Page 307 - ILAE_Lectures_2015

Chapter 30

Drug treatment of paediatric epilepsy

RICHARD E. APPLETON1 and J. HELEN CROSS2

1The Roald Dahl EEG Unit, Paediatric Neurosciences Foundation, Royal Liverpool
Children’s Hospital, Alder Hey, and 2Neuroscience Unit, UCL Institute of Child Health,
Great Ormond Street Hospital for Children, and Young Epilepsy, Lingfield

Basic principles

Once the diagnosis of epilepsy and the epilepsy syndrome have been established (see also
Chapter 23), there are a number of decisions which must be taken regarding the use of
antiepileptic drugs (AEDs) (Table 1). Only the first four points in Table 1 will be discussed in
this chapter.

The decision to treat a child with a drug depends upon the individual (frequency of seizures,
epilepsy syndrome and neurological findings) and also the wishes of the parents/carers. It
remains unclear when drug treatment should beginl-3, and numerous attempts have been made
to accurately predict the risk of epilepsy developing (i.e. recurrent, spontaneous seizures) after
the first unprovoked seizure3. Nevertheless, the decision to treat  and when to treat  remains
an individual one. Most clinicians would not recommend starting treatment after a single, brief
generalised tonic-clonic seizure, but would after a cluster of seizures or, possibly, after an
episode of unprovoked status epilepticus. Similarly a child with severe physical and learning
difficulties who develops infrequent myoclonic or generalised atypical absence or focal
seizures may not necessarily require an AED. The recently published ILAE working definition
of epilepsy takes these considerations into account4.

Table 1. Decisions regarding AEDs in children.

When to start a drug
Which drug and in what dose
When to change the drug
When (and how) to add a second drug (and which one)
When to seek a specialist opinion (paediatric neurologist)
When to stop the drug(s)
When to consider alternative therapies, including surgery