Practice parameter: Evaluating a first nonfebrile seizure in children: Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society

To the Editor:

In the practice parameter evaluating children with a first nonfebrile seizure, the authors recommended obtaining an EEG as a standard.1 However, they failed to support this strong recommendation with appropriate evidence.

The authors noted the importance of EEG for syndrome diagnosis. However, the class I pediatric studies cited do not support the utility of EEG for syndrome diagnosis at the time of the first seizure because they do not report the percentage of children in which clinically unsuspected epilepsy syndromes were reliably diagnosed. More importantly, they do not show that making a syndrome diagnosis in this setting improves patient outcomes.

The authors overstate the importance of EEG data for assessing recurrence risk and long-term prognosis. EEG combined with other variables does help to identify those with high and low recurrence risk, but because all of the other variables are readily available clinical information, this is an inadequate justification for performing an EEG in all children with a first apparent seizure. It is more effective to use clinical data to select high-risk patients to test.2 Regarding long-term prognosis, the presence or absence of epileptiform discharges on EEG at the onset of epilepsy does not predict the likelihood of seizure freedom at 2 years.3

No data support the implication that treatment decisions based on EEG results improve patient outcomes. In the first unprovoked seizure studies cited, progressively fewer children were treated with anticonvulsants (68% in 1985, 61% in 1989, 14% in 1996, and 0% in 1998). In no study was there a significant difference in recurrence rates between those treated and untreated, nor …