Seizure Control in Kids - 2

What can trigger a seizure?
There are a number of common environmental triggers. The most well-recognized is fever, and very common in children, especially between about one and five years of age, a high fever can trigger a seizure. Under those circumstances it is called a febrile seizure. Almost all children with febrile seizures grow out of it, and they do not need treatment.

Other types of seizures can also be provoked by sleep deprivation, flashing lights, and, in older children, alcohol.



How do you diagnose epilepsy?
The most important aspect of diagnosing epilepsy is to take a good history from the family or the patient. The backbone diagnostic test for a patient with seizures or epilepsy is an EEG, which is a brain wave test. The EEG will provide more evidence, telling us what kind of seizure the patient is having, maybe where in the brain the seizure is coming from, and will also assist in deciding what kind of treatment would be best for that child.



What is the goal in managing epilepsy in children?
The primary goal is to completely control the seizures with medication. Based upon the clinical history and the kind of seizures that the patient has, in some patients, it's likely that you will have very good control of seizures, and in a period of time—two years, four years—and you will be able to stop the medication.

And then there is the group of patients who have seizures that are not easy to control with medication, due to the cause of the seizures, such as a scar in the brain. When you have a hard time controlling the seizures and they are coming from an identifiable area in the brain, there are alternative forms of treatment that may result in seizure cure. For example, you may be able render the patient seizure-free surgically.



What medications are available to treat epilepsy?
There really has been a dramatic change in the treatment of epilepsy over the last five to ten years with the advent of new medications. The older group of medications consists of very effective antiepileptic drugs, but they have a host of side effects. Whenever you use a medication for a problem in the brain, it's going to have the potential to affect other brain functions. So you may get an effect on cognition, or awareness and learning. You may get dizziness. You may get double vision. Depending on the child and on the medication, children may have problems with learning, they may have difficulty with sleeping or they may sleep too much, and they may be hyperactive or irritable or have behavioral problems. The newer agents are at least equally effective as the older medications, but there is a definite superiority with the newer agents with respect to safety and side effects.



What is the best strategy for treating epilepsy?
Everybody agrees that the initial treatment is monotherapy, which means using one drug to try and control the seizures completely. If that drug fails, in general, you will gradually replace it with another new second drug.

If that second drug fails, that's where the agreement over what to do varies. It varies because, number one, it depends upon the patient, the patient's seizure type and whether there is a lesion or something else causing the seizures. So you may then go to a third-line monotherapy or try using more than one drug at a time. Or, at that point, you might consider other options such as surgery or a device that is implanted in the brain called a vagal nerve stimulator, or even the ketogenic diet.



What is a ketogenic diet?
The ketogenic diet has been around since the beginning of the 20th century. The premise of the diet is that if you eat predominantly fat; the energy source that you get from the fat are ketones, and the ketones protect against seizures for reasons that we don't understand.



How can epilepsy affect children's activities?
I think the answer to how epilepsy can limit or does not limit your life is really an issue of common sense. I do not restrict patients in terms of what they can and can't do. But common sense would tell you that you don't want them to go mountain climbing, deep-sea diving or bungee-jumping. Now, can they play football? Absolutely. Can they play tennis? Can they go bicycling? Yes. Even if you look at driving, the driving law differs in different states, but in general if your seizures are well controlled and you've been seizure-free for more than six months, in many states you are eligible to drive under those circumstances.



What kinds of psychological and social issues can kids have?
I'm actually surprised at how well adjusted so many kids are who do have seizures. But one shouldn't underplay the severity to which it may affect socialization and other issues. The kind of issues that children encounter depends on the frequency of the seizures and the extent to which it affects them on a daily basis. In some children, especially those who have infrequent seizures, I think it has little impact on their lives. But in the children who have more frequent seizures, it begins to affect them socially because kids begin to see them as different. Sometimes, even if other kids don't see them as different, they perceive that that's the way they're seen.

In general, there's a complex interaction in terms of the psychological impact of epilepsy because, number one, they have something there that's causing the seizures that may affect them. Number two, they're on medications that can affect them as well from a psychological standpoint. And number three, they have the stigma of having epilepsy. But I actually think that over the years, there has been a general improvement in sophistication in terms of understanding epilepsy, and that the stigma of epilepsy has also lessened quite dramatically.