Neuromodulation in Pediatric Epilepsy: When All Is Not About Resection-A Review.

Nearly 1% of the global population suffers from epilepsy. There are over 65 million people worldwide with epilepsy and approximately 10.5 million of those are children. One third of these people have drug-resistant epilepsy (DRE). Neuromodulation is an adjunct treatment option for these patients. This manuscript aims to describe the history, patient/parent perspective, current use, and future directions of neuromodulation in the management of pediatric DRE. We conducted a nonsystematic search of the literature through different databases as part of the Pediatric State of The Art Symposium at the 2025 American Epilepsy Society meeting in Atlanta. Three neuromodulation therapies, all using implanted devices and electrodes, have been approved by the Food and Drug Administration (FDA) to treat DRE, namely, vagus nerve stimulation (VNS) (1997 and lately 2017), deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) in 2018 (2010 in Europe), and responsive neurostimulation (RNS) in 2013. Only VNS is approved in pediatric patients. Emerging noninvasive neuromodulation modalities such as noninvasive VNS and transcranial magnetic stimulation showed mild adverse effects and exhibit the most encouraging seizure and neurocognitive outcomes to date, but larger multicenter studies are essential before these modalities can be offered and integrated into standard pediatric epilepsy care.