The Child Neurology Society of North America has about 1,800 members; subsequently, the ratio of child neurologist to each child in the United States is estimated to be 1:41,000.1 Therefore in the vast majority of cases, it is pediatricians who initiate treatment on patients with suspected neurological disorders and decide on whether the child would benefit from consulting with a neurologist. No condition exemplifies this dilemma more explicitly than a child with suspected seizures. In addition to the dramatic nature of the events, there is often a fear that a child with seizures may experience untimely death. This issue of Pediatric Annals has been tailored to address the issues of what seizures look like in children, what epilepsy syndromes are most likely to be encountered in clinical practice, what treatment modalities are currently available in the United States (pharmacological and otherwise), and provide information on paroxysmal spells that mimic seizures.
For example, “funny spells” in children can be a cause for concern in parents and care-givers. Such patients frequently end up being extensively investigated with a variety of imaging modalities and diagnostic procedures in search of the elusive abnormality when in reality the “spell” may be entirely physiological.
The first article, “Paroxysmal Nonepileptic Events in Infancy, Childhood, and Adolescence,” describes the nature of such spells and how in certain circumstances the physician can reassure the family that their child does not have seizures and that a neurological consultation can be deferred. Further, the article can provide guidance regarding investigations that can be completed prior to the neurologic visit to expedite the diagnosis.
When communicating with each other, physicians often use certain standard terms and this is also true of discussing the nature or “semiology” of a seizure. An epileptologist or neurologist will base his diagnosis to a large extent on such descriptions from pediatricians. Use of standard terminology can be helpful and can accelerate the diagnostic process. Steven M. Wolf, MD, and Patricia E. McGoldrick, NP, MPA, have provided a broad description of the different types of seizures in children using the terms used in the latest International League Against Epilepsy Classification.
Once it is certain that the spells the child is experiencing are seizures, it is common practice to attempt to classify them into an epilepsy syndrome. Such “lumping” may help to select appropriate pharmacologic agents, discuss prognosis regarding developmental outcome, and guide duration of treatment. It is also helpful in teaching physicians in training how to recognize benign epilepsy patterns from the more serious ones. Jun T. Park, MD, and Asim M. Shahid, MD, and Adham Jammoul, MD, outline the epilepsy syndromes most commonly encountered in clinical practice from the neonatal period through adolescence.
A wide variety of antiepileptic drugs are now available in the United States ranging from the time-tested “older” drugs such as phenobarbital and phenytoin to the more recent groups of medications that are targeted toward specific types of seizures or epilepsy syndromes. Ram Sankaraneni, MBBS, and Deepak Lachhwani, MBBS, MD, give a bird’s-eye view of the commonly used drugs, their indications, and drug interactions. We believe the tables provided will help a pediatrician obtain necessary information regarding monitoring and observation when he or she is caring for a child who has been prescribed one or many antiepileptic drugs. Gregory B. Sharp, MD, Debopam Samanta, MD, and Erin Willis, MD, give interesting insight into what many parents are curious about and may already be implementing—although they may not necessarily voice it, ie, “alternative” treatments for epilepsy.2 The ketogenic diet is now a well-validated modality of treatment for epilepsy as is the vagus nerve stimulator. However, much controversy still rages regarding the use of medical marijuana in childhood neurologic disorders. Parents are also interested in knowing the value of vitamins and herbs in the treatment of epilepsy. The article by Dr. Sharp’s group addresses these and other related issues in an evidence-based manner.
The diagnosis of epilepsy no longer carries the stigma it did in the past, and as physicians we have an obligation to ensure that these children are well integrated into society. We hope this issue will help the pediatrician be the source of accurate information for children with epilepsy and their families.
- Forum on Child and Family Statistics. www.childstats.gov. Accessed January 16, 2015.
- Doering JH, Reuner G, Kadish NE, Pietz J, Schubert-Bast S. Patterns and predictors of complementary and alternative medicine (cam) among pediatric patients with epilepsy. Epilepsy Behav. 2013;29(1):41–46. doi:10.1016/j.yebeh.2013.06.025 [CrossRef]