Epilepsy in Children
On this page
Direct answer
Hypsarrhythmia — a chaotically disorganised electroencephalogram in an infant with clusters of flexor spasms on waking — means West syndrome, treated with ACTH and carrying a guarded prognosis, while a schoolchild who blanks out mid-sentence for ten seconds, dozens of times a day, provoked by hyperventilation in your clinic, has childhood absence epilepsy with its 3 Hz spike-and-wave discharge, best treated with ethosuximide. Childhood epilepsy is syndrome-first medicine: the seizure type and the electroencephalographic pattern choose the drug — valproate for generalised and myoclonic seizures, carbamazepine or oxcarbazepine for focal — and status epilepticus beyond five minutes is a benzodiazepine emergency followed by a second-line agent.
What you must remember
- Epilepsy is two or more unprovoked seizures more than 24 hours apart (or one with a high recurrence risk); classification runs focal versus generalised, then by syndrome.
- West syndrome: infantile spasms at 3–12 months in clusters on waking, hypsarrhythmic electroencephalogram, developmental arrest; causes include hypoxic-ischaemic injury and tuberous sclerosis; first-line is ACTH, with vigabatrin the choice when tuberous sclerosis underlies.
- Childhood absence epilepsy: brief staring with abrupt resumption, fluttering eyelids, hyperventilation-provokable in clinic, 3 Hz spike-and-wave; ethosuximide is the drug of choice, valproate when tonic-clonic seizures coexist; most children outgrow it.
- Juvenile myoclonic epilepsy: early-morning myoclonus — things fly from the hands after waking — with tonic-clonic seizures and polyspike discharges; valproate is the classic choice, and relapse on withdrawal must be counselled.
- Lennox-Gastaut syndrome: multiple seizure types including tonic and atypical absence, slow spike-and-wave below 2.5 Hz, intellectual disability, refractory — clobazam, rufinamide, valproate and the ketogenic diet.
- Self-limited epilepsy with centrotemporal spikes (rolandic): nocturnal focal seizures with facial twitching in a normal child, remitting by adolescence — often no drug needed.
- Drugs of choice: focal — carbamazepine or oxcarbazepine; generalised tonic-clonic — valproate, with levetiracetam a common alternative; absence — ethosuximide; infantile spasms — ACTH; neonatal seizures — phenobarbitone.
- Valproate in adolescent girls demands the reproductive counselling conversation — teratogenicity and polycystic ovary risk — with documentation; carbamazepine can worsen absence and myoclonic epilepsies, the classic prescribing trap.
- Refractory disease after two appropriate drugs earns the ketogenic diet, vagus nerve stimulation or surgery evaluation; status epilepticus is any seizure over five minutes — benzodiazepine first (lorazepam 0.1 mg per kg intravenously or midazolam buccally), repeated once, then levetiracetam, phenytoin 20 mg per kg or valproate, with anaesthesia if it continues, checking glucose and cause alongside.
Choosing the drug in two clinics
The first clinic is a failure of recognition: a seven-year-old punished for "daydreaming" — twenty blank episodes daily, each under fifteen seconds, schoolwork sliding. In your room the child blows on a pinwheel for three minutes and arrests mid-blow; the electroencephalogram shows 3 Hz spike-and-wave. Ethosuximide starts, the episodes stop, the class notes return. The phrase missed in exams is that absence with tonic-clonic seizures needs valproate instead, because ethosuximide does not protect the big seizures. The second clinic is a drug-choice chain: a thirteen-year-old with morning jerks and one generalised seizure gets valproate plus a lecture on sleep — the commonest trigger; a ten-year-old with focal motor seizures gets oxcarbazepine; a two-year-old with a frontal dysplasia refractory to two drugs is referred for surgical evaluation, not a fifth medication. Match the syndrome, then the drug, then know when to leave the prescription pad.
Where students slip
Absence is called inattention and punished at school for years — the hyperventilation provocation is the two-minute test that changes the child's life, and the exam mirrors it. Myoclonic jerks are dismissed as clumsiness or tics. Carbamazepine is prescribed for a generalised epilepsy and the seizures worsen — the classic pharmacology vignette. Valproate is handed to adolescent girls without counselling documented. And status is managed by repetition — third and fourth benzodiazepine doses without moving to a second-line drug or asking about glucose; the ladder, not the first rung, is the answer.
Frequently asked questions
What is hypsarrhythmia?
A completely disorganised, high-voltage chaotic electroencephalographic pattern in West syndrome with infantile spasms — the signature that mandates ACTH therapy and developmental evaluation.
Which drug treats childhood absence epilepsy?
Ethosuximide is the drug of choice; valproate or lamotrigine is preferred when generalised tonic-clonic seizures accompany the absences.
How is juvenile myoclonic epilepsy recognised?
Adolescent myoclonic jerks in the first hours after waking, tonic-clonic seizures, polyspike-wave discharges and provocation by sleep deprivation; valproate is the classic choice, usually lifelong.
Why can carbamazepine worsen some epilepsies?
Sodium-channel blockers aggravate absence and myoclonic generalised epilepsies — prescribing by label without syndromic classification is the trap.
When is the ketogenic diet used?
In refractory childhood epilepsies, especially Lennox-Gastaut and glucose transporter defects, after two appropriate drugs fail — a supervised high-fat, low-carbohydrate protocol.
What is the drug ladder for status epilepticus?
A benzodiazepine (lorazepam intravenously or midazolam buccally or intranasally) within five minutes, repeated once, then levetiracetam, phenytoin 20 mg per kg or valproate, with anaesthetic infusion if seizures persist.