Objectives:Early-life epilepsies (epilepsies in children 1 to 36 months old) are common and may be refractory to anti-seizure medications. We summarize findings of a systematic review commissioned by the American Epilepsy Society to assess evidence and identify evidence gaps for surgical treatments for epilepsy in children aged 1 to 36 months without infantile spasms.Methods:EMBASE, MEDLINE, PubMed, and the Cochrane Library were searched for studies published from 1/1/1999 to 8/19/21. We included studies reporting data on children aged 1 month to ≤ 36 months undergoing surgical interventions or neurostimulation for epilepsy and enrolling ≥ 10 patients per procedure. We excluded studies of infants with infantile spasms or status epilepticus. For effectiveness outcomes (seizure freedom, seizure frequency), studies were required to report follow-up at ≥ 12 weeks. For harm outcomes, no minimum follow-up was required. Outcomes for all epilepsy types, regardless of etiology were reported together.Results:Eighteen studies (in 19 articles) met inclusion criteria. Sixteen pre/post studies reported on efficacy and twelve studies addressed harms. Surgeries were performed from 1979 to 2020. Seizure freedom for infants undergoing hemispherectomy/hemispherotomy ranged from 7% to 76% at 1 year after surgery. For non-hemispheric surgeries seizure freedom ranged from 40% to 70%. For efficacy, we concluded low strength of evidence suggests some infants achieve seizure freedom after epilepsy surgery. Over half of infants undergoing hemispherectomy/hemispherotomy achieved a favorable outcome (Engel I or II, ILAE I to IV, or >50% seizure reduction) at follow-up of >1 year, although studies had key limitations.Surgical mortality was rare for functional hemispherectomy/hemispherotomy, and non-hemispheric resections. Low strength of evidence suggests post-operative hydrocephalus is uncommon for infants undergoing non-hemispheric procedures for epilepsy.Conclusion:Although existing evidence remains sparse and low quality, some infants achieve seizure freedom after surgery and ≥50% achieve favorable outcomes. Future prospective studies in this age group are needed. In addition to seizure outcomes, studies should evaluate other important outcomes (developmental outcomes, quality of life [QOL], sleep, functional performance, and caregiver QOL).Registration:This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.

Background and Objectives:Early-life epilepsies are common and often debilitating, but no evidence-based management guidelines exist outside of those for infantile spasms. We conducted a systematic review of effectiveness and harms of pharmacologic and dietary treatments for epilepsy in children aged 1-36 months without infantile spasms.Methods:We searched EMBASE, MEDLINE, PubMed, and the Cochrane Library for studies published from 1/1/1999 to 8/19/21. Using prespecified criteria, we identified studies reporting data on children aged 1-36 months receiving pharmacologic or dietary treatments for epilepsy. We did not require that studies report etiology-specific data. We excluded studies of neonates, infantile spasms, and status epilepticus. We included studies administering one of 29 pharmacologic treatments and/or one of five dietary treatments reporting effectiveness outcomes at ≥ 12 weeks. We reviewed the full text to find any subgroup analyses of children age 1-36 months.Results:Twenty-three studies met inclusion criteria (6 randomized studies, 2 non-randomized comparative studies, and 15 pre-post studies). All conclusions were rated Low strength of evidence. Levetiracetam leads to seizure freedom in some infants (32% and 66%, respectively in studies reporting seizure freedom), but data on six other medications were insufficient to permit conclusions about effectiveness (topiramate, lamotrigine, phenytoin, vigabatrin, rufinamide, and stiripentol). Three medications (levetiracetam, topiramate, and lamotrigine) were rarely discontinued due to adverse effects, and severe events were rare. For diets, the ketogenic diet leads to seizure freedom in some infants (rates 12%-37%), and both the ketogenic diet and modified Atkins diet reduce average seizure frequency, but reductions are greater with the ketogenic diet (one RCT reported a 71% frequency reduction at six months for ketogenic diet, vs. only a 28% reduction for the modified Atkins diet). Dietary harms were not well-reported.Discussion:Little high-quality evidence exists on pharmacologic and dietary treatments for early-life epilepsies. Future research should isolate how treatments contribute to outcomes, conduct etiology-specific analyses, and report patient-centered outcomes such as hospitalization, neurodevelopment, functional performance, sleep quality, and patient and caregiver quality of life.Registration:This systematic review was registered in PROSPERO (CRD42021220352) on March 5, 2021.