Infantile spasms is a potentially devastating early-onset epilepsy that affects infants, typically between three and nine months of age. Many cases of infantile spasms occur in children who are already have brain abnormalities, such as children with tuberous sclerosis, down syndrome, or brain injuries sustained as newborns. However, in about one third of affected infants, infantile spasms occur for no known reason.
There are three first-line treatments used for infantile spasms. Most pediatric neurologists select one of these three as the initial treatment.
First, adrenocorticotropic hormone (ACTH) is a naturally occurring hormone that is made by the pituitary gland. It stimulates the body to produce steroids. There are several versions of ACTH available throughout the world — in the US, physicians can prescribe a pharmaceutical grade purified ACTH for infantile spasms. ACTH must be given by injection into the infant’s thigh twice a day for two weeks, and then gradually tapered over the next several weeks. There are significant side effects. Many babies become very irritable when taking this medication. It increases their appetite, and some gain weight during treatment. ACTH can also increase blood pressure and, on occasion, lead to an increase in the size of the heart. These side effects fade after the medication is stopped.
Second, oral prednisolone is a corticosteroid, which comes as a liquid. This is the same medicine given for children with asthma attacks; although, for infantile spasms we use a higher dose for a longer period of time (usually several weeks). It can have the same side effects as ACTH, but these are usually less severe.
Third, vigabatrin is a medication that comes as a packet of powder, which can be disolved in water. The major worrisome side effect of vigabatrin is loss of peripheral vision. This is uncommon. Usually when vigabatrin is prescribed, the infant will also need to see an ophthalmologist to monitor for this potential side effect.
Current evidence suggests that ACTH has the best overall response rate. The one exception is that for children who have infantile spasms due to tuberous sclerosis, vigabatrin seems to work better.
First-line therapy works between half and three quarters of the time. If it fails, there is not good evidence to guide us on what to try next. Many physicians will switch to a different first-line agent. For example, if a child continues to have seizures after ACTH, the physician may try vigabatrin next. Rarely, a deficiency of vitamin B6 can cause infantile spasms, and many physicians will give infants this vitamin. Other physicians may try dietary therapy. For example, there is a diet called “the ketogenic diet” that avoids carbohydrates and sugars. This diet can lead to changes in how the brain makes fuel for itself, which can, in turn, reduce seizures.
In some cases, children with infantile spasms may have a subtle area of the brain which is abnormal, which is difficult to see on MRI scans. Some physicians will order other kinds of brain scans, such as a PET scan (positron emision tomography), in order to look for these kinds of abnormalities. This is important, because some infants benefit from epilepsy surgery to remove the abnormal area of brain.
Dr. Zachary Grinspan, MD
Dear EpilepsyNYC Community,
I am Kate Spratt. I am 28 years old, and I have epilepsy.
When I was six years old, I had my first seizure: on Christmas Eve, I was looking at the twinkling lights on our Christmas tree and my Grandma was talking to me but I wasn’t responding, I just kept looking at the lights.
However, I don’t remember this. All I remember is waking up in the hospital and being very confused. Worried that I was going to miss out on Christmas, I spent that night in the hospital having multiple tests and a spinal tap done. After that, for the next five years of my life, I was seizure free.
Then suddenly, when I was eleven, I had three grand-mal seizures and I was put on medication. During my pre-teen and teenage years, my seizures were under control (for the most part). I did have some “jerks,” but they didn’t affect me enough to debilitate me. I went to school, hung out with my friends, and participated in after school activities. I am grateful for that. I didn’t really talk about my epilepsy when I was a teenager, only a few of my close friends knew. Looking back, I think I didn’t tell people because I wasn’t sure how they would react.
Then, when I was around sixteen, I was in class one day, about to take a test, and I had a seizure. Next thing I knew, I was on my side, on the floor, and the ambulance was there. Luckily, my teacher at the time, used to work with children who had epilepsy and knew what to do when a student had a seizure. I had never had a seizure in school before. I was very tired (as I usually am after a seizure), but mostly very embarrassed. I swore I wouldn’t go back to school.
That night, the teacher called my house and spoke with my mom. She wanted to see how I was doing, and knowing I was probably embarrassed, also wanted me to know that everyone was very concerned about me. When my mom told me, I was relieved, but still kind of nervous of how people would react. Upon my return to school, no one said anything. When one girl shyly asked if I was feeling better I realized people were concerned. It was time to tell my friends, all my friends. Because seizures can happen, anywhere at any time, and people should know what to do.
Opening up about my epilepsy made my classmates comfortable enough to open up to me. I realized that a lot of people had family-members who had it too, while others, who were not familiar with epilepsy, wanted to know more. I knew then it wasn’t something to be embarrassed about; it was just a part of me. I think of it like this: some people have allergies, some people have asthma, and some people have epilepsy.
I proceeded to go to college and graduated with a Bachelor of Science in Secondary Education, with a 3.15 GPA and in four years. I did miss days sometimes because I had seizures and couldn’t go to school. I once even fell down the stairs on campus because I just kept walking and couldn’t stop. Graduating college was a huge accomplishment for me, because of how challenging it was at times. I couldn’t pull “all-nighters” like other students, and the workload could be quite stressful.
After graduating from college, I found a job that I loved at an after school program. On May 18, 2009, while I was taking a shower to get ready for work, I reached over, simply to adjust the water temperature slightly, and had a seizure, which caused me to accidentally turn the hot water on all the way and fall down. I don’t know how long I was under the scalding hot water and when I re-gained consciousness I didn’t even realize I was burnt; it was like I was in a fog. Twenty percent of my body was scalded and I had third degree burns. My whole back, my left arm and my thumb were burnt. I was in the hospital for five weeks. They said if I had passed out face forward I would have died. I had three skin grafts, I couldn’t walk, I couldn’t bend down, and I didn’t have range of motion in my arm for months. I had to wear compression garments for a year and do months and months of physical therapy in the hospital and everyday at home with my dad.
Ever since 2009 my epilepsy has gotten worse; the doctors don’t know why this is or why I even have epilepsy. No one in my family has ever had it, I never ran fevers as a child, or had any head injuries. I’ve been hospitalized numerous times and endured all sorts of different side effects brought on by my medications. I’ve been on so many different medications it feels like I’ve been on every AED out there.
I have my ups and downs with my epilepsy. I try to stay strong or say that I’m a medical mystery, since no one knows why or how my epilepsy has gotten worse. It’s always great when you take a few steps forward but such a defeat when you then take those steps back. Because of everything that has happened, especially in the past few years, people don’t understand how I’m an optimist. When it comes down to it, it would probably be easier to be a pessimist, but it’s important to appreciate the good things in your life, like your family and friends, the moments when you’re not having seizures, and most of all, the fact that I’ll never give up hope for that one day when I’ll stop being a medical mystery.