A first seizure in a child is one of the most frightening things a parent can witness. The combination of loss of consciousness, abnormal movements, and a period of unresponsiveness that follows can look like the child is dying. Most single seizures in children are not epilepsy and do not recur. When seizures do recur unprovoked, the diagnosis is epilepsy, and what follows is a process of determining which type – because epilepsy is not one condition but dozens of distinct syndromes with different causes, behaviours, treatments, and outcomes.
The good news is that 60-70% of children with epilepsy become seizure-free with the first or second medication tried. For those who do not, newer antiseizure medications, dietary treatments, and surgical options have expanded considerably over the past two decades.
Healthbooq (healthbooq.com) covers childhood neurological conditions and health.
What Epilepsy Is
Epilepsy is defined by the International League Against Epilepsy (ILAE) as: at least two unprovoked seizures occurring more than 24 hours apart; or one unprovoked seizure with a high probability of further seizures (over 60%) based on the underlying brain condition. An isolated febrile seizure, a single seizure during an acute illness, or a single first unprovoked seizure without clear evidence of high recurrence risk does not meet the diagnostic criteria.
Seizures are caused by abnormal synchronised electrical discharge in groups of neurons. Focal seizures begin in one part of the brain; generalised seizures involve both hemispheres from the onset. The clinical features depend entirely on which brain regions are affected.
Common Childhood Epilepsy Syndromes
Childhood absence epilepsy typically begins between ages 4 and 10, with very brief (5-30 second) staring episodes, eye fluttering, and brief unresponsiveness occurring many times per day. The child comes back immediately and is often unaware of the episode. It responds well to ethosuximide (first-line), sodium valproate, or lamotrigine. Most children outgrow it by adolescence.
Benign epilepsy with centrotemporal spikes (BECTS, also called Rolandic epilepsy) is the most common focal epilepsy of childhood, affecting school-age children between about 5 and 12. Seizures often occur at night or early morning and typically involve face and mouth twitching, drooling, and inability to speak while consciousness is preserved. The EEG has a characteristic pattern. It is almost always outgrown by mid-adolescence.
Juvenile myoclonic epilepsy (JME) begins in adolescence and is characterised by early morning jerks (myoclonic jerks), generalised tonic-clonic seizures, and sometimes absence seizures. It responds well to sodium valproate but is usually lifelong and requires ongoing medication.
Dravet syndrome is a rare but severe epilepsy beginning in the first year of life, usually associated with SCN1A gene mutations. It is highly drug-resistant and causes significant developmental regression. It illustrates that epilepsy in childhood encompasses conditions with very different severities and prognoses.
Sodium Valproate: A Critical Safety Issue
Sodium valproate (Epilim) is highly effective for generalised epilepsies including JME and is one of the most effective antiseizure medications available. However, it causes serious harm to babies when taken during pregnancy. Fetal Valproate Syndrome includes neural tube defects, congenital malformations, and neurodevelopmental problems (autism spectrum disorder, intellectual disability, ADHD, and language disorders) affecting 30-40% of children exposed in utero.
MHRA guidance updated in 2023 states that sodium valproate must not be used in girls and women of childbearing potential unless a pregnancy prevention programme is in place (highly effective contraception plus annual review and a signed form acknowledging the risks). For girls under 18, this means a paediatric neurologist must review the decision at least annually.
Parents of girls prescribed valproate need to understand this risk and plan proactively when their child reaches puberty.
Rescue Medication
All children with epilepsy should be prescribed emergency rescue medication for use if a seizure lasts more than five minutes or if they have a cluster of three or more seizures without recovery between them. The most commonly used medications are buccal midazolam (placed inside the cheek) and rectal diazepam. Buccal midazolam is preferred for community use.
Parents and schools need written instructions on when and how to administer rescue medication. School staff have legal obligations under the Children and Families Act 2014 to support the medical needs of children, and schools cannot refuse to administer prescribed rescue medication with appropriate training.
Investigation
EEG (electroencephalogram) records electrical brain activity and shows the characteristic patterns associated with different epilepsy syndromes. It does not always show abnormality between seizures, and a normal EEG does not exclude epilepsy. MRI brain imaging is used to look for structural causes.
A detailed history – what the child was doing, what happened at the start, how long it lasted, what happened after, and whether there was any warning – remains the most important diagnostic tool. Videos of seizures taken on a phone and shown to the epilepsy team are invaluable.
Living Well with Epilepsy
With appropriate medication and safety measures, most children with well-controlled epilepsy participate in normal school activities, sports (including swimming with supervision), and childhood experiences without restriction. Epilepsy Action (epilepsy.org.uk) and Young Epilepsy (youngepilepsy.org.uk) provide detailed, practical guidance for families.
Key Takeaways
Epilepsy is defined as a tendency to have unprovoked recurrent seizures, and affects approximately 1 in 200 children in the UK. There are many distinct epilepsy syndromes in childhood, and accurate classification determines treatment choice and prognosis. Common childhood syndromes include childhood absence epilepsy, benign epilepsy with centrotemporal spikes (BECTS), and juvenile myoclonic epilepsy. Sodium valproate is highly effective for many epilepsy types but carries a significant risk of serious foetal harm (Fetal Valproate Syndrome) and must not be used in girls and women of childbearing potential without a pregnancy prevention programme. All children with epilepsy should have emergency (rescue) medication prescribed for prolonged seizures. NICE guideline NG217 covers diagnosis and management.
