Epilepsy in children: Types and treatment options

Febrile convulsions (related to a fever) are the most common type of convulsion in early childhood. But most children who have these convulsions don't have epilepsy because they only occur when they have a fever. About 3% of all children have at least one febrile convulsion before their 7th birthday.

Many types of epilepsy already start in childhood and last into adulthood. Different people will have different symptoms, but that doesn't depend on their age. There are also certain types of epilepsy that occur in childhood or puberty but go away in adulthood.

The following is true for both children and adults: Sometimes no clear cause of the epilepsy can be found, and sometimes it is caused by brain damage, a metabolic disease or genetic factors. The diagnosis and treatment of epilepsy is similar in children, teenagers and adults. But epilepsy affects their lives differently – children have different needs than adults do, and cope differently with illness.

It is harder to recognize epileptic seizures in newborn babies and infants than it is in older children. The symptoms can sometimes be seen as eye movements, lip smacking, flailing arms and jerking movements. They often already occur in the first few days of life.

Convulsions in babies are usually the result of a medical problem such as a lack of oxygen, bleeding or poor blood circulation in the brain. But there are also mild forms of epilepsy that go away again on their own within a few weeks of the birth. In rarer cases, epilepsy is inherited (passed down from parents through their genes). Then it starts soon after birth and is usually very severe.

The most common types include:

• Absence epilepsy: Brief spells during which the child loses awareness for a few seconds. They become pale, stare into space and don’t respond if you talk to them. Their eyelids may also twitch, and their eyes or head may roll back. These brief absences can occur up to one hundred times a day.
• Rolandic epilepsy: One side of the face twitches, and sometimes one arm or one leg twitches too. The child may also experience tingling, numbness, problems with speech and swallowing, and start salivating more (“drooling”). They are usually aware of this happening. This kind of seizure typically happens while falling asleep or waking up.
• Juvenile myoclonic epilepsy: This type of epilepsy first arises in puberty. The seizures involve muscle twitching and jerking movements of the arms and shoulders. They usually happen in the morning after waking up. The knees sometimes give way too.
• Infantile spasms (West syndrome): This severe type of epilepsy nearly always starts in babies. During seizures, the child's whole body bends and stretches, and the muscles in their neck and torso convulse (jerk and twitch). The seizures usually occur shortly after waking up or while falling asleep. They often only last a few seconds, but can occur up to a hundred times in a row with short breaks between them.

Many children have a mild type of epilepsy that goes away after a few years. These children generally develop normally and don’t have any long-term problems related to epilepsy. The milder (also called “benign”) types of epilepsy include rolandic epilepsy and absence epilepsy. Children who have rolandic epilepsy often don’t even need to use medication because the seizures usually aren’t much of a problem.

In other children, the epilepsy doesn’t go away and may be very severe. Sometimes the seizures can be effectively suppressed with medication. But this medication usually has to be taken for the rest of your life. Very severe types of epilepsy, such as infantile spasms, can affect the child’s development. Medication may not work or be very effective here either.

Doctors can predict how the epilepsy is likely to develop over the long term, often within weeks or months of the diagnosis. This prognosis will depend on the type of epilepsy that was diagnosed and how well the first medications that are tried out work.

About 70% of all children with epilepsy have a normal mental development and are just as intelligent as children who don’t have epilepsy. The epilepsy doesn't affect their daily life much. The medication often works well, and sometimes isn’t needed at all.

Frequent seizures, on the other hand, can have physical and emotional effects. These include the following:

• Poor concentration: The children are tired or very restless. This might reduce their performance.
• Low self-esteem: Many children are ashamed of having seizures. Knowing that you might have an epileptic seizure can be unsettling because it's beyond your control.
• Fear of having another seizure: Many children and parents live with this fear. As a result, they might start avoiding activities with other people and doing less sports – even though there’s no need to do so in many cases.

There's also a risk of injury, for instance due to a seizure-related fall. But with enough treatment and support, it's often possible to live a good life despite having epilepsy.

Developmental disorders, brain damage and mental disability are more common in people who have epilepsy. These may be either the result or the cause of the seizures.

Medications are very effective in some people, but are ineffective or don't work well in others:

• About 60% of all children with epilepsy stop having seizures after taking the first medication they try out.
• In about 10%, this only happens after switching to a different medication.
• About 30% of all children with epilepsy still have seizures despite using medication.

When a child has a seizure for the first time, they often aren't given any medication yet because in many cases it's the only seizure they will ever have, or one of only a few. It only makes sense to use medication if the seizures happen more often.

Sometimes different drugs have to be tried out before finding one that works. But the more medications that have to be tried out, the less likely it is that an effective treatment will be found. It is also possible to combine two or more medications. It is not clear whether this has any advantages, though.

If a child stops having seizures, they still carry on using the medication for some time (e.g. two years). Whether and when they can stop taking it will depend on the cause and type of epilepsy.

Most of the epilepsy medications that are used in adults are also used in children. Some of these medications have been approved for use in children, and others haven’t. If they haven’t, they can only be used “off label” in children – in other words, in a way that hasn't been officially approved by the authorities. The medication may have different effects in children than it does in adults, and children may tolerate it differently too.

If someone has a type of epilepsy that is hard to treat, doctors sometimes recommend following a certain diet – known as a ketogenic diet, or “keto diet” for short. It involves eating mainly fats and hardly any carbohydrates.

This diet causes your metabolism to change: Your body breaks down fats instead of sugars to get energy. There are more fatty acids (building blocks of fats) in the blood as a result. Fatty acids are thought to affect the way signals are passed between nerve cells in the brain, and it is believed that this reduces the number of epileptic seizures. But it's not exactly clear how the keto diet works.

A number of studies have suggested that a ketogenic diet can reduce the number of seizures in children who don’t respond well to medication:

• Most of the children in the studies had noticeably fewer seizures than before.
• They generally felt more active and less anxious.

The possible side effects of a ketogenic diet include nausea, vomiting, constipation and diarrhea. Another problem is that many children find it difficult to stick to this diet over the long term.

There’s a lack of research on the long-term effects of the keto diet. Doctors recommend coming off this diet after about two years. If seizures then start occurring more often, the diet can be started again.

Surgery is considered if someone has epilepsy that greatly affects their life and can't be treated effectively with medication. It is only possible to do surgery if the seizures start in a very specific area of the brain (known as “partial seizures” or “focal seizures”). Seizures that affect the whole brain (“generalized seizures”) cannot be treated with surgery.

To find out whether surgery is an option, various examinations and tests have to be done. These include a magnetic resonance imaging (MRI) scan, video recordings of brain activity measurements (EEG) and tests to assess the person’s emotional and mental development (neuropsychological tests). All of these examinations also help to find the area of the brain where the seizures start.

Various surgical techniques can be used. They often involve removing brain tissue from the area where the epileptic seizures start. It is also possible to stop activity in this area of the brain by cutting nerve fibers.

Research has shown that about 30 to 80 out of 100 children stop having seizures after surgery for epilepsy. Some of them no longer need to use medication. The chances of surgery helping depend on the cause of the epilepsy and which area of the brain is affected. Surgery for epilepsy is always associated with risks, of course, because removing brain tissue can also have side effects.

There's also another procedure that can be done, known as vagus nerve stimulation. This involves pushing an electrode up to the vagus nerve on the left side of the neck and attaching it to a small device that is implanted under the skin in the chest area. The device sends electrical signals along the electrode to the vagus nerve, and those signals are passed on to the brain. The signals are meant to prevent seizures by stopping certain types of brain activity. There are only a few good-quality studies on the benefits of this therapy. So in Germany, statutory health insurers only pay for vagus nerve stimulation in certain situations.