EEG in the diagnosis & management of epilepsy

in neonates and children

Normal EEG in infants and Children
Magda Lahorgue Nunes, MD, PhD

Division of Neurology and INSCER

Pontificia Universidade Catlica do Rio Grande do Sul
Hospital Sao Lucas PUCRS.
Av. Ipiranga 6690 room 315
90610-000 Porto Alegre RS, Brazil

Email: nunes@pucrs.br

The content of this document reflects the position of the individual contributor(s) and may not necessarily reflect the opinions of ILAE and other contributors to the course.
@International League Against Epilepsy 2012

Table of Contents
Foreword.....................................................................................................................................3
1 Introduction to this unit............................................................................................................3
2 EEG in infancy (2 -12 months)................................................................................................4
3 EEG in early childhood (1-3 years)..........................................................................................5
4 EEG in Preschool age (3-5 years)............................................................................................6
5 EEG in older children (6-12 years)..........................................................................................7
6 EEG in adolescents (13-20 years)............................................................................................8
7 Glossary....................................................................................................................................9
8 Register of Figures & Tables.................................................................................................10
9 References .............................................................................................................................11

Foreword

Foreword
It is a pleasure to start this unit with you. I am a Pediatric Neurologist that
has worked since I was in Medical School with research in different aspects of the developing brain. I am also board certified in Sleep Medicine
and dedicate my research to aspects of ontogenesis and bioeletrogenesis
of preterm newborns. It is very important to recognize normal patterns of
EEG development in order to be an expert Clinical Neurophysiologist. I
hope you enjoy this chapter as much as I enjoyed preparing it.

Learning Goals
At the end of this learning unit you should know how to identify
normal EEG age related patterns and its variants during
childhood, in wake and sleep recordings.

1 Introduction to this unit

The maturation of the EEG across childhood is a challenge subject for the
neurophysiologists, as patterns may vary according to age. Besides,
sometimes the presence of physiological acute or spike-like transients or
even the presence of slow patterns may lead to a misdiagnosis. It is very
important to be aware of those variants. In this chapter we will expose
students to different samples of children recordings in order to help the
recognition of normal patterns and to avoid misdiagnosis.

2 EEG in infancy (2 -12 months)

2 EEG in infancy (2 -12 months)

After the neonatal period (that is considered the first four weeks of life
for term infants) and during the first three months of life the EEG is characterized by a gradual transition from neonatal to infantile patterns. In
very preterm neonates, the neonatal patterns may be seen for longer periods, during the first year of life, as according to conceptional age (gestational age plus days\weeks of life).
The technical approach to record an EEG in an infant is strongly related
to the technician skills and experience on handling an awake and a sleep
infant. The 10-20 International Electrode System should be used for electrode placement.

Table 1: Maturation of EEG across childhood: Infancy

Pattern/Age

2-12 months

Basal rhythm (sleep)

Transition from trac alternant to continuous

slow wave, No significant asynchrony. After ,
diffuse slow activity (0.75-3Hz) with maximum posterior voltage and moderate fast activity.

Posterior basal
rhythm (awake)

No alpha rhythm, waves at about 4 Hz around

3-4 months and 6Hz around 12 months

Other characteristics
(awake)

Considerable slow activity and very moderate

fast activity. Hyperventilation not feasible, intermittent photic stimulation with improving
driving to low flashes rates by 6 months

Drowsiness

After 6th month, rhythmic theta

NREM

Increase percentage with increasing age

Spindles

Appear after the 2nd month, sharp contoured,

12-14 Hz

Vertex waves and K

complexes

Large complexes appears after the 5th month

POSTS*

none

REM

Mostly slow activity. Decrease percentage during the first years of life

Sleep starts

in NREM after the 1st month of life

*POSTS (positive occipital sharp transients of sleep)

Figures 1 6
see separate file

For illustration see Figures 1 to 6.

3 EEG in early childhood (1-3 years)

3 EEG in early childhood (1-3 years)

At this age it is generally difficult to get a good waking record. EEG features are evolving to more mature patterns.

Table 2: Maturation of EEG across childhood: Early Childhood

Pattern/Age

1 3 years

Basal rhythm (sleep)

High voltage slow pattern (1-3Hz) and medium voltage(4-6Hz), maximum amplitude at
occipital region

Posterior basal
rhythm (awake)

6-7 Hz at 2 years, 7-8Hz at age 3 years

Other characteristics
(awake)

Blocking response to eyes opening present,

slower activity (2-5Hz)widely scattered

Drowsiness

Generalized high voltage rhythmic theta activity(4-6Hz)-hypnagogic theta hypersynchrony

NREM
Spindles

Present, 12-14 Hz, sharp, maximum at vertex

Vertex waves and K

complexes

Large and pointed

POSTS

Absent or poorly developed

REM

Slow activity (2-5Hz), start signs of desynchronization

Sleep starts

in NREM
Figures 7 9 see separate file

For illustration see figures 7 to 9.

4 EEG in Preschool age (3-5 years)

4 EEG in Preschool age (3-5 years)

At this age recording the awake EEG becomes a little easier, as children
may understand the procedures and collaborate. All patterns had developed in a more mature presentation.

Table 3: Maturation of EEG across childhood: Preschool age

Pattern/Age

3 5 years

Basal rhythm (sleep)

Diffuse delta activity, posterior maximum amplitude not so pronounced

Posterior basal
rhythm (awake)

Alpha range (8Hz), amplitude reaches 100uV,

higher amplitudes may be seen over the nondominant hemisphere. Intermixed delta waves (1.54Hz) may interrupt the alpha train.

Other characteristics
(awake)

Appearance of rolandic mu rhythm. Pronounced

slow responses to hyperventilation.

Drowsiness

Admixture of posterior slow activity, hypnagogic

theta activity tends to disappear until age 6 years

NREM

Figures 10 - 14
see separate file

Spindles

Well defined maximum amplitude over vertex

Vertex waves and K

complexes

More prominent sharp compounds

POSTS

Absent or poorly delineated

REM

Little desynchronization

Sleep starts

in NREM

For illustration see figures 10 to 14.

5 EEG in older children (6-12 years)

5 EEG in older children (6-12 years)

At this age a complete EEG with awake record, hyperventilation, intermittent photic stimulation and spontaneous sleep is easier to be obtained
as children are much more collaborative. In the sleep EEGs vertex waves
of high voltage can be seen. The differentiation from pathological rolandic spikes and vertex waves , remains in the slight longer duration and
higher voltage of the physiologic vertex activity.
Table 4: Maturation of EEG across childhood: Older Children
Pattern/Age

6 - 12 years

Basal rhythm (sleep)

Posterior basal
rhythm (awake)

Alpha rhythm gradually reaches 10Hz around

10 years, higher amplitude at nondominant
hemisphere. Considerable admixture of posterior slow activity.

Other characteristics
(awake)

Hyperventilation with pronounced slowing,

starting in posterior regions. Intermittent photic stimulation with a more mature type of occipital driving response.

Drowsiness

Increasing theta and delta frequencies with

gradually fading of posterior alpha rhythm.

NREM
Spindles

Features of maturity, waves rounded with 1012 Hz, trains usually shorter than1 second.

Vertex waves and K

complexes

Vertex waves appear before the transition

from stage I to II. K complexes appear in association with spindles at stage II

POSTS

Appears prior to onset of stage II

REM

Less slow activity and increasing desynchronization with mixed theta, alpha and beta frequencies.

Sleep starts

in NREM

For illustration see figures 15 to 20.

Figures 15 20
see separate files

6 EEG in adolescents (13-20 years)

6 EEG in adolescents (13-20 years)

Although significant biological and psychological alterations occurs in
the transition from the last years of childhood to adolescence, the EEG
maturation does not shows striking changes.

Table 5 - Maturation of EEG across childhood: Adolescence

Pattern/Age

13 - 20 years

Basal rhythm (sleep)

NREM and REM sleep with pattern similar to

adulthood

Posterior basal
rhythm (awake)

Entire alpha range present, mean frequency

around 10Hz, gradual decrease and disappearance of admixture slow activity

Other characteristics
(awake)

Fast activity over frontal areas, rolandic mu

rhythm and lambda waves with typical mature
configuration, low voltage records may occur.
Anterior rhythmical 6-7Hz activity has its
peak prevalence at ages 13-15 years. Hyperventilation without pronounced slowing.

Drowsiness

Gradual alpha dropout

NREM

(by age 16 years around 75% of the sleep

cycle)

Spindles

Similar to adults

Vertex waves and K

complexes

Similar to adults

POSTS

Similar to adults

REM

Desynchronized (by age 16 years around 25%

of sleep cycle)

Sleep starts

in NREM

7 Glossary

7 Glossary
REM sleep: rapid eyes movement sleep, its percentage decreases dramatically from the neonatal period (around 80% of the sleep cycle). By 8
months active sleep occupies approximately 30% of the sleep cycle and
at age 5 years the adult volume is reached (20 to 25% of the sleep cycle).
NREM sleep: non rapid eyes movement sleep, divided in three stages
(N1, N2 and N3), were n1 is the more light sleep, N2 phase characterized
by the appearance of sleep spindles and K complexes) and N3 (deep slow
wave sleep). Its percentage increases from the neonatal period to adolescence. The complete differentiation of the three NREM sleep stages can
be done around the 6th month of life. In normal healthy young adults
stage 1 accounts for less than 5% of the cycle, stage 2 from 45-55% and
stage 3 13 to 23%.
Drowsiness: the EEG features that represent the transition from awake
state to sleep modify according to age. During the first year of life it is
observed a transition to theta activity, latter from 1 to 6 years the hypnagogic theta hypersynchrony is the prominent pattern, after an increased
theta and delta frequencies with gradually fading of posterior alpha
rhythm, and the more mature pattern is the alpha dropout.
Hypnagogic hypersynchrony: generalized high voltage rhythmic theta
activity(4-6Hz) marker of drowsiness from age 1 to 6 years.
Vertex waves: hallmark of deep drowsiness, , they are secondary evoked
potentials, the morphology varies according to ontogenesis, and the mature pattern is a small spiky discharge of positive polarity the precedes a
large negative wave (more prominent).
Sleep spindles: also called sigma activity or sigma waves, they are
rhythmic waves with a frequency varying from 10-14 Hz, with waxing
and waning amplitude. During childhood they have a more sharp contoured morphology, faster frequency and longer duration of the trains.
K complexes : considered a response to arousing stimuli. The spatial distribution shows a maximum over vertex. The morphology consists of an
initial sharp component, followed by a slow that fuses with a superimposed fast component. In older children and early adolescence the sharp
component is impressive.
Positive occipital sharp transients of sleep: they appear in deep drowsiness and may persist during light and deep sleep, the morphology is a
positive spike-like waves in the occipital areas. They are more common
in adolescents and young adults.

7 Glossary
Lambda waves: sharp transients (biphasic or triphasic, with a positive
most prominent phase) , sawtooth shaped, with amplitude between 2050uV, occurring over the occipital region of subjects in the awake state
during visual exploration.
Mu rhythm: rolandic mu rhythm or wicket rhythm is related in frequency and amplitude to posterior alpha rhythm. This pattern can be observed in children and adult EEGs, but it is more prevalent in adolescents
(11 to 15 years) and adults.
Patterns of marginal and possibly abnormal character occurring
during wakefulness and sleep

Figure 21
see separate file

Rhythmical frontal theta (6-7Hz) activity: this pattern, that occurs during wakefulness, has two main peaks of appearance being the first
between 6-12 years and the second between 13-15 years. It is not considered a clear abnormality, as it appears in the EEGs on health young
subjects; however, some authors have related it to children with predisposition to generalized epilepsies. (Figure 21)
14and 6/seconds positive spikes: are seen during drowsiness and sleep,
form age 6 to 12 years. There is by now evidence that this pattern is not
categorically abnormal, unless if very frequent.

Figure 22
see separate file

Psychomotor variant: Describe in the sixties by Gibbs and Gibbs, they

are predominantly seen during sleep in adolescents and young adults.
Characterized by bursts of temporal theta (5-6.5Hz) rhythmical activity,
with a maximum over midtemporal areas and considerable spread into
posterior and anterior temporal and occipital regions. (Figure 22)

8 Register of Figures & Tables

Figures
See the separate fileNormal EEG patterns in infants & children. Figures posted within this unit.

Tables
Table 1: Maturation of EEG across childhood: Infancy.............................4
Table 2: Maturation of EEG across childhood: Early Childhood..............5
Table 3: Maturation of EEG across childhood: Preschool age .................6
Table 4: Maturation of EEG across childhood: Older Children ...............7
Table 5 - Maturation of EEG across childhood: Adolescence...................8

10

9 References

9 References
(not posted within the Virtual Library due to copyright restrictions)
Niedermeyer E. Maturation of the EEG: development of waking and
sleep patterns. In: Niedermeyer E & Lopes da Silva F (eds),Electroencephalography: Basic Principles,Clinical Applications and Related Fields.Baltimore: Urban & Schwarzenberg 1987, pp 133-161.

For Portuguese readers

Nunes ML & Da Costa JC. Manual de EEG e Polissonografia neonatal:
Atlas de Traados, Porto Alegre:EDIPUCRS, 2003.
Garzon E. Video-Eletroencefalografia.Conceito e metodologia. In:
Yacubian
EM,Garzon
E,
Sakamoto
AC
(eds),
VideoEletroencefalografia: Fundamentos e Aplicao na Investigao das
Epilepsias.So Paulo: Lemos Editorial, 1999,pp29-43.
Gomes MM, Bello H. Eletroencefalografia Fundamentos. Rio de
Janeiro: Revinter, 2008.
Montenegro MA, Cendes F,Guerreiro MM, Guerreiro CAM. EEG na
Prtica Clinica. So Paulo: Lemos Editorial 2001.

For Spanish readers

Davi P, Blanco M, Pedemonte M, Velluti R, Tufik S. Medicina Del
Sueo (chapters 43 and 44). Santiago: Mediterrneo, 2008.

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