Epilepsy in children
Epilepsy affects all ages groups. But for children, a variety of issues exist that can affect one's childhood.
Some epilepsy ends after childhood. Some forms of epilepsy are associated only with conditions of childhood that cease once a child grows up. Approximately 70% of children who have epilepsy during their childhood eventually outgrow it. There are also some seizures, such as febrile seizures, that are one-time occurrences during childhood, and they do not result in permanent epilepsy.
Pediatric epilepsy may cause changes in the development of the brain. For this reason, epilepsy in children is vastly distinct from epilepsy in adults and they must be considered differently in most regards.
Epilepsy can affect a child's education, thereby leading to trouble learning and lower grades. While many children are capable of functioning in a normal classroom environment, many end up in special education.
The child may be forced to miss a lot of school due to seizures. The seizures can impair a child's ability to memorize learning materials.
Absence seizures can have a high negative impact on a child's education. As they are less obvious than tonic-clonic seizures, they can occur many times within a single day, thereby resulting in the child's ability to learn being impaired, and leading to low grades. Often, these educational deficits lead to the investigation of neurological conditions and result in the diagnosis of this seizure subtype. Children may appear to be 'zoning out' or day-dreaming during classes when in actuality they are experiencing uncontrolled absent seizures. Once treatment begins, these children often exhibit improved attention and their grades improve.
Many children with epilepsy are overprotected by their parents, who do put restrictions on them in the name of safety, requiring more adult supervision than other children, and not allowing them to participate in certain activities normal to the age group, such as sports. It is a subject of debate if a child with controlled seizures needs additional protection or restrictions, or if the benefits outweigh the losses a child would face.
In cases of chronic pediatric epilepsy there is often an association with reduced language skills. The classically understood language areas of the brain are Broca’s area and Wernicke’s area. Realistically, language is significantly more complex and involves several cortical areas beyond these regions.
Language deficits may present with a wide variety of symptoms ranging from odd patterns of speech to complete aphasia of speech. Unfortunately there is not a significant amount of data that parses out how an epileptic firing patterns will cause a resulting language deficit. The correlation of epileptic activity and language deficit is undeniably present, but the mechanisms involved have yet to be unraveled.
In the developing brain, epilepsy may cause the language areas to be structurally altered leading to developmental difficulties. In turn, a child may have trouble acquiring communication skills at a normal rate. This delay may in some children be resolved by compensatory mechanisms or alleviated by medication and therapy, but in some children with persistent epilepsy, the delay may remain or worsen as they age.
In the case of temporal lobe epilepsy (TLE), studies have shown that there is structural compromise to the fiber tracts associated with memory and language, providing some explanation for the impairments in patients with epilepsy.
Language abilities in pediatric epilepsy cases are evaluated using electrical cortical stimulation (ECS) language mapping, electrocorticography (ECoG), fMRI, Wada testing, and magnetoencephalography (MEG).
fMRI has been shown to offer a promising strategy for defining language activation patterns as well as laterization patterns.
It is important to identify language regions involved in epilepsy, particularly temporal lobe epilepsy, before surgical resection in order to reduce the risk of postoperative language deficits. Currently, ECS mapping is the standard of care in localization of areas involved in focal seizure onset and pre surgical planning.
Many pediatric and adult epilepsy patients develop atypical language lateralization due to the reorganization of connections in the epileptic brain. There have been documented cases of interhemispheric and intrahemispheric reorganization of language areas. Several factors may be involved in the extent to which reorganization occurs.
"Table 1: Variables Associated With Interhemispheric and Intrahemispheric Reorganization Found in fMRI and ECS Studies."
|Variable||Effect on Language Organization||Interhemispheric/Intrahemispheric/Both|
|Early age of seizure onset||Yes||Both|
|Left-sided seizure focus||Yes||Both|
|Cortical dysplasia (vs discrete tumors)||Yes||Intrahemispheric|
|Lower IQ scores||Yes||Intrahemispheric|
|Age at mapping||No|
|Treatment with antiepileptic medications||No|
|Ictal zone location||No|
|Duration of epilepsy||No|
|Seizure propagation patterns||No|
The effects of epilepsy on language may be impacted by location of epileptiform activity, severity and duration of electrical discharges, age of onset, treatment method, and surgical resection areas.
In some cases, language impairment may be the first indicator of epileptiform activity in the brain of children. A study done at the University of Gothenburg showed that language impairments were more common in children with epileptic brain activity than children without. They then investigated whether the epileptic activity was the cause of the language deficit or whether there were other factors involved. They found the greatest impairments in language in the children with misfiring on the left side of the brain, the side that controls linguistic abilities. This likely indicates that epileptic activity leads to language difficulties and suggests that in children with language impairments of unknown etiology, evaluations for epilepsy should be considered.
The causes of epilepsy in childhood vary. In about ⅔ of cases, it is unknown.
- Unknown 67.6%
- Congenital 20%
- Trauma 4.7%
- Infection 4%
- Stroke 1.5%
- Tumor 1.5%
- Degenerative .7%
Most children who develop epilepsy are treated conventionally with anticonvulsants. In about 70% of cases of childhood epilepsy, medication can completely control seizures. Unfortunately, medications come with an extensive list of side effects that range from mild discomfort to major cognitive impairment. Usually, the adverse cognitive effects are ablated following dose reduction or cessation of the drug.
The ketogenic diet is used to treat children who have not responded successfully to other treatments. This diet is low in carbohydrates, adequate in protein and high in fat. It has proven successful in two thirds of epilepsy cases.
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