It is important to treat epilepsy for
several reasons. Untreated epilepsy places children at increased risk
of accidents, such as drowning, head injury from a fall, or choking.
Frequent seizures may create both social and academic disadvantages
for children.
Most seizures do not cause brain damage. Sometimes, however, it
can be difficult to control generalized seizures. Sometimes a child
having this kind of seizure will need intensive care to prevent brain
damage or death.
About 75 per cent of young children with epilepsy can control
their seizures by using one or more anticonvulsant medications.
Unfortunately, however, a significant number of chldren will continue
to have several seizures per day, even when they are using
medication. As a result, researchers are actively investigating new
medications and non-drug treatments for epilepsy.
Treatment Options
Anticonvulsant
Medications
The most commonly prescribed medications for
epilepsy in young children are listed below. Potential side effects, particularly those that affect development
and behavior, are reviewed. A neurologist usually helps the family
choose the best medication for a child's epilepsy.
With some medications, a child will need to have regular blood
tests to ensure that the blood level of the anticonvulsant drug is
within a therapeutic range. The level may be affected by recent
illness, other medications, and the child's nutritional status.
- Phenobarbital
Phenobarbital is one of the oldest and safest anticonvulsants
for children. It is most commonly used for infants and toddlers.
Initially, phenobarbital may cause drowsiness, but the child
usually develops tolerance to this side effect.
- Side effects
After several weeks or months of treatment, some children
may develop hyperactivity, aggression, and insomnia. These side
effects may respond to a decrease in dosage. However, some
children may need to stop taking this medication.
- Valproic Acid (Depakene, Depakote)
Valproic acid (Depakene or Depakote) is effective in treating
many childhood seizure disorders.
- Side effects
- Children taking valproic acid may exhibit appetite
increase and weight gain. Nausea and vomiting also have been
reported. The most serious adverse effect of valproic acid,
however, is liver failure.
At highest risk for liver damage are children:
- With mental retardation.
- Younger than 2 years of age.
- Who are taking several medications in addition to
valproic acid.
- In general, sedation and other symptoms of central
nervous system depression are not common as side
effects.
- Phenytoin (Dilantin)
In addition to its use as a daily anticonvulsant, phenytoin
(Dylantin) is often given intravenously in the emergency room to
stop an ongoing seizure.
- Side effects
Potential side effects include involuntary eye movements,
rashes, balance difficulties, weakened bones, nausea, and
drowsiness. Attention and memory problems can occur, but are
generally less severe than those associated with
phenobarbital.
- Overgrowth of the gums (gingival hyperplasia) can also be
associated with phenytoin use. Careful oral hygiene is
necessary to avoid infection, bleeding, and decay.
- Phenytoin may also affect a child's appearance. Effects
that concern families include:
- Growth of dark hair on the child's face and body
(hirsutism)
- Coarsening of the child's facial features
- Carbamazepine
Carbamazepine (Tegretol) is most often used for the treatment
of partial seizure disorders. It is a useful medication for
students because it seldom causes sedation or learning
problems.
- Side effects
The most serious potential side effect of carbamazepine is
neutropenia, which means that the body's white blood cell count
is very low. Children with neutropenia are at risk for
overwhelming infection. For this reason, children on
carbamazepine therapy should have periodic blood
tests.
- Felbamate
Approved by the FDA in 1993, Felbamate is effective against
many types of seizures. It is most often used in patients with
Lennox-Gastaut syndrome. These children are typically boys with
autistic symptoms and seizures resistant to drug therapy.
- Side effects
Common side effects include nausea, poor appetite, and
constipation. Central nervous system problems can include
insomnia, fatigue, balance problems, and aggression. As with
valproic acid, rare cases of liver failure have been reported
with the use of this drug. Bone marrow failure associated with
felbamate also has been reported. However, none of these cases
occurred in a child under 13 years of age
- Lamotrigine
Lamotrigine was approved by the FDA in 1994. Like Felbamate, it
is used with other medications, particularly in the treatment of
Lennox-Gastaut syndrome.
- Side effects
The side effects of this medication are generally mild. The
most common reason for stopping the medication is a rash, which
develops in about 3% of people who use Lamotrigine. Other, less
frequent side effects include headache, drowsiness, abnormal
eye movements, and balance problems.
- Topiramate
Topiramate was approved early in 2000 for use with other
medications as an adjunct treatment for seizures in children.
- Side effects
Potential side effects include loss of appetite, fatigue,
dizziness, and tingling in the hands and feet. Cognitive
effects may include problems with concentration and word
finding. Because there is a moderately increased risk of kidney
stones for children who use topiramate, they should be
encouraged to drink fluids.
Ketogenic
Diet
An older epileptic treatment, the ketogenic
diet is effective for some individuals with epilepsy. It is based on
the observation that depriving the body of carbohydrates promotes the
release of a class of blood chemicals, called ketones. Ketones can
help prevent some seizures.
Children must consume a diet composed largely of fat--the
ratio of fat to carbohydrates and protein is typically 4 to 1. Much
of the fat must be taken as heavy cream, mayonnaise, or butter. The
diet requires that the child's foods be weighed. The proportion of
nutrients must be calculated for each meal. Even the carbohydrate
content of the child's medications are taken into account. Strict
compliance is necessary for the diet to be effective.
Challenges related to the diet stem from its highly restrictive
nature. Many children don't like the foods, and as a result may eat
foods that they shouldn't. Families may also find food preparation
and monitoring to be a burden. Because the diet has a low fiber
content, constipation is common. Children on the diet also have an
increased (3%) risk of kidney stones.
Surgery
Occasionally, young children with intractable epilepsy are
candidates for surgery. The very young surgical candidate has
seizures of a frequency and severity to interfere with quality of
life and development. Seizures that respond well to surgery include
those that originate from a specific zone of the brain, rather than
from multiple areas.
Available surgical procedures range from removal of a
circumscribed portion of temporal lobe to hemispherectomy--removal of virtually half the brain. The long-term risks of surgical
removal of major brain structures need to be weighed against the
actual risks of ongoing intractable epilepsy. Infants seem to have a
better developmental outcome after surgery. They also, however, have
a higher mortality rate during and after the procedure than older
children.
Vagal Nerve Simulator
The vagal nerve stimulator is a small, battery powered electrical
device. It is implanted below the collarbone. In a cyclical fashion,
it delivers intermittent electrical signals to the vagus nerve. These
signals are then transmitted to the brain. Through a poorly
understood process, the signals inhibit seizures.
An attractive feature of the stimulator is that users can "pulse"
themselves by swiping a magnet across the implant site if they sense
the onset of a seizure. The resulting signal may abort or shorten the
episode.
The stimulator has been shown to reduce seizure frequency
substantially for some individuals with epilepsy. It is usually
intended only as adjunct therapy, and not as a replacement for
anticonvulsant medications.
- Side effects
Some users have complained of coughing or shortness of
breath.
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