Childhood
epilepsies are a heterogeneous group of conditions that differ in diagnostic criteria and management and have dramatically different outcomes. Despite increasing data on treatment of
epilepsy, research findings on childhood
epilepsy are more limited and many clinical questions remain unanswered, so that clinicians must often rely on clinical judgment. In such clinical situations, expert opinion can be especially helpful.
METHODS: A survey on pediatric
epilepsy and
seizures (33 questions and 645 treatment options) was sent to 41 U.S. physicians specializing in pediatric
epilepsy, 39 (95%) of whom completed it. In some questions, the experts were asked to recommend overall treatment approaches for specific syndromes (the order in which they would use certain strategies). Most of the questions asked the experts to rate options using a modified version of the RAND 9-point scale for medical appropriateness. Consensus was defined as a non-random distribution of scores by chi-square test, with ratings used to assign a categorical rank (first line/usually appropriate, second line/equivocal, and third line/usually not appropriate) to each option.
RESULTS:
Valproate was treatment of choice for symptomatic myoclonic and
generalized tonic-clonic seizures except in the very young, with
lamotrigine and
topiramate also first line (usually appropriate).
Zonisamide was first line only if the child also has
myoclonic seizures. For initial monotherapy for
complex partial seizures,
oxcarbazepine and
carbamazepine were treatments of choice, with
lamotrigine and
levetiracetam also first line. As initial
therapy for
infantile spasms caused by
tuberous sclerosis, viagabatrin was treatment of choice, with
adrenocorticotropic hormone (
ACTH) also first line. As initial
therapy for
infantile spasms that are symptomatic in etiology,
ACTH was treatment of choice, with
topiramate also first line. As initial
therapy for
Lennox-Gastaut syndrome,
valproate was treatment of choice, with
topiramate and
lamotrigine also first line. For acute treatment of a prolonged
febrile seizure or cluster of
seizures, rectal
diazepam was treatment of choice. For
benign childhood epilepsy with centro-temporal spikes,
oxcarbazepine and
carbamazepine were treatments of choice, with
gabapentin,
lamotrigine, and
levetiracetam also first line. For
childhood absence epilepsy,
ethosuximide was treatment of choice, with
valproate and
lamotrigine also first line. For
juvenile absence epilepsy,
valproate and
lamotrigine were treatments of choice. For
juvenile myoclonic epilepsy in adolescent males,
valproate and
lamotrigine were treatments of choice, with
topiramate also first line; for
juvenile myoclonic epilepsy in adolescent females,
lamotrigine was treatment of choice, with
topiramate and
valproate other first-line options. As initial
therapy for neonatal
status epilepticus, intravenous
phenobarbital was treatment of choice, with intravenous
lorazepam or
fosphenytoin also first line. As initial
therapy for all types of pediatric
status epilepticus,
lorazepam was treatment of choice, with intravenous
diazepam also first line. For generalized tonic-clonic
status epilepticus, rectal
diazepam and
fosphenytoin were also first line; for
complex partial status epilepticus,
fosphenytoin was also first line; and for
absence status epilepticus, intravenous
valproate was also first line.
CONCLUSION: The expert panel reached consensus on many treatment options. Within the limits of expert opinion and with the understanding that new research data may take precedence, the experts' recommendations provide helpful guidance in situations where the medical literature is scant or lacking. The information in this report should be evaluated in conjunction with evidence-based findings.