Educationals

Such issues are often overlooked. These would be different in different situations. For example an adolescent who wants to drive may want AED control of even a single generalized seizure while a young infant/child with infrequent seizures in a supervised home environment may be spared the toxic effects of long term AEDs. Often unnecessary restrictions are placed on the child by the parents, sometimes on the advice of the physician. This leads to overprotection by the parents, loss of self-esteem and overdependance in the child, etc which becomes more of a problem than the seizures themselves. Often we forget the impact of this diagnosis on the family. Parents become overanxious and sometimes sit up all night looking for any slight twitch, which is then reported to the doctor who increases the AEDs dosage in a knee jerk reaction. Sibs often feel neglected and resentful. This complete disruption of family dynamics is often not communicated to the physician in the busy consulting room. As physicians we should reassure parents about the benign nature of most childhood epilepsies and downplay the seriousness of the more difficult to control epilepsies without compromising on the truth. In the intractable and serious epilepsies the author

Who Needs Treatment?

Does treatment alter natural history?
The answer to the first question has changed as the natural history of the various epilepsy syndromes has been delineated and the adverse effects of the various AEDs elucidated more fully. The impact of seizures varies a great deal depending on patient age, type and timing of seizure, frequency of attacks and most important the family's and sometimes the child's attitude and reaction to the illness.

This questions is most relevant for three groups of patients:
those with

• a first seizure
• acute symptomatic seizures and
• benign epilepsy syndromes in childhood.
  

First seizures

Historically, seizures were thought to beget more seizures and hence were always treated as soon as the diagnosis was made.

This concept has changed radically and several studies have shown that AEDs do not alter the natural history or prognosis of epilepsy-they have no effect on epileptogenesis, only on recurrence rates.

This discussion is not applied to myoclonic or absence seizures as by the time medical help is sought many seizures have already occurred. The same may apply in convulsive first seizures. Often on history minor complex partial episodes preceding the first generalized convulsive seizure may have been missed by the patients and/or parents. In those with the true first seizure several studies have shown relapse rates as low 23% to as high as 71%. This is not surprising, as epilepsy being a heterogeneous disorder, the relapse rate would differ between different groups. The most consistent risk factors across studies predicting recurrence are

• abnormal epileptiform EEG
• presence of underlying etiology i.e. symptomatic seizures.
  

The risk is lowest (24%) with idiopathic seizures with normal EEG, intermediate (48%) with either abnormal EEG or with underlying etiology and highest (65%) when both risk factors are present.

Other less consistent risk factors include :

• sleep related seizures
• positive family history
• partial as opposed to generalized seizures. Gender and status epilepticus are not associated with an increased risk of recurrence. Age at onset of seizures may be relevant as a recent study of first seizures in Italy found higher rates in children & adolescents, as opposed to adults.
  

In summary, the overall risk of recurrence of a first seizure is about 38%. An abnormal EEG and symptomatic first seizures have higher relapse rates and if present, make many physicians inclined to treat. In our situation many a normal pediatric EEG is often misinterpreted as `abnormal' and this should be considered before reaching a decision.

Acute symptomatic seizures

As mentioned earlier, these lead to chronic epilepsy in only 10- 15% and AEDs do not influence this from happening. This process of epileptogenesis takes from a few months to a few years to develop. This was well studied using phenytoin `prophylaxis' in patients with significant head trauma. It was found that phenytoin is useful in preventing recurrence in only the first week after the trauma and did not influence the development of epilepsy. It is therefore recommended that all acute symptomatic seizures be treated either with short term AEDs till such time that the acute event is resolved. This usually means discontinuing the AEDs at discharge or within a few months.

Benign epilepsy syndromes

In childhood these are age-limited time-bound disorders with natural resolution within a few years of onset in the majority.

They include febrile seizures, benign partial epilepsies with centrotemporal spikes (BECTS) and with occipital paroxysms (BEOPS). The latter often have very abnormal EEGs that do not necessarily correlate with occurrence of clinical seizures. Often these syndromes have only infrequent recurrences, many of them at night. Also many children are young and parental supervision is already in place. These various factors lead most neurologists to suggest a withholding of treatment after the first or even subsequent seizures.

In clinical practice other non medical factors often influence decision making. Parents may be very anxious or may be working and hence want immediate treatment. Sometimes medical help is far away as in rural areas and may influence this decision. Also some patients, especially teenagers want treatment as they want to drive etc.

In case no treatment is given parents should be instructed on how to use rectal diazepam in case of a recurrence. As the maximum risk is within one year, it is reasonable to supervise or restrict activities like swimming, cycling on the road driving for this period.