Hirsutism, gingival hyperplasia, and rash are adverse effects associated with _____.

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 percent of young children with epilepsy can control their seizures by using one or more anticonvulsant medications. Unfortunately, however, a significant number of children 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
• Ketogenic diet
• Surgery
• Vagal nerve stimulator

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 percent) 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 stimulator

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.

Dianne McBrien, MD

Peer Review Status: Internally Peer Reviewed

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