Note from SIGN and NGC: In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A-D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis
Who Should Make the Diagnosis?
D: The diagnosis of epilepsy should be made by a paediatric neurologist or paediatrician with expertise in childhood epilepsy.
History Taking and Clinical Features
D: An accurate history of the event should be taken from first-hand witnesses and the child.
Investigative Procedures
Electroencephalography (EEG)
D: An EEG should only be requested after careful clinical evaluation by someone with expertise in childhood epilepsy.
Standard EEG
C: All children with recurrent epileptic seizures should have an EEG. An early recording may avoid the need for repeated EEG investigations.
Repeat EEG Recordings and Sleep EEG
D: For children with recurrent epileptic seizures and a normal standard EEG, a second EEG recording including sleep should be used to aid identification of a specific epilepsy syndrome.
Ictal EEG Recording
D: Where the clinical diagnosis of epilepsy is uncertain and if events are sufficiently frequent, an ictal EEG should be used to make a diagnosis of an epileptic or non-epileptic seizure.
Brain Imaging
D: Most children with epilepsy should have an elective magnetic resonance imaging (MRI) brain scan. Children with the following epilepsy syndromes (which are following a typical course) do not need brain imaging:
- Idiopathic (primary) generalised epilepsies (e.g., childhood absence epilepsy, juvenile myoclonic epilepsy, or juvenile absence epilepsy)
- Benign childhood epilepsy with centrotemporal spikes (benign rolandic epilepsy)
Management
Information for Discussion with Children, Young People and Their Carers
D: All children with epilepsy and their carers should be given information appropriate to their condition. A summary of the contents of these discussions should be recorded.
D: Families should be given information to take home in the most suitable format, making adjustments for different sociocultural contexts (e.g., leaflets, fact sheets, videos).
Management of Risk
Safety
D: Children with epilepsy should be encouraged to participate in normal activities with their peers. Supervision requirements should be individualised taking into account the type of activity and the seizure history.
Death in Epilepsy
D: Families should be advised if the child has an increased risk of sudden unexpected death in epilepsy (SUDEP). They can be reassured if the risk is considered to be low.
Antiepileptic Drug Treatment
When to Start Antiepileptic Drug Treatment
Febrile Seizures
B: Children with febrile seizures, even if recurrent, should not be treated prophylactically with antiepileptic drugs.
Provoked Seizures
A: Long term prophylactic antiepileptic drug treatment for children with head injuries is not indicated.
Unprovoked, Tonic-Clonic Epileptic Seizures
A: Antiepileptic drug treatment should not be commenced routinely after a first, unprovoked tonic-clonic seizure.
Choice of First Antiepileptic Drug (AED)
Generalised Epilepsies
C: The choice of first AED should be determined where possible by the syndromic diagnosis and potential adverse effects.
West's Syndrome and Epileptic Infantile Spasms
B: In West's syndrome, corticotropin or corticosteroids should be used as first line treatment. Where West's syndrome is caused by tuberous sclerosis, vigabatrin is superior.
Antiepileptic Drug Combination Therapy
Focal Seizures
A: When appropriate monotherapy fails to reduce seizure frequency, combination therapy should be considered.
Adverse Effects of Antiepileptic Drugs
Monitoring for Adverse Effects in Antiepileptic Drugs
B: Routine AED level monitoring is not indicated in children.
Withdrawal of Antiepileptic Drugs
A: Withdrawal of antiepileptic drug treatment should be considered in children who have been seizure free for two or more years.
Management of Prolonged or Serial Seizures and Convulsive Status Epilepticus
Prolonged or Serial Seizures
B: Prolonged or serial seizures should be treated with either nasal or buccal midazolam or rectal diazepam.
Behaviour and Learning
Epilepsy and the Use of Other Medications
Neurostimulants
D: Neurostimulant treatment should not be withheld, when indicated, from children with epilepsy and attention deficit hyperactivity disorder (ADHD).
Melatonin
D: Epilepsy, or a history of seizures, are not contraindications to the use of melatonin for the treatment of sleep disorders in children and young people.
Models of Care
Role of Epilepsy Nurse Specialists
D: Each epilepsy team should include paediatric epilepsy nurse specialists.
Definitions:
Grades of Recommendations
Grade A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rate as 2++
Grade D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion
