Long-Term Outcomes and Risk Factors Associated With Acute Encephalitis in Children

Abstract

Background

Factors associated with poor outcomes of children with encephalitis are not well known. We sought to determine whether electroencephalography (EEG) findings, magnetic resonance imaging (MRI) abnormalities, or the presence of seizures at presentation were associated with poor outcomes.

Methods

A retrospective review of patients aged 0 to 21 years who met criteria for a diagnosis of encephalitis admitted between 2000 and 2010 was conducted. Parents of eligible children were contacted and completed 2 questionnaires that assessed current physical and emotional quality of life and neurological deficits at least 1 year after discharge.

Results

During the study period, we identified 142 patients with an International Classification of Diseases 9th Revision diagnosis of meningitis, meningoencephalitis, or encephalitis. Of these patients, 114 met criteria for a diagnosis of encephalitis, and 76 of these patients (representing 77 hospitalizations) had complete data available. Forty-nine (64%) patients were available for follow-up. Patients admitted to the intensive care unit were more likely to have abnormal EEG results (P = .001). The presence of seizures on admission was associated with ongoing seizure disorder at follow-up. One or more years after hospitalization, 78% of the patients had persistent symptoms, including 35% with seizures. Four (5%) of the patients died. Abnormal MRI findings and the number of abnormal findings on initial presentation were associated with lower quality-of-life scores.

Conclusions

Encephalitis leads to significant morbidity and death, and incomplete recovery is achieved in the majority of hospitalized patients. Abnormal EEG results were found more frequently in critically ill children, patients with abnormal MRI results had lower quality-of-life scores on follow-up, and the presence of seizures on admission was associated with ongoing seizure disorder and lower physical quality-of-life scores.

INTRODUCTION

Encephalitis is a serious illness that affects children worldwide. It is defined by the presence of an inflammatory process of the brain associated with clinical evidence of neurological dysfunction [1]. The initial presentation can include seizures, headache, paresis, vision loss, hearing impairment, and behavioral changes [2, 3]. Diagnosis is made by clinical presentation, cerebrospinal fluid (CSF) findings, and electroencephalography (EEG) or magnetic resonance imaging (MRI) abnormalities. For children, neurological impairment, which can lead to significant morbidity and death and affect long-term quality of life, has been reported in 25% to 60% of cases [3, 4]. Common long-term sequelae include epilepsy, developmental delay, learning disabilities, and chronic headaches [5].

The etiological agent is an important predictor of outcomes in patients with encephalitis [6], the epidemiology of which is geographically dependent [1]. Long-term outcomes have been explored for patients with a number of different viruses, such as herpes simplex virus (HSV) [7–10], Japanese encephalitis [11], enterovirus [12, 13], and Epstein Barr virus [14]. However, in up to 75% of cases of encephalitis, an etiology is not found [1, 15]. There have been few published studies regarding the long-term neurological outcome of pediatric patients with encephalitis, accounting for those without an etiology, using standardized outcome measures. The use of standardized measures can enhance our understanding of the outcomes associated with encephalitis and help us to identify potential risk factors for more severe disease; these measures are used also for other pediatric neurological insults, such as traumatic brain injury and stroke [16, 17]. Therefore, there were 2 main objectives of this study. The first objective was to use standardized measures to explore the long-term outcomes of children with encephalitis to further characterize the impact of this disease state in quantifiable terms. The second objective was to determine whether EEG and MRI abnormalities and the presence of seizures on initial presentation are risk factors for persistent neurological abnormalities or if they impact quality of life.

METHODS

Study Population

We reviewed the medical records of patients admitted to Children's Hospital Colorado, Aurora, between 2000 and 2010 with an International Classification of Diseases 9th Revision (ICD-9) discharge diagnosis code of encephalitis, meningoencephalitis, or meningitis. Patients were eligible for the study if they had a diagnosis of encephalitis, which was defined as documented encephalopathy (depressed or altered level of consciousness lasting >24 hours, lethargy, or personality change) plus 2 or more of the following: temperature of >38°C; new-onset seizure(s); focal central nervous system findings; abnormal EEG findings compatible with encephalitis; abnormal brain computed tomography (CT) scan or MRI results; or CSF pleocytosis >2 standard deviations of the mean for their age [18]. Patients with insufficient data, anti–N-methyl D-aspartate receptor encephalitis, or a hematologic/oncologic diagnosis were excluded from the study. Demographic, clinical laboratory, EEG, and neuroimaging data of each patient were obtained. Approval for the study was obtained from the Colorado Multiple Institutions Review Board (08-1299). Informed written consent was obtained for the follow-up questionnaires.

Follow-Up

Patients who met the study criteria for a diagnosis of encephalitis were eligible for follow-up if at least 1 year had passed since their original diagnosis. A structured telephone interview was conducted with parents of eligible patients using 2 questionnaires designed to assess quality of life; they were also mailed if requested by a parent. The first questionnaire was the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales [19], which is a 23-item scale designed to measure health-related quality of life in 4 categories: physical functioning (8 items), emotional functioning (5 items), social functioning (5 items), and school functioning (5 items). The psychosocial score is a composite of the emotional, social, and school functioning scores. The PedsQL questionnaire was validated previously, is reliable in patient populations [20], and is suggested as a core global outcome measure by the National Institute of Neurological Disorders and Stroke Common Data Elements [16]. The second questionnaire was used to determine the persistence of specific neurological symptoms or difficulties with areas of daily living such as weakness, speech, headaches, and seizures, and it covered areas relevant to encephalitis follow-up that were not addressed in the PedsQL questionnaire (see Appendix). The questionnaire was pilot tested with parents of children with chronic medical conditions and modified on the basis of results from this testing.

Statistical Analysis

Summary statistics are reported as medians (interquartile ranges [IQRs]) for continuous data and counts (proportions) for categorical data. The χ² and Fisher exact tests for association were used to compare certain clinical factors on admission with persistent abnormalities at least 1 year after the diagnosis of encephalitis. Persistent neurological abnormalities were defined as the presence of seizures, behavioral problems, or 1 or more neurological deficits, such as weakness, speech problems, developmental delay, and learning problems. Comparisons for clinical findings at admission and the presence of neurological deficits, behavioral problems, and seizures at discharge were also examined with the χ² and Fisher exact tests for association. Neurological deficits at discharge were defined as the presence of psychiatric problems or at least 1 physical problem, such as motor deficits, ataxia/cerebellar signs, or movement disorder. Spearman partial correlation was used to measure the strength of the association between PedsQL scores and clinical findings at admission and at discharge while controlling for the effect of age at the time that the survey was administered. The following empirical guidelines for interpreting the magnitude of the correlation coefficients were used: values less than 0.2 indicate weak correlation, values between 0.2 and 0.3 indicate moderate correlation, and values greater than 0.3 indicate large correlation. The McNemar test for paired data was used to test for differences in proportions in abnormalities at admission and during hospitalization against those present at discharge. P values were adjusted for multiple comparisons within each subanalysis by using the Hochberg method, which preserved the overall type I error rate for each subanalysis, allowing the adjusted P values to be interpreted at the 0.05 level of significance. Statistics were performed by using SAS version 9.4 statistical software (SAS Institute, Cary, NC) and SPSS version 22 (IBM Corp., Armonk, NY).

RESULTS

We identified 142 patients with an ICD-9 diagnosis of meningitis, meningoencephalitis, or encephalitis during our study period. Of these patients, 114 met our criteria for a diagnosis of encephalitis and underwent chart review. Twelve patients were excluded because of a diagnosis of anti–N-methyl D-aspartate receptor encephalitis, and 26 patients were excluded because of oncologic comorbidity or insufficient data regarding clinical presentation in the medical record. Seventy-six patients (representing 77 hospitalizations) had data available for review. One patient had a repeat hospitalization for encephalitis 3 years after the initial episode; the etiology was not identified for either presentation. An etiology was identified in 29 (38%) of the cases, 93% of which were from an infectious source. The most common etiologies were HSV, enterovirus, and influenza (Figure 1). The median age at diagnosis was 7 years (IQR, 2–13 years). One patient had a previous history of developmental delay, 1 had a history of seizures, and 2 had a history of migraine. Thirty-two (42%) patients were admitted to the ICU, and 4 (5%) patients died. Neurological deficits present on admission and persistence of deficits at discharge are summarized in Figure 2. Most patients who presented with motor deficits, personality changes, and/or ataxia/cerebellar signs were likely to have resolution of their symptoms before discharge.

Figure 1.

Flow diagram showing study participants with encephalitis at Children's Hospital Colorado (2000–2010), from initial assessment through follow-up. Abbreviations: HSV, herpes simplex virus; ICD-9, International Classification of Diseases 9th Revision.

Figure 2.

Neurological deficits and persistence of symptoms and signs on discharge among patients with encephalitis at Children's Hospital Colorado, 2000–2010 (N = 49); significant differences in proportions were evaluated by the χ² and Fisher exact tests.

Forty-nine patients were available for follow-up. The median time to follow-up was 1.3 years. Subjects with and without follow-up data were similar in terms of demographics and clinical characteristics (Table 1). Persistent neurological outcomes and PedsQL scores with normative data [20] are listed in Tables 2 and 3, respectively. Persistent deficits were reported in 38 (78%) patients. The most common residual neurological symptoms reported were psychiatric abnormalities, weakness, behavioral or cognitive deficits, vision problems, and headaches. Seventeen patients (35%) reported ongoing seizures. Patients with an etiology identified had lower median physical scores than patients without an etiology identified (87.5 vs 97; P = .02), but their overall and psychosocial scores were not significantly different. Patients with HSV and influenza had lower median physical and psychosocial scores, and patients who tested positive for enterovirus had higher median scores, but these differences were not statistically significant.

Table 1.

Demographics, Clinical Characteristics, and Hospital Course of Patients With Encephalitis Seen at Children's Hospital Colorado, 2000–2010^a

Variable	Total Patients	Follow-Up Group (N = 49)	No-Follow-Up Group (N = 27)b
Demographics
Age at diagnosis, years; median (interquartile range)	7 (2.6–12.7)	6.8 (2.6–12.8)	7.9 (2.4–11.6)
Male	41 (54.0)	25 (51.0)	16 (59.3)
Ethnicity/race
White	47 (61.8)	31 (63.3)	16 (59.3)
White (Hispanic)	19 (24.7)	13 (26.5)	5 (18.5)
Black	1 (1.3)	1 (2)	0 (0)
Asian	3 (4)	2 (4)	1 (4)
Other	3 (4)	0 (0)	3 (11)
Unknown	3 (4)	2 (4)	1 (4)
	Total Episodes of Encephalitis	Follow-Up Group (N = 49)	No-Follow-Up Group (N = 28)b
Clinical presentation/comorbidity
Any underlying comorbidity	11 (14.5)	8 (16.7)	3 (10.7)
History of recent acute illness	37 (49.3)	21 (44.7)	16 (57.1)
Headache	30 (39.3)	22 (44.9)	8 (28.6)
Behavioral changes	29 (38.2)	20 (41.7)	9 (32.1)
Altered mental status	77 (100)	49 (100)	28 (100)
Fever	49 (64)	31 (63.3)	18 (64.3)
Seizures	47 (62)	29 (60.4)	18 (64.3)
Central nervous system abnormality	33 (43)	23 (46.9)	10 (35.7)
At least 1 physical finding	45 (59.2)	29 (60.4)	16 (57.1)
Motor deficit	37 (48.7)	23 (47.9)	14 (50.0)
Ataxia/cerebellar signs	21 (27.6)	14 (29.2)	7 (25.0)
Movement disorder	8 (10.7)	6 (12.8)	2 (7.1)
Psychiatric problem	22 (28.9)	16 (33.3)	6 (21.4)
Laboratory/imaging/EEG findings
CSF pleocytosis	61 (80)	40 (83.3)	21 (75.0)
MRI/CT abnormalities	39 (51.3)	26 (54.2)	13 (46.4)
EEG abnormalities	47 (71.2)	31 (73.8)	16 (66.7)
Treatment
IVIg	5 (6.8)	4 (8.9)	1 (3.6)
Steroids	19 (27.5)	11 (25.0)	8 (32.0)
<21 days of acyclovir	37 ( 59.7)	19 (51.4)	18 (72.0)
>21 days of acyclovir	25 (40.3)	18 (48.6)	7 (28.0)
Hospital course
Rehabilitation admission	20 (29.0)	15 (34.1)	5 (20.0)
ICU admission	32 (44)	18 (38.3)	14 (56.0)
Days in ICU	4 (2–7)	4.5 (2–6)	3.0 (2–7)
Length of stay, days; median (interquartile range)	7.0 (3.9–21.0)	7.2 (3.0–21.0)	7.0 (3.9–22.6)
Death	4 (5.8)	0 (0)	4 (16)
Clinical factors on discharge
At least 1 physical finding	18 (23.7)	11 (22.9)	7 (25.0)
Motor deficit	16 (21.1)	10 (20.8)	6 (21.4)
Ataxia/cerebellar signs	4 (5.3)	2 (4.2)	2 (7.1)
Movement disorder	3 (4)	1 (2.1)	2 (7.1)
Psychiatric problem	8 (10.5)	5 (10.4)	3 (10.7)

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; EEG, electroencephalography; ICU, intensive care unit; IQR, interquartile range; IVIg, intravenous immunoglobulin; MRI, magnetic resonance imaging.

^a Values shown are number (percentage) unless otherwise specified.

^b There was no statistically significant difference between the follow-up and no-follow-up groups.

Table 2.

Persistent Neurological Deficits at Least 1 Year After Diagnosis of Encephalitis Among Patients Seen at Children's Hospital Colorado, 2000–2010 (N = 49)

Variable	n	% (95% CI)
Neurological deficit
Any deficit	38	78 (66–90)
Weakness	16	33 (20–46)
Behavioral problem	15	31 (18–44)
Developmental delay	17	35 (22–48)
Anxiety/depression	18	37 (23–51)
Vision problem	17	35 (22–48)
Speech problem	15	31 (18–44)
Sleep problem	9	18 (7–29)
Learning problem	20	41 (27–55)
Swallowing problem	5	10 (2–18)
Hearing problem	3	6 (0–13)
Headache	17	35 (22–48)
Seizures	17	35 (22–48)
Services/aids/medications required
On antiepileptic(s)	12	24 (12–36)
Glasses	13	27 (15–39)
Hearing aid	1	2 (0–6)
Speech therapy	24	49 (35–63)
Physical therapy	24	49 (35–63)
Occupational therapy	24	49 (35–63)

Abbreviation: CI, confidence interval.

Table 3.

PedsQL Scores for Patients at Least 1 Year After Diagnosis of Encephalitis Among Patients Seen at Children's Hospital Colorado, 2000–2010 (N = 49)

Age Category	PedsQL Score (Median [IQR])
Physicala	94 (75–100)
2–4 y of age	95 (53–100)
5–7 y of age	97 (30–100)
8–12 y of age	89 (63–97)
>13 y of age	94 (88–100)
Psychosociala	75 (60–92)
2–4 y of age	73 (56–100)
5–7 y of age	76 (56–91)
8–12 y of age	78 (62–93)
>13 y of age	75 (60–79)

Abbreviations: IQR, interquartile range; PedsQL, Pediatric Quality of Life Inventory; SD, standard deviation.

^a Parent proxy-report mean scores for PedsQL physical health among 8696 families of healthy children were 84.08 (SD, 19.7), and mean scores for psychosocial health among 8714 families were 81.24 (SD, 15.34) in a study by Varni et al [20].

There were no significant associations observed between factors on admission, such as CSF pleocytosis, CT/MRI or EEG abnormalities, or neurological deficits present at discharge. Patients admitted to the ICU were more likely to have had EEG abnormalities (P = .013).

Long-term outcomes were assessed by evaluating the PedsQL scores and the presence of neurological symptoms and signs at least 1 year after diagnosis. Having seizures present on admission was significantly associated with ongoing seizures at least 1 year after the diagnosis of encephalitis (94% vs 42%; P = .0036). Partial correlation coefficients of clinical factors on admission with PedsQL scores at least 1 year after diagnosis are presented in Table 4. After removing the effects of age, having abnormal MRI results on admission was associated with lower psychosocial and physical scores, and the presence of seizures on admission correlated with lower physical scores. The presence of EEG abnormalities on admission did not correlate with PedsQL scores. However, an increase in the number of clinical factors on admission (MRI abnormalities, EEG abnormalities, seizures, and CSF pleocytosis) correlated with lower PedsQL scores.

Table 4.

Partial Correlations of PedsQL Scores (Obtained at Least 1 Year After Diagnosis) With Clinical Factors on Admission After Adjusting for Age Among Patients With Encephalitis Seen at Children's Hospital Colorado, 2000–2010

Clinical Factor on Admission	n	Physical Score		Psychosocial Score		Overall Score
		Median	Spearman rhoa	Median	Spearman rhoa	Median	Spearman rhoa
MRI/CT
Abnormal	26	71.9	–0.26	88.8	–0.43b	76.5	–0.29
Normal	22	77.4		100		81.4
EEG
Abnormal	31	73.3	0.05	90.6	−0.14	76.2	0.06
Normal	11	75.0		100		80.0
Seizures
Yes	29	75.0	−0.08	90.6	–0.2	76.3	−0.11
No	19	87.5		96.9		85.0
CSF pleocytosis
Yes	40	75.0	−0.16	93.8	0.05	78.0	−0.09
No	8	85.8		94.4		84.6
No. of clinical factors present
1	10	92.5	–0.24	100	–0.34	92.1	–0.22
2	14	76.9		93.8		74.2
3	12	65.3		98.4		68.3
4	13	76.3		87.5		72.9

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; EEG, electroencephalography; MRI, magnetic resonance imaging; PedsQL, Pediatric Quality of Life Inventory.

^a Values of 0.1–0.2 represent weak correlation; values of 0.2–0.3 represent moderate correlation; and values of >0.3 represent strong correlation.

^b The adjusted P value is <.05.

DISCUSSION

In our study of long-term outcomes of children with encephalitis, we found that almost 80% of patients with encephalitis had persistent neurological symptoms on long-term follow-up. MRI findings and the presence/absence of seizures on admission were helpful in predicting long-term outcomes. We found that abnormal MRI findings and seizures were correlated with lower quality-of-life scores. The presence of seizures at presentation was associated with patients having ongoing seizure disorder. Finally, although EEG abnormalities were more commonly seen among critically ill patients, EEG findings were not helpful in predicting long-term outcomes. Given the limited data regarding long-term outcomes in children with encephalitis, these findings are important for informing which factors on presentation might predict quality-of-life outcomes.

The results of our study suggest a role for MRI for not only diagnosing and assisting with the etiology of encephalitis but also the prognostic information it may provide. Although abnormal MRI findings in our study were not associated with findings at discharge or gross neurological deficits, they were potentially associated with more subtle deficits identified by the PedsQL questionnaire. The strongest correlation was noted for the psychosocial score, which evaluates mental and emotional health and incorporates perception of self and ability to function in the community. Klein et al [2] reported that MRI abnormalities were predictive of abnormal neurological outcome at hospital discharge, but their study did not follow patients to assess long-term outcomes. Wang et al [3] reported that focal cortical parenchymal abnormalities that appeared on MRI predicted poorer long-term outcomes. Despite having detailed radiographic characterization of the lesions in those patients with MRI abnormalities, our study did not find an association between specific MRI abnormalities and adverse outcome, but this finding might have been limited by sample size.

In contrast, although EEG is a useful tool for assessing acute brain dysfunction [4], EEG findings do not predict long-term outcomes. The results of our study show that any EEG abnormalities, particularly severe EEG findings, were more prevalent in patients admitted to the pediatric ICU. We did not, however, find an independent association between EEG abnormalities or ICU stay and poor long-term outcomes, in contrast to the findings of Wang et al [3]. Our findings suggest that patients who present with more severe clinical signs and symptoms at presentation are more likely to have EEG abnormalities, but they do not necessarily correlate with long-term outcomes.

Although EEG findings may not be useful for prognosis, our study results show that seizures on initial presentation correlated with poorer long-term outcomes, which has been corroborated by other reports [2, 3]. From their study, Misra et al [21] reported that seizures resulting from encephalitis were associated with poor outcomes at 3 months’ follow-up. The study did not identify specific outcome domains as we did. It should be noted that the most common etiological agents reported by Misra et al, specifically, Japanese encephalitis and dengue, were different than those in our study. In addition, our finding that the presence of seizures at presentation increased the risk of subsequent seizure disorder was described previously [4]. These findings raise questions about whether identifying and optimizing seizure management early in the hospital course could serve as a neuroprotective strategy, and they warrant further study.

The majority of previous studies in which long-term outcomes of patients with encephalitis were explored focused on a specific etiological agent [7, 11, 13, 14, 22]. However, given that the majority of cases of encephalitis are without an etiology, we sought to explore the long-term outcomes of encephalitis regardless of whether an agent was identified, because it is more relevant to the usual clinical setting. We found that the identification of an etiological agent did not influence quality-of-life scores, but our data are limited by the lack of standardized testing at our institution.

Although other studies have explored short-term outcomes during hospitalizations [2] or focused primarily on long-term outcomes [23, 24], a strength of our study is that we report both long-term and short-term outcomes. In addition to reporting initial presentation and outcomes at discharge, we sought to follow patients at least 1 year after their initial diagnosis of encephalitis, by which time their deficits are usually persistent [25]. We selected the PedsQL questionnaire for our study because it was validated for use in studies of neurological disorders, it is brief and reliable, and it can be administered by telephone, which likely contributed to our high response rate. Because this tool does not account for specific deficits, we included an additional questionnaire related to neurological deficits, which provided further insight into the long-term morbidity associated with encephalitis.

There are limitations to our study. Our study showed an increase in the number of deficits correlated with lower physical, psychosocial, and overall PedsQL scores. However, we were not able to determine whether they were independent predictors because of our small sample size. There was a significant percentage of patients excluded from analysis because of incomplete medical records, which may have skewed our data. Selection bias exists because of the nature of our follow-up. Also, there were variable times to patient follow-up for the completion of the questionnaires. However, because most patients with encephalitis who show full recovery are likely to do so within 12 months of their initial diagnosis [4], we ensured that follow-up was obtained at least 1 year after their diagnosis, by which time their clinical characteristics were more likely to be persistent. In addition, there are certain neurological deficits that are nonspecific and may not be related to encephalitis (such as the presence of headaches) or may have been present before the diagnosis of encephalitis. We documented in our detailed questionnaire only those symptoms that were new after the diagnosis of encephalitis, but reporting was subject to recall bias and may have influenced the PedsQL scores. A prospective longitudinal study that includes active methods of subject follow-up and formal neuropsychological assessments linking early indicators to etiology, disease progression, and prognosis would yield an improved understanding of long-term outcomes.

This study of long-term outcomes of patients hospitalized with encephalitis found that long-term deficits are seen in approximately 80% of patients, and subsequent seizure disorder is seen in 35% of patients. Abnormal MRI findings at presentation correlate with worse quality-of-life outcomes. The presence of seizures on presentation predicts subsequent seizure disorder and is associated also with lower physical quality-of-life scores. Our data suggest that MRI findings might provide some prognostic information. Close follow-up of these patients is advised, because they are at risk of impairment with regards to their quality of life and subsequent epilepsy. Additional prospective studies with larger cohorts and more detailed outcome measures are needed to further determine risk factors that are predictive of poor outcomes.

Potential conflicts of interest. All authors: No reported conflicts.

All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

APPENDIX

TCH Neurological Outcomes Questionnaire

Child's Name:

Date of Birth:

Your Name:

Relationship to child:

General health:

In general, would you say your child's health is:

Excellent

Very good

Good

Fair

Poor

Have you been told by a doctor, nurse, or other health professional that your child has any of the following problems?

Weakness of the arms or legs	no	yes
Behavior problems	no	yes
Developmental delay	no	yes
Depression or anxiety problems	no	yes
Vision problems	no	yes
Speech problems	no	yes
Sleep disturbance	no	yes
Learning problems	no	yes
Swallowing problems	no	yes
Hearing problems or deafness	no	yes
Headaches	no	yes

If you have answered yes to any of the above, was this present before the diagnosis of encephalitis? If so, please circle:

Since your child's encephalitis, does he or she currently:

Use a wheelchair?	no	yes
Wear glasses?	no	yes
Wear hearing aids?	no	yes

Has your child ever needed any of the following services after discharge from a hospital for encephalitis?

Speech therapy	no	yes
Occupational therapy	no	yes
Physical therapy	no	yes

Seizures:

2. Does your child have seizures since having encephalitis?

no

yes

If the answer is yes, answer questions 3–5 below:

3. What best describes the type of seizure pattern your child has:

Staring episodes

Focal seizures (affecting one part of the body)

Generalized seizures (affecting multiple parts of the body)

Other (describe)

4. During the past 4 weeks, how many seizures has your child had?

5. Does your child take medication(s) for the seizures?

no

yes

Author notes

Correspondence: S. Rao, MBBS, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, B055, 13123 E 16th Ave, Aurora, CO 80045 ().