You are an integral part of the epilepsy care team
EXPERT ANALYSIS FROM AAP 2017
Epilepsy management
After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.
Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.
Children with epilepsy and normal cognitive development have no greater rate of injuries than children without epilepsy, but risk increases as seizures increase, and if the child has ADHD, intellectual disability, or generalized-onset seizures, that can lead to falls.
Still, children with epilepsy can play contact sports such as soccer or volleyball without worrying it will cause a seizure. They also should always wear a helmet while bicycling, rollerblading, skating, and using scooters or anything else with wheels.
Swimming, water sports, harnessed rock climbing, horseback riding, and gymnastics also are fine with appropriate supervision. Showers are preferred to baths because of the risk of drowning should a seizure occur in the bathtub. Bathing and swimming require a specified supervisor.
Unsafe activities include free climbing, sky-diving, hang-gliding, and scuba diving. Parents should supervise their children around irons, hairdryers, curling irons, stove tops, camp fires, BBQs, and playground equipment. TV and video games are fine if children do not sit close to the screen and have ambient light in the room.
A teen with uncontrolled seizures should not drive, and pediatricians should be aware of their state’s laws related to epilepsy and driving (www.epilepsy.com/driving-laws). Pennsylvania, California, Delaware, Nevada, New Jersey, and Oregon, for example, have physician reporting laws.
Physical health and learning differences
Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.
Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.
You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.
Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.
Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:
• Education
• Parenting
• Independence (including driving)
• Learning
• Eating (nutrition and bone health)
• Pharmacotherapy (anticonvulsants)
• School
• You (the child’s caretakers).
Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.
