Treatment of epilepsy in children and adolescents

Therapeutic strategies for treating epilepsy in childhood and adolescence markedly depend on the underlying electroclinical syndromes. In self-limiting epilepsies with focal seizures of genetic or unknown etiology, e.g. benign infantile seizures, rolandic epilepsy and Panayiotopoulos syndrome, a considerable number of patients may not require any pharmacological therapy but if they do, sulthiame, levetiracetam or oxcarbazepine should easily control seizures. Early application of corticosteroids should be considered in atypical forms, such as pseudo-Lennox syndrome, syndrome of continuous spike waves in sleep (CSWS) and Landau-Kleffner syndrome. Lamotrigine, slow release oxcarbazepine and levetiracetam are drugs of first choice for treating focal seizures in epilepsy of structural/ metabolic or unknown causes. Various antiepileptic drugs are available in case of difficulties in controlling seizures; however, the possibility of epilepsy surgery should be evaluated early in these cases. Ethosuximide is the first line drug in childhood absence while valproate is the most effective drug in juvenile absence epilepsy and juvenile myoclonic epilepsy. Because of the lower teratogenic risk an initial trial with lamotrigine, possibly combined with levetiracetam is justified in girls. Valproate, lamotrigine and ethosuximide are the most important options in myoclonic atonic epilepsy. In addition, a ketogenic diet is a promising option. While corticosteroids and vigabatrin should be administered for infantile spasms, valproate is the basis for different combinations in the treatment of Lennox-Gastaut syndrome. Efficacy of lamotrigine, topiramate, rufinamide, clobazam and felbamate has been shown in placebo-controlled randomized trials. Vagus nerve stimulation and ketogenic diets are further options. In cases of Dravet syndrome early treatment with either bromide or valproate in combination with clobazam and stiripentol should be established. Combinations of valproate, topiramate and bromide and ketogenic can be effective. In general, the increasing number of available anticonvulsants allows an individually optimized therapeutic strategy in many cases, considering gender, age, body weight, behavior and cognition. Maintaining the best possible development should always be a major issue in the treatment of childhood epilepsy.