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Epilepsy: the facts-long-term outlook in children EPILEPSY: THE FACTS-LONG-TERM OUTLOOK IN CHILDREN
It is difficult, if not impossible to provide an overall prognosis for epilepsy in children, because of the differing ages of onset, different epilepsy syndromes, differing causes of epilepsy, and the varying response to treatment.
However, certain factors are known to be associated with a poor outcome, with seizures unresponsive or only partly responsive to treatment. These factors include:
• epilepsy that starts before the age of two or three years;
• seizure types that include myoclonic (jerk) or atonic (drop) seizures;
• seizures that are initially difficult to control;
• the need for more than one anti-epileptic drug to obtain control of the seizures;
• the association of other neurological problems, such as moderate or severe learning difficulties, or a physical handicap such as cerebral palsy; and
• if a cause has been identified (e.g. abnormal development of the
brain, as in tuberous sclerosis, or following meningitis or encephalitis.
There are other factors which indicate a good prognosis. These include:
• epilepsy that starts after 5 but before 13 years of age;
• seizure types that include typical absence (petit mal) seizures or tonic-clonic (grand mal) seizures;
• ready control of seizures, using just one anti-epileptic drug;
• a lack of other associated neurological problems;
• the absence of an identified cause; and
• the presence of a strong family history of epilepsy.
Many of the epilepsies in children can be classified into epilepsy syndromes. One of the purposes of this classification is to give some guidance on the prognosis or outcome. Syndromes that have a poor prognosis include the West syndrome (the seizure type in which is infantile spasms or myoclonic seizures) and the Lennox-Gastaut syndrome (seizure types include atonic, tonic, and myoclonic seizures). Seizures in both these syndromes start before the age of 3 years (rarely between 3 and 7 years in Lennox-Gastaut syndrome), and this in itself carries an unfavourable prognosis. Syndromes that have a good outcome include typical absence epilepsy (petit mal) and some partial epilepsies (for example, benign partial epilepsy with centro-temporal (rolandic) spikes). In typical absence epilepsy, between 70 and 75 per cent of children will stop having absence seizures by the age of 14-16 years and the anti-epileptic medication can be withdrawn. The remaining 25-30 per cent may need to continue taking medication into adult life, perhaps even for the rest of their life. The children that are likely to fall into this group are those in whom absences began after the age of 11 or 12 years, were associated with generalized tonic-clonic (grand mal) seizures, and in whom the seizures were difficult to control.
Benign partial epilepsy with centro-temporal (rolandic) spikes is, as the name suggests, really benign. All the children with this epilepsy syndrome will have stopped having seizures by 14-16 years of age, and medication can be withdrawn with no risk of relapse (recurrence) of seizures.
Some syndromes have an intermediate outlook. One of these is juvenile myoclonic epilepsy which usually starts between 10 and 16 years of age. The seizures (myoclonic and generalized tonic-clonic) are usually easily controlled by one drug (sodium valproate), but if the medication is withdrawn, the seizures may recur. Many (but not all) patients who have this type of epilepsy will have to take the treatment for the rest of their lives.
Overall, approximately 30-40 per cent of children will 'outgrow' their epilepsy before they become an adult. This means that the anti-epileptic medication can be withdrawn. Over 70 per cent of children with typical absence epilepsy will probably be able to have their medication withdrawn after they have been seizure-free for between two and three years. In contrast, over 90 per cent of children with Lennox-Gastaut syndrome will probably need to take anti-epileptic drugs for most of their lives.
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Epilepsy
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