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those included had symptomatic focal epilepsy, which is less common than idiopathic focal
epilepsy in children.

A follow-on study, SANAD II, commenced in April/May 2013. In this study the ‘standard’
drug in the generalised or unclassified arm will be sodium valproate (the ‘winner’ in SANAD
I) and the ‘new’ comparator drug will be levetiracetam. In the focal arm, lamotrigine will be
the ‘standard’ drug (the ‘winner’ in SANAD I) and the ‘new’ comparator drugs will be
levetiracetam and zonisamide. The results will be interesting and should hopefully be published
in 2017/18.

One major syndrome to consider is West syndrome, characterised by infantile spasms and
hypsarrhythmia on EEG; most, but not all children also demonstrate developmental plateau or
even regression, particularly if the diagnosis is delayed. It is recommended that hormonal
treatments (ACTH, tetracosactide or prednisolone) or vigabatrin should be used as first-line
monotherapy drugs in treating infantile spasms11,12. Vigabatrin is particularly effective in
treating infantile spasms caused by tuberous sclerosis12 but appears to be slightly less effective

than tetracosactide or prednisolone in treating spasms due to other aetiologies61,62. However

there are currently differences of opinion regarding the treatment of infantile spasms, in part
reflecting clinicians’ concerns over drug safety and in part availability of medication. In the
US, ACTH or prednisolone is the preferred treatment61; until recently vigabatrin has not been
freely available, whereas in many European countries vigabatrin is widely used. Which is used
will depend on family and physician choice, weighing up the risk:benefit of the treatment
involved. Although use of vigabatrin in adults and older children has been associated with
visual field constriction, this appears to be related to dose and duration of treatment21 and does
not necessarily prevent or reduce the use of this drug in treating infantile spasms when weighed
up against the risk of short-term high-dose steroids.

In Dravet syndrome, previously called severe myoclonic epilepsy of infancy, medications of
choice are sodium valproate, clobazam and topiramate. Furthermore a well-constructed
randomised crossover study demonstrated stiripentol, a cytochrome P450 inhibitor, to be
significantly more effective than placebo when added to sodium valproate and clobazam63;
however, this drug may be associated with significant somnolence as well as loss of appetite.
Of greater note is the observation that medications acting on sodium channels (e.g. lamotrigine,
phenytoin) may cause aggravation of seizures in this syndrome64,65 and therefore should be
avoided.

Several studies have been conducted evaluating treatments against placebo in Lennox-Gastaut
syndrome as add-on therapy. A Cochrane Review was able to evaluate seven randomised
controlled trials. All but two studies evaluated different therapies. Overall the authors
concluded that no study to date had shown any one drug to be effective over and above another
but lamotrigine, rufinamide, clobazam, topiramate and felbamate may be helpful as add-on
therapy66. Therefore until further research has been undertaken clinicians will need to continue
to consider each patient individually, taking into account the potential benefit of each therapy

weighed against the risk of adverse effects.

There is still probably a clear need for novel AEDs in childhood epilepsy. These must be
effective (preferably with a broad spectrum of action against a wide range of seizure types),
safe and be available in child-friendly formulation. However, while the advent of the new
AEDs should be welcomed, it is important to use the older, ‘conventional’ AEDs appropriately
and initially, particularly in view of the limited data on both monotherapy efficacy and long-
term safety for newer compounds. In this regard, it is common for a child to be falsely described
as being refractory to treatment because they have been prescribed the wrong drug for their
epilepsy syndrome. The classic example is the use of carbamazepine or oxcarbazepine for
juvenile-onset absence or juvenile myoclonic epilepsy, when it is known to exacerbate both