Rationale for treating epilepsy in children

Growing evidence indicates that the effects of antiepileptic drugs on childhood epilepsies are partly linked to the specific type of epilepsy or epilepsy syndrome. Most (but not all) types of epilepsy can be classified into categories that are conceptually meaningful. It is likewise logical to set treatment targets and to estimate the risks according to the main syndromic groups, as they share common, electroclinical presentations and long-term prognosis. Treatment should then be adjusted to each patient's clinical characteristics. Treatment should be started soon, whenever there is indication that delay would harm the child. However, if seizures are not disabling, treatment may be delayed, in order to acquire more knowledge about the spontaneous expression of the disorder and the plan thoughtfully explained to the parents. In children presenting with partial symptomatic or cryptogenic epilepsy, it is important to assess the patient's response to several different drugs. However, in patients regarded as having refractory epilepsy, possibilities for a surgical solution must be evaluated early in the course of the disease. In severe epileptic encephalopathies, complete seizure control is impossible and, ideally, treatment should provide as much integration and autonomy, with alleviation of frequent seizures. Again, this should be carefully explained to the parents. In children with severe epileptiform EEG abnormalities coexisting with brain dysfunction (diffuse or specific), the extent of EEG-related neurological dysfunction should be determined, and vigorous treatment should be started to abate its effects. Finally, seizures could be worsened by inappropriate drugs, paradoxical reaction or intoxication. Severe childhood epilepsies are particularly at risk and mild idiopathic epilepsies may be transformed into severe disorders, priming a vicious circle of heavy treatment, whereby the original disorder is no longer recognizable.