Support for withholding AEDs after the first unprovoked seizure in childhood

The authors of a prospective study report that initiating treatment after the first unprovoked seizure would not have altered mortality in any of the children studied. They say that this supports practice guidelines for withholding chronic antiepileptic drug (AED) therapy following a first seizure in children and adolescents.The authors followed 407 children for a mean of 14.2 years after experiencing a first unprovoked seizure and assessed mortality risk. Of the 407 children, 86% were either not treated with AEDs or treated for less than two weeks after the first seizure and only 9% of patients were treated for 3 months or more. A total of 184 (45%) of children experienced a seizure recurrence. Nine deaths had been recorded by June 1, 2004. Five deaths were definitely or probably not related to seizures and occurred as a result of various causes. Four deaths, however, were probably or possibly related to seizures, and all four children were taking AEDs at the time of death - two having been treated after the first seizure and two after the second seizure.The authors say, "The focus of this report is on whether treatment following the initial seizure may have any impact on mortality. The answer in this large cohort is clearly no." They point out that, even in the two children who received AEDs immediately after the first seizure but subsequently died of a seizure-related cause, "...waiting until the second seizure would not have altered mortality as they each had more than five seizures before their death."The authors discuss the potential concern of the risk of sudden unexplained death in epilepsy (SUDEP) and consideration for whether initiating AED therapy after the first seizure may reduce the risk. However, they say, "SUDEP in otherwise normal individuals is primarily seen in adolescents and adults and only rarely in children. The one death from SUDEP in an otherwise normal subject occurred in an 18 year old." Reference...