. So you may get an effect on cognition, or awareness and learning. You may get dizziness. You may get double vision. Depending on the child and on the medication, children may have problems with learning, they may have difficulty with sleeping or they may sleep too much, and they may be hyperactive or irritable or have behavioral problems. The newer agents are at least equally effective as the older medications, but there is a definite superiority with the newer agents with respect to safety and side effects.
What is the best strategy for treating epilepsy?
Everybody agrees that the initial treatment is monotherapy, which means using one drug to try and control the seizures completely. If that drug fails, in general, you will gradually replace it with another new second drug.
If that second drug fails, that's where the agreement over what to do varies. It varies because, number one, it depends upon the patient, the patient's seizure type and whether there is a lesion or something else causing the seizures. So you may then go to a third-line monotherapy or try using more than one drug at a time. Or, at that point, you might consider other options such as surgery or a device that is implanted in the brain called a vagal nerve stimulator, or even the ketogenic diet.
What is a ketogenic diet?
The ketogenic diet has been around since the beginning of the 20th century. The premise of the diet is that if you eat predominantly fat; the energy source that you get from the fat are ketones, and the ketones protect against seizures for reasons that we don't understand.
How can epilepsy affect children's activities?
I think the answer to how epilepsy can limit or does not limit your life is really an issue of common sense. I do not restrict patients in terms of what they can and can't do. But common sense would tell you that you don't want them to go mountain climbing, deep-sea diving or bungee-jumping. Now, can they play football? Absolutely. Can they play tennis? Can they go bicycling? Yes. Even if you look at driving, the driving law differs in different states, but in general if your seizures are well controlled and you've been seizure-free for more than six months, in many states you are eligible to drive under those circumstances.
What kinds of psychological and social issues can kids have?
I'm actually surprised at how well adjusted so many kids are who do have seizures. But one shouldn't underplay the severity to which it may affect socialization and other issues. The kind of issues that children encounter depends on the frequency of the seizures and the extent to which it affects them on a daily basis. In some children, especially those who have infrequent seizures, I think it has little impact on their lives. But in the children who have more frequent seizures, it begins to affect them socially because kids begin to see them as different. Sometimes, even if other kids don't see them as different, they perceive that that's the way they're seen.
In general, there's a complex interaction in terms of the psychological impact of epilepsy because, number one, they have something there that's causing the seizures that may affect them. Number two, they're on medications that can affect them as well from a psychological standpoint. And number three, they have the stigma of having epilepsy. But I actually think that over the years, there has been a general improvement in sophistication in terms of understanding epilepsy, and that the stigma of epilepsy has also lessened quite dramatically.