Epilepsia

BMJ 1997; 315 : 924 (Published 11 October 1997)
Clinical Review
Fortnightly review: Epilepsy in childhood
B G R Neville, professor of paediatric neurologya
+ Author Affiliations
a Neurosciences Unit, Wolfson Centre, Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, University College London Medical School, London WC1N 2AP, and St Piers, Lingfield, Surrey 
Next Section
Introduction
Childhood epilepsy requires integrated medical, educational, and community services, and its treatment spans acute and disability medicine.
There are many childhood epilepsies, and seizures are the commonest paediatric neurological symptom. Epilepsy—that is, susceptibility to continuing seizures—occurs in 0.5-1.0% of the population and is intractable to currentantiepileptic drug treatment in 20-25%. Epileptic seizures, including febrile convulsions, occur in 3-5% of children. Epilepsy starts in childhood in 60% of cases, and most of the clinically significant aspects of the disease occur during childhood.1
Previous SectionNext Section
Method
I chose the studies on which I have based my review because they support the development of clinical guidelines.The six crucial clinical issues are:
Identifying non-epileptic seizure syndromes
Identifying benign epilepsy syndromes with a comitemtively good outcome
Identifying malignant syndromes in which continuing and increasing disabilities occur and need detailed investigation, aggressive treatment, and research
Identifying, assessing, and managing the four major disabilities that result from earlybrain damage or dysfunction and commonly coexist—epilepsy, motor disorder (cerebral palsies), cognitive disability, and psychiatric disability—particularly for the many epilepsy syndromes that start in the first two years of life
Ensuring that antiepileptic drugs are used in an ordered fashion with audit of results
Anticipating and managing status epilepticus.
Summary points
Identifynon-epileptic attacks
Identify benign and malignant syndromes
Use predicted prognosis to guide management
Identify and manage coexisting disabilities
Ensure multidisciplinary and multiagency coordination of treatment
Select cases amenable to surgery as soon as possible
Previous SectionNext Section
Non-epileptic attacks
Non-epileptic attacks include simple blue breath holding attacks, white reflexasystolic attacks, reflex syncope, benign paroxysmal vertigo, benign myoclonus of infancy, vasovagal attacks, sleep phenomena, pseudoseizures, and Munchhausen syndrome by proxy. There are more than 20 such syndromes, identified by specific clinical characteristics2 and the setting in which they occur, particularly the provoking factors.
Simple blue breath holding attacks, usually after the ageof 6 months, provoked by frustration or other upset, consist of a positive Valsava manoeuvre, cyanosis, stiffening, and coma. White reflex asystolic attacks may start earlier, usually follow minor injury, and consist of vagal asystole, pallor, rapid coma, stiffening, and opisthotonos. Faints while standing or sometimes from sitting are usually well recognised. All three conditions may beaccompanied by late true epileptic phenomena of jerking secondary to cerebral hypoxia or ischaemia, but their natural history remains self limiting and harmless like that of the first episode. Such episodes are, however, frightening for carers.
Non-epileptic attacks may be misdiagnosed and treated with antiepileptic drugs, the attacks tending to persist despite treatment and good prognostic features (seetable 1).
View this table:
In this window
In a new window
Table 1
Good and adverse prognostic features for outcome of epilepsy
Previous SectionNext Section
Management of epilepsy
The principles of management of epilepsy fall easily into a problem oriented approach:
Take detailed description of seizures
Draw up a problem list and include some assessment of cognition
Clarify the...