Multivariable analyses identified BMI z-score as a major independent determinant of metabolic alterations and thyroid hormone sensitivity, while antiepileptic drug exposure and disease duration showed variable and modest associations.<h4>Conclusions</h4> Pediatric epilepsy is characterized by preserved central thyroid regulation but altered peripheral thyroid hormone metabolism, as reflected by an increased FT3/FT4 ratio. Here, TG is linked to epilepsy.