Outcomes in Childhood Seizures
ABSTRACTS & COMMENTARY
Sources: Verity CM, et al. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med 1998;338:1723-1728; Sillanpää M, et al. Long-term prognosis of seizures with onset in childhood. N Engl J Med 1998; 338:1715-1722.
Childhood seizures are a topic of considerable interest, given the possible development of lifelong epilepsy and impairments of the child's ultimate development. The studies by Verity and colleagues and Sillanpää and asssociates address the long-term outcomes in children with seizures. One examines febrile convulsions and the other reviews non-febrile attacks.
Verity et al investigated the long-term behavioral and intellectual outcomes of febrile seizures in more than 16,000 infants born in the United Kingdom during 1970. Follow-up information was obtained 10 years later via parental, physician, and educator questionnaires, as well as by self-reported information. Data were available for study in approximately 15,000 children. Seizures developed in 1318 children; 381 had febrile convulsions without underlying neurodevelopment abnormalities. Among the 381, 287 had simple febrile convulsions and 94 had complex febrile seizures (defined as seizures exceeding 15 minutes, focal events, or repeated events in the same febrile episode). The 381 with febrile seizures were compared with the remaining 937, using 102 outcome assessments, including intelligence, school performance, speech and language development, and behavior. Significant differences were found in only four of the 102 categories. Compared with controls, children with febrile convulsions had an increased incidence of impulsivity and anxiety, a self-reported increased difficulty with gymnastics, and better reading skills. Children with complex febrile or recurrent febrile seizures had the same outcome as those with simple febrile events and the control population.
Sillanpää et al followed more than 200 children with epilepsy for nearly 30 years and compared their remission rates, mortality rates, and socioeconomic and educational outcomes to a random, matched sample of the general population in Finland. Patients were followed by a single pediatric neurologist and subclassified according to the International League Against Epilepsy guidelines as: remote symptomatic epilepsy (history of a prior brain injury associated with an increased risk for seizures), cryptogenic epilepsy (otherwise neurologically normal without clear seizure etiology), and idiopathic epilepsy (epilepsy of a presumed genetic origin).
Data revealed that patients with remote symptomatic epilepsy were more likely than the other two groups or controls to die from causes both related and unrelated to seizures. Eighty-nine percent of patients who died were not in remission at the time of death. Eighty-one patients achieved a remission in this study, but nearly one-half subsequently later relapsed. Patients with remote symptomatic epilepsy fared worse than those in other groups, with only 45% achieving a remission.
Compared to controls, all children with epilepsy were significantly less likely than controls to obtain higher education, marry, be gainfully employed, or have a driver's license despite having equivalent socioeconomic opportunities and successful completion of 12 years of schooling. This was even true of patients who were seizure-free without medication.
COMMENTARY
Verity et al's data are encouraging and verify that febrile seizures do not affect intelligence and academic achievement. The minor differences reported above are certainly not alarming. These data are similar to those of the National Collaborative Perinatal Project (Ellenberg J, Nelson K. Arch Neurol 1978;35:17-21) and probably reflect a more accurate portrayal of outcome than previous hospital-based studies that found differences between febrile seizure patients and controls.
The Sillanpää study is more concerning. Although a sizable proportion of children with epilepsy ultimately achieved seizure control, even those who achieved remission and were off medication were less likely to seek higher education, reproduce, or even marry. Nevertheless, these children came from similar socioeconomic backgrounds as controls and had similar passing rates for a qualifying exam at the end of 12 years of schooling. The findings indicate that whether epileptic children have structural brain disease, they appear to do worse than non-epileptic children, making it imperative for the treating neurologist to recognize that all epileptic children need more attention, encouragement, and early therapeutic intervention to stop their seizures. -Michael H. Geffner, MD, and A. Maurine Packard, MD, Pediatric Neurologists, New York Hospital-Cornell Medical Center.
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