Epilepsy in children

What is epilepsy?

Epilepsy is a neurological condition where there is abnormal electrical activity in the brain that causes recurrent episodes of seizures.
How is this associated with electricity? All of the information in our nervous system is transmitted between nerve cells as signals, and some of these signals are comprised of electrical signals, based on the movement of charged molecules (and we have chemical signals in our body too).

What is a seizure?

A seizure, also known as a convulsion, is a sudden change in the normal neurological functioning, and it can have a variety of characteristics. The cause of seizures is a sudden disruption in the electrical activity of nerve cells in the brain.
Most people imagine a seizure as a situation in which a person loses consciousness, lays on the ground while their limbs jerk involuntary. Everybody agrees that it is a scary event, and that it is probably also one of the reasons why such episodes seem to stick to people’s memories, and why different myths and stigmas have risen about seizures.
But the truth is that this is only one type of seizure. Seizures can manifest in different ways, especially in children. For example – a partial alteration in consciousness such as blank outs, change in behaviour, involuntary shivering, sometimes loss of tone without any movements, jerking movements in one of the limbs, repetitive blinking of the eyes, repetitive twitches of the mouth, sensory disruptions, visual hallucinations, auditory, taste, etc.

What are the different stages of a seizure?

Generally, seizures are divided into three stages:
1. The prodromal stage when there is sometimes a general feeling that the seizure is about to start, there may be an aura which is a sensation that can manifest in a variety of symptoms, such as a change in vision, an auditory change, different smells, a tingling sensation etc. The symptoms are usually particular to the patient and tend to recur every time the person experiences a seizure.
2. The ictal stage is the convulsion itself including whatever it may entail.
3. The post-ictal stage is the stage that occurs following the seizure, during which the child may be still a bit sleepy or weak, and it may take them some time to get back to themselves.

What are the different types of seizures in children?

Seizures can be divided into:
# Generalized seizures – these are seizures that involve large parts of the brain. Under this type of seizures we have the tonic-clonic seizures (or Grand mal), which are the seizures that everyone is familiar with where a child loses consciousness, experiences an increase in muscle tone which manifests in the stretching of the limbs, and afterwards, jerking of the limb, and sometimes experiences loss of bowel and bladder control. Some seizures are only tonic (include only the stretching/stiffening of the limbs) and some are only clonic (with only the jerking of the limbs). Some seizures are a-tonic, where the child has a complete loss of muscle tone and falls. Additional seizures included in this group of seizures are the blanking-out seizures (or Petit mal) and the myoclonic seizures where the the child experiences sharp, rapid, involuntary movements of the limbs.
# Focal seizures – focal seizures involve one part of the brain and therefore the characteristics of the seizure will depend on the area of the brain that is involved. If it is an area that involves movement – there child will experience be movements, an area involving vision – there may be hallucinations, etc. There are simple focal seizures where the child retains consciousness and complex focal seizures where there is usually an alteration in consciousness.

Do all seizures signify epilepsy?

No. In this regard it is important to remember three things:
• There are episodes that may look like seizures but are not real seizures. What I’m trying to say is that not every episode of fainting is a seizure. Fainting can have many different causes. For example, causes that are related to a reduction in blood pressure and a disruption of blood supply to the brain, heart rate disorders that cause a reduction in blood pressure, a drop in blood sugar, and more. Allow your pediatrician or neurologist to determine whether the episode your child experienced was a real seizure or an episode mimicking a seizure.
• Secondary seizures – there are conditions that may cause seizure (and are not defined as epilepsy) such as head trauma, infections such as meningitis or infection of the brain, poisonings and medications, salt imbalances in the body, tumors, etc.
• Febrile seizures – this certainly falls under seizures that are not epileptic. It is worthwhile reading more about febrile seizures, the most common seizures in children, in the following link.
And this is why it is important to correctly diagnose seizures, to accurately guide the investigation and determine the appropriate therapy as you will see below.

Is epilepsy a common condition?

Yes. One in 100 people within the general population could develop epilepsy, at any age. That is considered a lot.
It is more common in boys than it is in girls.

What are the causes of epilepsy in children?

So, as mentioned above, there can be secondary causes for seizures such as head trauma, infection in the nervous system, congenital defects, defects in the vessels of the brain, tumors, metabolic disorders and more.
But most of the time, a cause is not found and there is simply a tendency for the brain to produce abnormal electrical activity. This tendency stems from certain genes that contribute to the imbalance, while environmental factors may affect the manifestation of these genes.
Nowadays, technological developments in the field of genetics have allowed us to detect more and more genes that are responsible for different types of epilepsies present in infancy or early childhood. It is very important to undergo genetic workup in cases where a genetic cause is highly likely.
And having said that, it is also important to keep in mind that despite all of this, to this day, we are still unable to detect the genes responsible for most types of epilepsies, with certainty.

What causes epilepsy to start out of nowhere?

Epilepsy can present at any age, the reasons for it are diverse and variable, and most of the time we do not know the cause. Nonetheless, we are familiar with certain triggers that can cause the first seizure to present and may cause further imbalance in the future. Among these are:
Stress
Sleep deprivation
Fever – not in the sense of classic febrile seizures but seizures that are caused because of a febrile illness that causes the body an imbalance.
Menstrual cycle in girls
Medications, drugs or all sorts of food additives
Flashing lights – in certain types of epilepsies only

Is epilepsy dangerous?

Most of the time, it is not. Most children do not have a specific cause for their epilepsy and most children function well between the episodes. In addition, the episodes are treatable and can be keptunder control, to the point where they sometimes completely disappear.
In situations where there is a cause for the epilepsy (such as a genetic cause or a genetic syndrome), this is what will affect the functioning difficulties of the child and the ability to keep the episodes under control.
So, what can be dangerous? The actual episode scan be dangerous because there is a chance that the child will hurt themselves depending on the seizure itself and how it manifests. The seizure itself is usually not life threatening and resolves within minutes, even though to the spectators, it may seem like a lifetime.
What is also important to keep in mind when it comes to epilepsy in children, and especially epilepsy in infancy, is that it can have a negative impact on the child’s development and it is therefore important to come to the correct diagnosis and to undergo high-quality EEG to demonstrate the electrical activity of the brain during awake periods, and different stages of sleep.

How is epilepsy diagnosed?

The diagnosis is confirmed with the help of a combination of medical history, physical examination, and auxiliary testing.
The description of the seizure – it is very important to try and understand what happened before, during and after the seizure. It is important in order to help rule out other reasons for collapsing that may not be a seizure, and if the story does seem to fit a seizure – to try and understand what it is that happened exactly. Many times, because the patient is unable to tell us what happened, we need the help of spectators, and we must question other people about what happened.
Physical and neurological examination – the purpose of these is to try and find the cause of the seizure, including any signs of illnesses that could manifest in seizures and any neurological deficiencies that could indicate a problem in the nervous system.
Additional examinations that could be helpful include an EEG, video EEG and imaging of the brain.

What is an EEG and how do we perform it on children?

An EEG is an examination of the electrical activity of the brain. A number of electrodes are attached to the head in order to detect the electrical activity of the brain. The examination is not painful nor dangerous.
Since the condition is caused by abnormal electrical activity in the brain, a recording of the electrical activity of different parts of the brain helps us detect abnormal patterns. This recording can be either performed during awake periods or during different stages of sleep. Sometimes, abnormal activity may be provoked with the help of a flashing light, hyperventilation, or sleep deprivation.
It is important to keep in mind that it is not always possible to detect abnormal activity on EEG examinations. This is because it is usually performed following a seizure and during this time, we will not necessarily be able to see any abnormal electrical activity. Therefore, a normal EEG does not rule out seizures or epilepsy.

What is a video EEG and how is it performed on children?

A video EEG is an EEG that is performed while a continuous video of the child is being recorded, in order to try and associate between changes on the EEG recording and their clinical manifestations, such as abnormal movements.
This study is done in cases where the diagnosis is not clear cut, the seizure is not clear, epilepsy is resistant to treatment or in order to characterize the seizure, or assess the efficacy of treatment, and more.

What types of brain imaging studies are used to diagnose epilepsy?

Of-course these are imaging studies such as CT or MRI. During the acute stage, a CT is usually performed to try and rule out any secondary causes of seizures (such as a bleeding following head trauma or due to a tumor). However, the study of choice for the proper investigation of seizures is a brain MRI. Brain MRIs allow us to detect congenital defects or acquired structural defects of the brain that could be causing the condition.
There are also more complex studies, but they are used much less frequently and are beyond the scope of this post.
Keep in mind that following the first convulsive episode, routine blood tests will usually be drawn, just like the blood tests drawn whenever a child visits the emergency room or is hospitalized (complete blood count, biochemistry, inflammatory markers, and so on). Sometimes, different types of blood tests are also drawn, and a lumbar puncture may be done to test the cerebrospinal fluid when a metabolic, genetic, infectious or autoimmune disease is suspected.

What is the goal of treatment of epilepsy?

The principle behind treatment of epilepsy is to allow the child, adolescent, or adult to live a normal life, just as their healthy friends do, and to realize their dreams and aspirations. This can be done by preventing the occurrence of seizures, especially with the use of anti-epileptic drugs.
Epilepsy patients are usually allowed to drive (when their condition is under control, as you will see below), exercise, travel and for women with epilepsy – get pregnant. All while taking into consideration the patient’s specific condition, the type of epilepsy they have and its characteristics.
Adjustment of the medical treatment is done by a pediatric neurologist that specializes in epilepsy and it may be affected by the child’s age, the type of epilepsy they have, the findings on EEG, the findings on MRI imaging, their response to treatment and the side effects they experience.
As a general rule, the goal of treatment is to try and stop the seizures from occurring while exposing the child to minimum side effects.

What does the treatment for epilepsy include?

Let’s divide this into the actual episode during which the seizure occurs and the condition in general.
During the episode – the first episode a child who is not known to have epilepsy experiences is very scary. Nonetheless, it is important to keep in mind several basic concepts:
Keep the child safe to avoid any injuries – keep potentially dangerous objects away (for example, if the episode occurs at a pool or in the tub or at the park, etc.), lay them on their side, ensure a patent airway, call for help (additional people or 911) and try to remember what happened so that you can describe it to the healthcare professionals you encounter following the episode.
Children who are known to have epilepsy and have had recurrent episodes typically have a plan of care set by their neurologist and they know what needs to be done if an episode occurs, including any medications that need to be given to them by mouth, or as a suppository, by their parents, in case of a prolonged episode (over 2-3 minutes).
What should you not do? And this is just as important.
Do not pour water on the child.
Do not give them a slap on the face or try to “wake them up”.
Do not stick your hands in their mouth to try and prevent them from “swallowing their tongue”.
Do not try to hold down the child down to stop the jerks.

What is the general treatment for epilepsy?

The principal treatment is pharmacotherapy.
There are several different excellent anti-epileptic drugs that aid in significantly reducing the number of episodes, and they are frequently able to stop them altogether from recurring.
About 70% of epilepsy patients reach a point where they have no seizures under treatment, but about 30% are defined as having epilepsy that is resistant to treatment (having failed to improve following the trial of 2-3 antiepileptic drugs) and these are the patients who need to be offered other types of therapies. The adjustment of the drugs is done by a pediatric neurologist who specializes in epilepsy, taking into consideration a wide span of factors while understanding that there are many different options out there. In addition, keep in mind the triggers we mentioned earlier. Avoidance of known triggers – reducing stress, techniques for dealing with stress, getting sufficient and structured sleep, eating a healthy and balanced diet, exercising regularly, taking medication regularly and on time can aid with treatment.

What types of non-medicinal treatments are there for epilepsy?

Keep in mind that most of the patients will be well-controlled on one of the medications and everything we will mention below is reserved for resistant cases.
Surgical treatment – patients with focal, resistant epilepsy (that is, caused by a focus in a specific part of the brain) are good candidates for resection of that specific epileptic focus in the brain.
These patients will undergo meticulous assessment to ensure the focus is found in a specific area of the brain, and just as importantly, to make sure that is is not located at a strategically challenging area where its resection could possibly risk a vital area in the brain.
In most cases, patients who have undergone surgery and no additional epileptogenic foci are found, will become free of seizures, and will often not need any medicinal treatment.
For those who are found to be unsuitable candidates for surgery (only about 25% are typically found to be suitable) there are two additional approaches to treatment:
Electrical stimulation of the brain (neuromodulation) with the help of a vagus nerve stimulator (VNS) and brain stimulator (DBS) or treatment with the help of a ketogenic diet.
A moment of explanations: a vagus nerve stimulator is a stimulator that is inserted under the skin, adjacent to the armpit, and attaches to an electrical cable that inserts at a nerve called the left vagal nerve. The stimulator transmits electrical impulses at set intervals (that can be modified by the physician). This stimulation reaches the brain through the vagal nerve and by doing so reduces or prevents an episode form occurring. Research has shown that between 40-65% of patients experience a 50% reduction in the number of episodes. Between 6-10% will stop experiencing any seizures.
The stimulator greatly improves the patient’s quality of life such that the episodes, if they do occur, become mild and occur much less frequently. In addition, insertion of these stimulators often allows for the reduction of the dose of anti-epileptic drugs required. There is no way to know in advance who will respond well to this type of treatment.
Deep brain stimulator (DBS) is a newer method of treatment, but it is also more invasive, and includes the insertion of electrodes in specific areas of the brain (thalamus), areas that play an important role in the epileptic process.

What about ketogenic diet as a way to treat epilepsy?

Ketogenic diets are fat-rich diets with little protein and sugar, but enough supply for proper growth and development. The exact mechanism in which ketogenic diets work to treat seizures is unknown but there are several theories. Despite it being referred to as a diet, it is certainly considered a type of medical treatment and requires stringent monitoring and medical management combined with the help of a dietician that specializes in ketogenic diets. This treatment should be offered to any child with drug-resistant epilepsy, when surgery is not an option.

Stigmas and epilepsy in children

Let’s start with the basics. Epilepsy is not associated with mental disorders. The only association between the two is that they are both related to the brain. Their underlying mechanism is completely different.
Can a child who has epilepsy go to a regular school and take part in regular activities?
Yes. It is important to make sure that the child is taking their medications regularly and it is important to emphasize that during activities that may be dangerous, such as swimming, riding a bike, climbing heights, etc., there has to be stringent supervision (once we’ve made sure the epilepsy is well controlled).
If a child’s epilepsy is well controlled, they do not need to be accompanied by a caregiver during school hours. Such caregivers are only required if the epilepsy is resistant to treatment and the child’s seizure can put them at risk.

Can a person with epilepsy get a driver’s license?

People who have epilepsy are allowed to take a driving test, provided they did not experience any seizures in the year prior to the test date, and provided they fulfil the remainder of the health criteria applicable to everyone.

In summary, this is a common condition in pediatrics and just like many other conditions, each case is individual. It is also the reason why proper management of the condition should be done by a pediatric neurologist that specializes in the field.
Keep in mind that the goal of treatment, also for those who are receiving medications, is to control the condition in such a way that allows for the child’s full potential to be reached. Their entire, full potential!