What is the primary treatment for epilepsy (ERPT) in children?

Primary Treatment for Epilepsy in Children

For children with partial onset seizures, oxcarbazepine and carbamazepine are the treatments of choice, with lamotrigine and levetiracetam also serving as first-line options; for generalized tonic-clonic seizures, valproate is the treatment of choice, with lamotrigine and levetiracetam as suitable alternatives, particularly for females of childbearing potential. 1, 2, 3

Initial Treatment Selection by Seizure Type

Partial Onset Seizures (Ages 4+)

• Start with oxcarbazepine or carbamazepine as the primary monotherapy options 1, 2
• Alternative first-line agents include lamotrigine and levetiracetam, both demonstrating equivalent efficacy 1, 2, 3
• Levetiracetam dosing: initiate at 20 mg/kg/day divided twice daily (10 mg/kg BID), increase by 20 mg/kg increments every 2 weeks to target dose of 60 mg/kg/day (maximum 3000 mg/day) 4
• Topiramate is FDA-approved for monotherapy in patients ≥10 years with partial onset seizures 5

Generalized Tonic-Clonic Seizures

• Valproate is the treatment of choice for symptomatic myoclonic and generalized tonic-clonic seizures, except in very young children and females of childbearing potential 2, 3
• Lamotrigine and levetiracetam are first-line alternatives, particularly important for females due to valproate's teratogenicity 1, 3
• For children ages 6-16 years with primary generalized tonic-clonic seizures: levetiracetam 20 mg/kg/day divided BID, increased by 20 mg/kg every 2 weeks to 60 mg/kg/day 4
• Topiramate is also considered first-line for generalized seizures 2

Syndrome-Specific Treatment Approaches

Childhood Absence Epilepsy

• Ethosuximide is the treatment of choice, with valproate and lamotrigine also first-line 2

Juvenile Myoclonic Epilepsy

• For adolescent males: valproate and lamotrigine are treatments of choice, with topiramate also first-line 2
• For adolescent females: lamotrigine is the treatment of choice (avoiding valproate teratogenicity), with topiramate and valproate as other first-line options 2

Benign Childhood Epilepsy with Centro-Temporal Spikes

• Oxcarbazepine and carbamazepine are treatments of choice, with gabapentin, lamotrigine, and levetiracetam also first-line 2

Lennox-Gastaut Syndrome

• Valproate is the treatment of choice, with topiramate and lamotrigine also first-line 2

Infantile Spasms

• For tuberous sclerosis-related spasms: vigabatrin is the treatment of choice, with ACTH also first-line 2
• For symptomatic infantile spasms: ACTH is the treatment of choice, with topiramate also first-line 2

Acute Seizure Management

Status Epilepticus (Seizures >5 minutes)

• First-line treatment: benzodiazepines, specifically lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) 1
• Intramuscular midazolam and buccal midazolam are equally effective alternatives in children 6
• Second-line treatment: valproate 20-40 mg/kg IV (maximum 3000 mg) is preferred based on meta-analysis showing 75.7% seizure cessation rate 1, 6
• Levetiracetam (68.5% cessation rate) and phenobarbital (73.6% cessation rate) are alternatives, with levetiracetam preferred due to favorable tolerability 6
• The ESETT trial demonstrated no significant difference between levetiracetam, fosphenytoin, and valproate for status epilepticus, with seizure cessation rates of 47%, 45%, and 46% respectively 7

Prolonged Febrile Seizures or Seizure Clusters

• Rectal diazepam is the treatment of choice for acute management 2

Monitoring and Follow-Up

Essential Monitoring Components

• Regular neurological assessments to evaluate seizure control and developmental progress 1
• EEG monitoring as part of ongoing neurodiagnostic evaluation 1
• Medication side effect surveillance, particularly behavioral changes in children under 4 years receiving levetiracetam 8

Behavioral Side Effects with Levetiracetam

• Behavioral changes and psychotic reactions occur more frequently in children <4 years 8
• Onset typically occurs early during titration phase, even at low doses (<20 mg/kg/day) 8
• These effects are reversible upon discontinuation 8

Treatment Failure Protocol

When First Medication Fails

• Refer to pediatric neurologist for medication management after first medication failure 1
• If two appropriate AED trials fail to control seizures, additional medications are unlikely to be effective, and referral to an epilepsy center for surgical evaluation should be considered 9
• Approximately 60-70% of patients with temporal lobe epilepsy become seizure-free with epilepsy surgery 9

Critical Caveats

Avoid phenobarbitone as first-line treatment: network meta-analysis demonstrates it performs significantly worse than all other treatments for both time to treatment withdrawal and overall tolerability in both partial and generalized seizures 3

Valproate in females: while highly effective, avoid in females of childbearing potential due to teratogenicity; use lamotrigine or levetiracetam instead 1, 3

Monotherapy preference: always initiate treatment with monotherapy rather than combination therapy to minimize side effects and drug interactions 1