34 HOW TO TREAT : CHILDHOOD EPILEPSY
34 HOW TO TREAT : CHILDHOOD EPILEPSY
12 JULY 2024 ausdoc . com . au
Figure 11 . Types of epilepsy surgery .
evidence to guarantee the safety of a person experiencing seizures by using commercially available seizure monitors and alert devices .
The decision to use a device is individualised . They may provide peace of mind for some families ; however , the patient and the family must understand that the device may not detect all seizures and there may be false alarms .
Epilepsy nurse specialists
Epilepsy nurse specialists are an integral part of the epilepsy management team in tertiary children ’ s hospitals in Australia .
They perform several critical roles . These include providing patient and family education and support , supporting epilepsy specialists and other healthcare professionals involved in the care of children with epilepsy and acting as a point of contact for families and other healthcare providers . 37
Transition of care from paediatric to adult services
Planning for transition from paediatric to adult healthcare services should start early and involve the young person with epilepsy .
The transition process may provoke feelings of anxiety and distress in the young person and their family . 49 Discussing and addressing the young person ’ s concerns are essential . These may include driving , participation in sports , ASM , education , career , emotional and psychological health , comorbidities , alcohol and illicit drug use , reproductive health , sleep and living away from family .
Ideally , a joint paediatric and adult multidisciplinary team review is required during the transition process . 37
ROLE OF THE GP
EPILEPSY is a common neurological disorder of childhood , often accompanied by other comorbidities , and
How to Treat Quiz . impacts on the child and family ’ s lives . Given the prevalence of epilepsy in the paediatric population , without the GP , paediatric specialists would struggle to provide patients and their families with the care they require and deserve .
The role of the GP in the care of a child with epilepsy includes referring all paediatric patients with suspected epilepsy to a paediatrician or paediatric neurologist , regular monitoring of the patient , and identification and treatment of comorbidities , as well as advocating for and supporting the patient and their family .
FUTURE DIRECTIONS
THE past few decades have seen tremendous progress in the genetics around epilepsy . Almost 1000 genes have been demonstrated to be associated with epilepsy , heralding the hope for precision medicine targeting the
50 , 51 underlying genetic aetiology . Less invasive surgical approaches ,
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1 . Which THREE statements regarding epilepsy are correct ? a Those under the age of five have the highest incidence of epilepsy . b An epileptic seizure is a result of abnormal and excessive , synchronous neuronal discharges in the brain . c Specific conditions must be fulfilled to make the diagnosis of epilepsy . d Epilepsy is uncommon .
2 . Which TWO statements regarding the aetiology of epilepsy are correct ? a A cause is not identified in most children who have epilepsy . b There is a range of immunemediated CNS disorders in which seizures are a core symptom . c Epilepsy from metabolic causes generally responds well to anti-seizure medication ( ASM ). d One gene may cause a spectrum of disease , and one clinical syndrome may result from different genes .
3 . Which THREE statement regarding febrile seizures are correct ? a Approximately a third of children with a febrile seizure will have another febrile seizure . b Febrile seizures warrant regular ASM . c An EEG and neuroimaging are not warranted in a neuro- logically normal child with a simple febrile seizure . d A febrile seizure confers a slightly higher risk epilepsy compared with the general population .
4 . Which THREE statements regarding the investigation of a seizure are correct ? a A normal EEG excludes epilepsy . b MRI is the modality of choice where imaging is indicated . c A negative genetic test does not mean the individual does not have a genetic epilepsy . d A 12-lead ECG is indicated as part of the evaluation of a person with a suspected first seizure to identify cardiac mimics .
5 . Which THREE statements regarding common seizure mimics are correct ? a The prognosis of breathholding attacks is excellent . b Daydreaming can be terminated with tactile stimulation . c Psychogenic non-epileptic seizures most commonly occur in older adolescent females . d Recovery after syncope is typically slow and prolonged .
6 . Which TWO statements regarding epilepsy are correct ? a Seizure type is classified by onset into focal , generalised or unknown . b A higher prevalence of ADHD and autism spectrum disorder has not been demonstrated in children with epilepsy . c All children with a SeLFE will require ASM during childhood . d Several common childhood epilepsy syndromes are described .
7 . Which THREE form the classical triad in infantile spasms syndrome ? a Epileptic spasms . b Associated with fever . c Developmental plateauing / regression . d Hypsarrhythmia .
8 . Which THREE statements regarding childhood epilepsy syndromes are correct ? a Sodium-channel medications are indicated as first-line therapy in Dravet syndrome . b Lennox – Gastaut syndrome is a medically refractory epilepsy with onset before the age of 18 .
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CHILDHOOD EPILEPSY
such as LiTT , have enabled access to seizure-causing lesions not amenable to typical surgical resective approaches . While there is limited experience in epilepsy surgery , the authors are hopeful this will increasingly be utilised and offer hope for a potential cure for patients previously not suitable for other epilepsy surgery techniques .
CASE STUDIES
Case study one
LILY , an eight-month-old girl , is brought to the GP by her concerned parents . They report a history of about one week of “ funny movements ”, where Lily seems to do “ abdominal crunching ” a few times in a row as she drifts off to sleep or soon after waking . The episodes cause her to cry .
Her development is normal , but she has been more irritable and less interactive since the movements started . The pregnancy and birth
c SeLFEs are responsible for 25 % of epilepsies in childhood . d Those with idiopathic generalised epilepsies have a higher rate of comorbid mood disorders , ADHD and learning disabilities compared with the general population .
9 . Which TWO statements regarding the management of epilepsy are correct ? a ASM is the mainstay of epilepsy treatment . b Ethosuximide is an appropriate single agent to use in an individual with absence seizures and generalised tonic – clonic seizures . c Cannabidiol is a safe and effective alternative in all forms of childhood epilepsy . d Sodium valproate or lamotrigine are first-line in tonic or atonic seizures .
10 . Which THREE statements regarding the management of epilepsy are correct ? a Surgery may offer a cure or reduce seizure frequency or severity . b Sudden unexpected death in epilepsy is the most common epilepsy-related cause of death . c Commercially available seizure monitors and alert devices are recommended in all patients . d Planning should start early for the transition of care from paediatric to adult services . were normal , and there is no significant family history .
Examination is normal . Head circumference is measured and found to be tracking along the 25th centile since birth . There are no birthmarks . The history is concerning for infantile spasms and warrants urgent paediatric neurology review
Lily is urgently referred for sameday review and EEG , demonstrating modified hypsarrhythmia . She is admitted to hospital and started on prednisolone . Investigations for a cause ( MRI , metabolic testing and genetic testing ) are negative .
The spasms stop after two days of treatment . Longer-term follow-up demonstrates normal development and no recurrence of spasms .
Case study two
Anna , a 14-year-old girl , attends her GP with her parents three days after being discharged from the local ED after her first generalised tonic – clonic seizure . History reveals early-morning clumsiness ( accidentally spilling milk and dropping her spoon ). She has no other concerns . There is no family history of epilepsy .
Her history is suggestive of juvenile myoclonic epilepsy with early morning myoclonic jerks . The GP asks about symptoms suggesting comorbid psychiatric , attention or learning problems ; none are present . Examination is normal .
The GP provides seizure safety and first-aid advice with written information for Anna and her family . The GP refers Anna for an EEG and paediatric review within the next four weeks . The EEG demonstrates generalised spike-and-wave discharges and a photoparoxysmal response consistent with juvenile myoclonic epilepsy .
Anna is reviewed by the paediatrician and started on lamotrigine .
CONCLUSION
EPILEPSY is the most common neurological disorder in paediatric patients . As such , the GP is a key member of the multidisciplinary team required to provide high-quality care to these patients .
Paediatricians and paediatric neurologists are reliant upon the patient ’ s GP to refer patients to further specialist care , help monitor effectiveness and side effects of therapy , identify and manage comorbidities and advocate for the patient and their families .
RESOURCES
• Paediatric Epilepsy Network NSW pennsw . schn . health . nsw . gov . au — Epilepsy management plans bit . ly / 49AOgLp
• Epilepsy Action Australia epilepsy . org . au — Epilepsy and risk bit . ly / 3SDncV5 — Online tools / resources bit . ly / 3SDJsyj — Epilepsy products bit . ly / 3wpHHNq
• International League Against Epilepsy ilae . org
• Australian Genomics australiangenomics . org . au
• Austroads website austroads . com . au
References Available on request from howtotreat @ adg . com . au