Residency · Residency · Medicine Pediatrics
Seizures and Epilepsy Across Ages
Introduction
Seizures represent one of the most common neurologic emergencies encountered by medicine-pediatrics physicians. The spectrum of epilepsy spans from neonatal seizures to new-onset epilepsy in the elderly, with age-specific etiologies, classification systems, and treatment strategies. A med-peds clinician must understand these differences to provide seamless care across the lifespan.
Definitions and Classification
ILAE 2017 Classification
Focal onset: Arising from networks limited to one hemisphere. Generalized onset: Engaging bilateral networks from onset. Unknown onset: Insufficient information to classify. Focal to bilateral tonic-clonic: Previously called secondary generalization.
Key Terminology
Seizure: A transient occurrence of signs/symptoms due to abnormal excessive or synchronous neuronal activity. Epilepsy: Defined by any of the following: two unprovoked seizures >24 hours apart, one unprovoked seizure with >60% recurrence risk, or a diagnosed epilepsy syndrome. Status epilepticus: Continuous seizure activity lasting >5 minutes or recurrent seizures without return to baseline.
Age-Specific Etiologies
Neonatal Period (0-28 days)
Hypoxic-ischemic encephalopathy (most common); Intracranial hemorrhage; Metabolic disturbances (hypoglycemia, hypocalcemia); Neonatal infections (meningitis, encephalitis); Inborn errors of metabolism (pyridoxine-dependent epilepsy).
Infancy and Early Childhood (1 month - 5 years)
Febrile seizures (most common; simple vs. complex); Genetic epilepsy syndromes (Dravet syndrome, infantile spasms); CNS infections; Structural abnormalities (cortical dysplasia).
School Age and Adolescence (6-18 years)
Childhood absence epilepsy (peak 4-8 years); Juvenile myoclonic epilepsy (peak 12-18 years); Benign epilepsy with centrotemporal spikes; Autoimmune encephalitis.
Adults and Elderly
Traumatic brain injury; Cerebrovascular disease (most common cause in adults >35); Brain tumors; Neurodegenerative diseases; Alcohol withdrawal seizures.
Diagnostic Workup
First Seizure Evaluation
Detailed history: semiology, duration, preceding aura, postictal state; EEG: Standard, sleep-deprived, or continuous monitoring. Neuroimaging: MRI preferred over CT (except in acute setting) Laboratory studies: glucose, electrolytes, toxicology screen; Lumbar puncture when infection is suspected.
Pediatric-Specific Considerations
Developmental history and regression assessment. Genetic testing for suspected epilepsy syndromes. Metabolic workup for neonatal and infantile seizures.
Adult-Specific Considerations
Cardiac evaluation to exclude syncope. Alcohol and substance use assessment. Occupational and driving implications.
Treatment Principles
When to Start Antiseizure Medications (ASMs)
After a second unprovoked seizure (standard recommendation) After a first seizure with high recurrence risk (abnormal EEG, structural lesion) Immediate treatment for status epilepticus.
First-Line ASMs by Age and Seizure Type
| Population | Focal Seizures | Generalized Seizures |
|---|---|---|
| Neonates | Phenobarbital, levetiracetam | Phenobarbital |
| Children | Oxcarbazepine, levetiracetam | Ethosuximide (absence), valproate |
| Adults | Lamotrigine, levetiracetam | Valproate, lamotrigine |
| Elderly | Lamotrigine, levetiracetam | Lamotrigine, levetiracetam |
Special Considerations
Valproate: Avoid in women of childbearing potential (teratogenicity) Carbamazepine/phenytoin: May worsen generalized epilepsy. Ketogenic diet: Effective in refractory pediatric epilepsy. Surgical evaluation for drug-resistant epilepsy (failed two adequate ASM trials)
Transition of Care
Adolescents with epilepsy need structured transition to adult neurology. Address medication adherence, driving laws, reproductive counseling. Update seizure action plans for school, work, and independent living.
Clinical Pearls
Febrile seizures do not require chronic ASM therapy; parental education is paramount. Juvenile myoclonic epilepsy typically requires lifelong treatment due to high relapse rates. Always consider autoimmune encephalitis (anti-NMDA receptor) in young patients with new-onset seizures and psychiatric symptoms. In the elderly, levetiracetam and lamotrigine are preferred due to fewer drug interactions. Med-peds physicians are uniquely positioned to manage epilepsy transitions from childhood through adulthood.
References
- Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy. Epilepsia. 2017;58(4):522-530.
- Kwan P, Arzimanoglou A, Berg AT, et al. Definition of drug resistant epilepsy: Consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia. 2010;51(6):1069-1077.
- Shellhaas RA, Wusthoff CJ, Tsuchida TN, et al. Profile of neonatal epilepsies: Characteristics of a prospective US cohort. Neurology. 2017;89(9):893-899.
- Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394.