Epilepsy is a relatively common neurologic disorder in children that has important implications for development, parents, and society. Making the correct diagnosis starts with an accurate and complete history that consequently leads to a directed diagnostic workup. This article outlines a diagnostic and management approach to paediatric seizures and epilepsy syndromes. Making the correct diagnosis of epilepsy or non epileptic imitators allows the practitioner to prescribe appropriate therapy. Initial management for typical epileptic syndromes and seizures and potential adverse effects are discussed. Alternative treatment options for pharmacologically resistant patients such as ketogenic diet, vagal nerve stimulation, and surgery are also discussed. While most children favourably respond to anti epileptic medications, early identification of medication failure is important to ensure optimal neuro development.
The appropriate management of childhood epilepsy begins with a clinical evaluation that precedes any therapeutic decisions.
Four diagnostic questions help to determine the clinical management and prognosis as follows:
(1) Seizure confirmation —“Are the described or witnessed events seizures?”
(2) Seizure classification—“What is the likely neuroanatomical location for the seizure”?
(3) Epilepsy classification—“What are the most likely causes or triggers for these seizures?”
(4) Syndrome identification—“Do age of onset of the seizures, developmental milestones, neurological exam, EEG pattern, and/or brain imaging fit a typical pattern or syndrome?”
Epilepsy and Seizures Management
Seizure management can be achieved either pharmacologically which is preferred and more efficacious or by nonpharmacologic measures such as resective surgery or ketogenic diet.
1. Pharmacological Treatment Options
Monotherapy is desirable because it decreases the likelihood of adverse effects and avoids drug interactions, which tend to happen sometimes with polypharmacy. In general, recommendations are to start anti-seizure therapy with a single drug, and most children with epilepsy achieve complete seizure control with mono therapy when using the correct drug for the seizure type. When using more than one drug, it is recommended to change only one drug at a time, because it is impossible to determine which drug is responsible for a beneficial or an adverse effect if we make several changes simultaneously. The less frequent the doses are, the more compliance rate will be achieved.
2. Non pharmacologic Treatment Options
Children with antiepileptic medication-resistant epilepsy or ongoing seizures with focal abnormality should be considered for epilepsy surgery.
For those who have a more serious paediatric epilepsy, optimal management and a favorable outcome will rely in part on patient-specific factors, education, and access to pharmacological and non-pharmacological treatments.