Long-Term Concerns with Levetiracetam in a 2.5-Year-Old Girl
The primary long-term concern with levetiracetam (Keppra) in young children is behavioral adverse effects, including irritability, aggression, and mood changes, which occur more commonly in patients with pre-existing psychiatric or neurobehavioral problems. 1, 2
Behavioral and Psychiatric Effects
- Behavioral side effects are the most serious concern with levetiracetam use and include hostility progressing to aggressive behavior, irritability, and mood disturbances. 3, 1
- These behavioral effects may be more pronounced in children and can manifest as increased irritability, emotional lability, or aggressive outbursts. 1
- In pediatric studies, behavioral adverse effects led to discontinuation in approximately 12% of children receiving high doses. 4
- Parents should monitor for personality changes, increased tantrums beyond normal developmental behavior, sleep disturbances, or unusual aggression. 1, 2
Cognitive and Developmental Considerations
- Levetiracetam does not cause cognitive impairment, which distinguishes it favorably from older antiepileptic drugs like phenytoin. 5, 2
- The drug is not associated with drug-induced weight gain, another advantage over many alternative antiepileptic medications. 2
- Long-term cognitive development appears preserved, though ongoing monitoring of developmental milestones remains important in any child on chronic antiepileptic therapy. 2
Common Transient Side Effects
- Drowsiness and ataxia are the most frequently reported acute effects in young children, particularly in those who are levetiracetam-naive. 6
- These effects are typically mild to moderate and transient, resolving with continued therapy or dose adjustment. 3, 6
- In a large pediatric ingestion study, 80.5% of children experienced no adverse effects, with only 18.3% having minor outcomes and 1.2% moderate outcomes. 6
Favorable Safety Profile
- No serious idiosyncratic side effects (such as severe rashes, hepatotoxicity, or bone marrow suppression) have been reported with levetiracetam, unlike many other antiepileptic drugs. 3
- The drug has no clinically relevant drug-drug interactions due to minimal hepatic metabolism through cytochrome P450 pathways. 3, 2
- Levetiracetam is generally well-tolerated in the pediatric population, with children tolerating doses up to 275 mg/kg/day in specialized cases without serious adverse effects. 4
Monitoring Recommendations
- Watch specifically for behavioral changes: increased irritability, aggression, mood swings, or personality alterations that differ from normal toddler behavior. 1
- Monitor for transient drowsiness or unsteadiness, particularly during dose adjustments. 6
- Ensure regular developmental assessments to confirm age-appropriate cognitive and motor milestone achievement. 2
- Consider dose adjustment or medication change if significant behavioral problems emerge, as these are the primary reason for discontinuation. 4, 1
Critical Caveat
The 3 mL daily dose (1.5 mL BID) requires verification of the concentration of the oral solution being used, as levetiracetam oral solution typically comes in 100 mg/mL concentration, which would provide 300 mg/day total—a reasonable maintenance dose for a 2.5-year-old child weighing approximately 12-15 kg. 7