SYMPOSIUM: NEUROLOGY
New developments in
epilepsy management
Adeline Ngoh
Alasdair PJ Parker
Abstract
The management of epilepsy has developed rapidly in the 21st cen-
tury, with scientic and technological development providing better
means of studying brain structure and function and improving
outcome. Since the human genome was sequenced, molecular ge-
netic technologies have developed at an astounding pace, acceler-
ating discovery of disease-causing genes, giving insight into
biological pathways and mechanisms underlying epilepsy and, paving
ideas for more targeted therapies. In addition, increasing sophisticat-
ion in structural and functional neuroimaging; and advances in neuro-
physiological techniques have improved our understanding of brain
development, the organization of neural function and neuronal net-
works; contributing to increasing success in surgical and other non-
pharmacological therapies. We highlight key recent developments of
which paediatricians treating children with epilepsy should be aware.
Keywords Epilepsy; management; paediatric
Introduction
Epilepsy is no more divine than any other disease. It is he-
reditary. Its cause lies in the brain, the releasing factors of the
seizures are cold, sun and winds which change the consistency
of the brain. Therefore epilepsy can and must be treated not by
magic, but by diet and drugs Hippocrates.
It is a testament to Hippocrates acumen that many of his per-
ceptions have been found to be true today.
Denitions
The Oxford dictionary defines a seizure as a sudden attack of
illness. In 2005, a Task force of the International League Against
Epilepsy (ILAE) defined an epileptic seizure as a transient
occurrence of signs and/or symptoms due to abnormal excessive
or synchronous neuronal activity in the brain. Epilepsy was
defined as a disorder of the brain characterized by an enduring
predisposition to generate epileptic seizures and the
Adeline Ngoh MBBS MRCPCH is a Paediatric Neurology Clinical
Research Fellow at Neurosciences Unit, University College London,
Institute of Child Health, London, UK. Conict of interest: none
declared.
Alasdair PJ Parker MBBS MRCP MD MA PG Cert E is a Consultant
Paediatric Neurologist and Associate Lecturer at Addenbrookes
Hospital, Cambridge University Hospital NHS Trust, Cambridge, UK.
Conict of interest: none declared.
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neurobiologic, cognitive, psychological and social consequences.
This definition is typically applied when a child has two unpro-
voked seizures 24 hours or more apart.
This has been amended to acknowledge circumstances where
there is high risk of further seizures after a single unprovoked
seizure. The ILAE now describes epilepsy as a disease of the
brain defined by any of the following conditions: (1) At least two
unprovoked (or reflex) seizures occurring more than 24 hours
apart; (2) one unprovoked (or reflex) seizure and a probability of
further seizures similar to the general recurrence risk (at least
60%) after two unprovoked seizures, occurring over the next 10
years; and (3) diagnosis of an epilepsy syndrome.
Epilepsy is not a single disorder, but a group of disorders. A
comprehensive system of organization and classification is
essential, as different epilepsies require different management.
Classication/concepts and terminology
The thrust of the current (2010) revision of the concepts, termi-
nology and approaches is to avoid using terms such as crypto-
genic or benign- that were either misunderstood or
misleading. Figures 1 and 2 outline systems for the classification
of seizures/epilepsies respectively; along with recent proposed
revisions. Information regarding currently recognized epilepsy
syndromes can be found in the diagnostic manual section of the
ILAE website, along with useful videos of various seizure types-
https://www.epilepsydiagnosis.org/index.html.
Diagnosis/investigations
Establishing if an event/seizure is epileptic is based on an ac-
curate description. Normally no specific investigation is required.
Smart phones enable witnesses to video paroxysmal events
relatively easily. Home videos are considerably more reliable in
picking up semiological signs than history provided by wit-
nesses, and they can contribute significantly to seizure classifi-
cation. Guidance for the public on how to take home videos of
seizures is available for download on various websites including
the Epilepsy Society website (https://www.epilepsysociety.org.
uk).
The National Institute of Clinical Excellence (NICE) recom-
mends that the diagnosis of epilepsy requires that seizure type,
epilepsy syndrome and any other underlying cause are
determined.
The role of clinical investigations in epilepsy, therefore,
chiefly lies in: (i) assisting a clinician in identifying electroclinical
syndromes and seizure/epilepsy classification; and (ii) deter-
mining the aetiology of a patients epilepsy.
Electroencephalogram (EEG)
The EEG plays an important role in the identification of electro-
clinical syndromes and classification of the epilepsies: guiding
investigations for an underlying aetiology.
NICE guidelines for diagnosis and management of the epi-
lepsies offer useful guidance on the use of EEGs.
Genetic investigations
Comparative Genomic Hybridization (CGH) arrays and single
nucleotide polymorphism (SNP) arrays, collectively known as
chromosome microarrays, detect copy number variants (CNV)-
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 SYMPOSIUM: NEUROLOGY
Figure 1 Classication of seizures e 2010. *2016 proposed revisions are presented in green boxes; these are still undergoing discussion and have
not been nalized.
deleted or duplicated regions of DNA. CNVs can be part of
normal variation in the human genome, but are also an impor-
tant cause of many neuro-cognitive disorders including epilepsy.
Microarray testing is now a routine diagnostic investigation
for children with epilepsy, particularly those with additional
features such as developmental delay, neuropsychiatric symp-
toms or dysmorphia. In a recent study of an unselected cohort of
805 patients with epilepsy, 5% had a pathogenic CNV explaining
the epilepsy phenotype.
Next generation sequencing (NGS), also known as massively
parallel or high-throughput sequencing, allows analysis of mil-
lions of short fragments of DNA simultaneously. Compared to
traditional Sanger sequencing e one DNA fragment at a time,
this radically reduces the time taken to analyse large quantities of
DNA. Currently, NGS main clinical utility lies in gene panels and
whole exome sequencing.
The collection of genes identified to be associated with epi-
lepsy grows almost daily. A single phenotype can be caused by
several different genes (heterogeneity) and mutations in a single
gene can bring about several different phenotypes (pleiotropy),
making it difficult for a paediatrician to pin-point a single gene
for any given phenotype. Apart from distinct phenotypes where
one gene accounts for the majority of cases (e.g. 80% of in-
dividuals with Dravet Syndrome have a mutation in the gene
SCN1A) testing and excluding a single gene at a time may be
neither time nor cost effective.
Gene panels analyse a set of genes that are known to account
for a given condition or set of conditions, simultaneously.
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Epilepsy gene panels vary amongst different diagnostic labora-
tories in the range of electroclinical syndromes/phenotypes they
cover. The clinician selects the appropriate one for his/her pa-
tients phenotype. Epilepsy gene panels have proven diagnostic
utility. One study analysing 46 genes with a combination of an
NGS platform and microarray copy number analysis in 400 pa-
tients with early onset epilepsy or developmental delay, identi-
fied causative mutations in 18% of children (39% in those with
seizure onset before 2 months of age). In only a small proportion
of cases, were clinicians able to name the candidate gene accu-
rately prior to testing. In many, the phenotype was not typical of
those previously reported, underscoring the advantage gene
panels have over individual gene testing.
Whole exome sequencing (WES) analyses all the exomes
(protein-coding regions) in the genome, whilst whole genome
sequencing (WGS) includes non-coding regions, enabling the
identification of variants in non-coding regulatory regions.
Whilst many diagnostic laboratories now offer clinical WES,
WGS, is still largely carried out on a research basis.
Due to the vast number of variants identified through this
technique, analysis of WES/WGS data is challenging. Often, a
diagnostic laboratory would only report previously published
variants that are known to be pathogenic and in genes previously
associated with the phenotype in question. It is therefore essen-
tial for the paediatrician to describe the phenotype as accurately
as possible.
Some propose establishing a genetic aetiology may not
significantly alter treatment options. However, a genetic
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 SYMPOSIUM: NEUROLOGY

Figure 2 An approach to the classication of epilepsies as proposed by Berg et al 2010. *2016 proposed revisions are presented in green boxes;
these are still undergoing discussion and have not been nalized. To place a patients epilepsy in the appropriate classication, the clinician is
advised to consider if the presenting features e age, seizure semiology, electroencephalogram ndings are compatible with a recognized elec-
troclinical syndrome or a distinct epilepsy constellation, or if the aetiology can be identied.

diagnosis can spare a child and family more invasive in-
vestigations such as lumbar punctures and skin/muscle biopsies.
Families also often value having a definitive diagnosis. Some
may secretly believe they are to blame for their childs difficulties
e perhaps due to an innocuous incident during pregnancy, a
superstition, or a minor accident, and a definitive genetic diag-
nosis can provide some reassurance. Furthermore, establishing a
genetic diagnosis facilitates genetic counselling/risk of recur-
rence. Lastly, specialists spend time reviewing aetiology at most
patient contacts, identifying the underlying cause allows greater
emphasis on management.
Neurometabolic investigations
Although metabolic disorders only very rarely present with epi-
lepsy, these are less rare in infancy, in instances where there is
developmental regression/progressive neurodegeneration, or
when co-morbidities involving other organs/systems occur.
Some metabolic epilepsies respond only to specific therapies, e.g.
pyridoxine dependency is often refractory to treatment with
standard anti-convulsants, but responds well to treatment with
pyridoxine. Similarly, children with GLUT1 deficiency syndrome
often do not respond to pharmacological therapy, but can ach-
ieve seizure control and better neurodevelopmental outcomes on
the ketogenic diet. For a number of children, genetic testing may
supersede neurometabolic investigations, e.g. if a causative
mutation is found in SLC2A1-suggesting GLUT1 deficiency,
lumbar puncture may be avoided. However, the reverse may not
be true. If a child has a clinical presentation suggesting GLUT1
deficiency, the disorder cannot be excluded by a negative
SLC2A1 gene test (10% of children with a clinical phenotype
consistent with GLUT1 do not have an SLC2A1 mutation detec-
ted, but may still respond favourably to the ketogenic diet). It is
possible that patients may have a significant variant in non-
coding regulatory regions, not covered in standard gene panels
or WES.
Neuroimaging and investigations for epilepsy surgery
Magnetic resonance imaging (MRI) remains the imaging modal-
ity of choice for children with epilepsy. The yield of imaging has
improved significantly. Specific imaging protocols and advances
in MRI technology, including 3 Tesla MRI, fluid attenuated
inversion recovery (FLAIR) imaging, and more sophisticated
methods of analysis such as voxel-based algorithms and curvi-
linear multiplanar reformatting, have enabled the identification
of previously undetected subtle epileptogenic lesions (e.g. occult
focal cortical dysplasiae).

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 SYMPOSIUM: NEUROLOGY

The indications for epilepsy surgery have broadened. Whilst it

was previously felt that only children with a localized or later- New AED
alized epileptogenic focus would benefit from surgery, it is now Drug Mechanism of Approved Common side
recognized that at times, even children with multiple epilepto- action indication within effects
genic foci, e.g. a multifocal cortical dysplasia, can benefit from the European
having the most epileptogenic lesion resected. Union
The ILAE recommend all children with drug resistant epilepsy
should promptly be referred for assessment at a tertiary epilepsy Stiripentol Enhancement of Adjunctive Nausea, anorexia,
specialist centre, usually including consideration of epilepsy sur- GABA-ergic therapy of behavioural
gery. The main objectives of epilepsy surgery assessment are to transmission refractory difficulty
identify brain regions that need to be resected, ablated or discon- generalized tonic- (aggression,
nected to maximize the chances of seizure control, and the impor- clonic seizures in hyperactivity,
tant brain regions that need to be preserved in order to minimize the conjunction with irritability),
risk of post-surgical neurological or cognitive deficits. valproate and weight loss, sleep
The last decade has introduced several innovations that have clobazam, for disorders,
refined our abilities to achieve the objectives of pre-surgical patients with hyperkinesia,
assessment. Stereoelectroencephalography (SEEG)- recording Dravets hypotonia
intracranial EEG through minimally invasive, robotic-assisted syndrome
stereotactic depth electrode placement, enables precise map- Perampanel Selective non- Adjunctive Fatigue, weight
ping of epileptogenic zones without the need for large invasive competitive therapy of focal increase,
craniotomies. Resting functional MRI identifies eloquent brain AMPAa receptor seizures in behavioural
regions and analyses neuronal connectivity without the need for antagonist patients aged 12 difficulties,
patients to perform tasks. years or above suicidal ideation
Rufinamide Voltage- Adjunctive Sedation, nausea,
Immune investigations dependent therapy of Lennox vomiting, weight
Immune investigations are now an important consideration, sodium channel eGastaut loss, skin rash
particularly for children with acute onset, difficult to treat epilepsy, antagonist syndrome in
with encephalopathic/neurodegenerative features. Some autoan- patients aged 4
tibodies such as anti N-methly-D aspartate (NMDA) receptor an- years or above
tibodies bring about acute encephalitis, with difficult to treat Lacosamide Enhances the Adjunctive Diplopia,
epilepsy as their primary presentation. In addition, anti NMDA- slow inactivation therapy of focal dizziness,
receptor antibodies and other antibodies including those associ- of voltage seizures with or headache and
ated with gamma-amino-butyric (GABAA and GABAB) receptors, dependent without evolution nausea
voltage gated potassium channels (VGKC), glutamic acid decar- sodium channels to generalized
boxylase (GAD), leucine-rich glioma inactivated 1 protein (LGI1), convulsive
and contactin-associated protein-2 (Caspr2) have been identified seizures in
in association with various other types of epileptic disorders such patients aged 16
as limbic encephalitis and fever induced refractory epilepsy in years and above
school-aged children (FIRES), a newly recognized epilepsy syn- a
a-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid.
drome, that starts with febrile status epilepticus, then evolves into
pharmaco-resistant seizures alongside neurodevelopmental Table 1
regression and behavioural difficulties.

receive carbamazepine, gabapentin, lamotrigine, topiramate or

Treatment
Pharmacological therapy
For most children anti-epileptic drugs (AED) would be the first
line of treatment, there are over 20 available including ones with
novel mechanisms of action introduced within the last decade
(Table 1).
Key trials include SANAD (Standard and New Anti-Epileptic
Drugs) e a national study with 90 centres participating across
the United Kingdom. SANAD recruited adults and children aged 5
years and above with a well-documented history of two or more
clinically definite unprovoked epileptic seizures within the last
year, for whom treatment with a single AED was felt to be the
optimal treatment option.
When the treating clinician deemed carbamazepine was the
optimal standard drug (Arm A), patients were randomized to
oxcarbazepine, and when clinicians chose valproate (Arm B),
patients were randomized to valproate, lamotrigine or topiramate.
Arm A (1,721 patients) in which 88% of patients had focal
epilepsies, and 10% had unclassified epilepsy, concluded that
carbamazepine and lamotrigine were superior to the other drugs.
Lamotrigine was more tolerable. Carbamazepine had better ef-
ficacy e lowest treatment failure due to inadequate seizure
control, shorter times to 1/2 year remission, and longer time to
first seizure. However, these differences were deemed small
enough to infer non-inferiority for lamotrigine.
Arm B (716 patients) in which 63% had generalized and 25%
unclassified epilepsies found that valproate was more efficacious
and tolerable than topiramate or lamotrigine.
Apart from SANAD, there have been a few smaller scale trials.
Overall, there is no convincing evidence to suggest that the

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 SYMPOSIUM: NEUROLOGY
newer generation drugs are significantly superior to the older
AEDs in terms of efficacy. Nonetheless, the newer generation
drugs may each have distinct profiles with advantages such as
better pharmacokinetic properties without enzyme induction.
This justifies their use in selected patients.
We refer the reader to the NICE guidelines for the diagnosis and
management of the epilepsies, for the choice of AED; these
recommend that the initial choice of AED should take into account
a patients seizure type(s), epilepsy syndrome and aetiology.
Epilepsy treatment has to be tailored to each individuals
lifestyle, co-morbidities and treatment goals. For instance, an
overweight teenager may be adverse to the appetite stimulation
sometimes seen with valproate; and levetiracetam may not be
suitable for a child who is prone to depression or mood swings.
For some epilepsy syndromes, it may be difficult to gain com-
plete seizure freedom, and a better treatment goal might be to
obtain an optimal balance between seizure control, side effects
and quality of life. Lastly, when treating females of child-bearing
potential, it is important to ensure they are aware of the possible
teratogenic effects of some AED. The Medicines and Healthcare
Products Regulatory Agency (MHRA) recently strengthened its
warnings on the use of valproate in women of childbearing po-
tential, and produced a toolkit to ensure female patients are well
informed about the risks.
Targeted AED therapy: in the wake of the insights we have
gained from genetic discoveries in epilepsy, comes the promise of
more targeted treatment options. For example, memantine, an N-
methyl D-Aspartate (NMDA) receptor antagonist has been shown
in vitro to reverse the gain of function effect associated with
some GRIN2A mutations, and may potentially be used to treat
epilepsy associated with such mutations. Similarly, quinidine has
been shown to reverse the gain of function effect of KCNT1
mutations in vitro; anecdotal reports of clinical use suggest
encouraging, but mixed results.
Immunomodulation therapies/hormonal therapies: epilepsies
resulting from autoimmune encephalitis such as anti NMDA re-
ceptor encephalitis, often do not respond to AED, but may
respond to immunomodulation therapies. Rasmussen encepha-
litis and FIRES have also been shown to respond favourably in
some children.
Corticosteroids and adrenocorticotrophic hormone (ACTH)
are also used empirically as first-line therapy to treat many
epileptic encephalopathies, including West and Landau Kleffner
Syndromes, though their mechanism of action for these condi-
tions is poorly understood.
The United Kingdom Infantile Spasms Study (UKISS) was a
multi-centre randomized controlled trial comparing the efficacy
of prednisolone or tetracosactide versus vigabatrin in infantile
spasms. Cessation of spasms at 14 days was more likely with
hormonal treatments. At 12e14 months, cessation of spasms was
similar in both groups. There was no significant difference in
neurodevelopmental outcomes in both treatment groups at 14
months and 4 years of age. The International Collaborative In-
fantile Spasms Study (ICISS) comparing hormonal treatment with
vigabatrin, versus hormonal treatment alone, found that the
proportion of spasm-free children between days 14e42 was
higher in the group given both hormonal treatment and
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vigabatrin (72%) compared to those receiving only hormonal
treatment (57%). Developmental outcome at 18 months for both
treatment groups is awaited.
Non-pharmacological therapy
Approximately, one in three children does not achieve adequate
seizure control on AED. If a child has not achieved seizure
control on two or more AED regimens, subsequent ones afford a
low chance of inducing remission; this is an indication to re-
evaluate the diagnosis and explore other management,
including epilepsy surgery, the ketogenic diet and neuro-
modulation therapies.
Epilepsy surgery: the Early Randomized Surgical Epilepsy Trial
(ERSET) 2012, compared early surgical treatment with continu-
ation of medical treatment in patients more than 12 years of age
with mesial temporal lobe epilepsy, hippocampal sclerosis and
disabling drug-resistant seizures. 11 of 15 patients in the surgical
group achieved seizure freedom within 2-years compared to
none of the 23 patients in the medical group. Adverse incidents
reported in the surgical group included verbal memory decrease
in four and transient neurological deficit for one patient.
Conversely, three patients in the medical group had episodes of
status epilepticus.
Children who may be candidates for epilepsy surgery should
have pre-surgical assessment performed as early as possible as
limiting the duration of epilepsy may result in better long-term
seizure outcomes, cognitive development and quality of life.
Epilepsy surgery options include lesionectomy, anterior tem-
poral lobe resection for temporal lobe epilepsy, hemispherecto-
my and palliative corpus callosotomy.
A recent advancement in epilepsy surgery techniques is the
development of MRI- guided laser ablation also known as MRI
guided laser interstitial thermal therapy (LITT). In this technique,
cooled lasers of various sizes are guided through a small hole in
the scalp into the brain with the aid of a stereotactic frame. This
procedure enables a greater degree of precision for the ablation of
targeted lesions with limited damage to surrounding areas and
promises shorter hospital stays/decreased morbidity.
The ketogenic diet: the classical ketogenic diet (KD) is a high fat,
low-protein and very low carbohydrate diet. Reported response
rates (more than 50% seizure reduction) have ranged from 38%,
to as high as 76% for specific syndromes. Overall, it is estimated
that the KD can be helpful for approximately 50% of children
who try it. The rigidity of the classical KD, its taste and the
substantial change in lifestyle it requires can be deterrents to the
diet for many families. Several variations of the KD now offer
more flexibility and palatability.
Indications for the KD have expanded, it is the treatment of
choice for children with GLUT-1 and pyruvate dehydrogenase
deficiencies, and has also been found to be beneficial in several
epilepsy syndromes including myoclonic astatic epilepsy, infan-
tile spasms, Dravet syndrome, Lennox Gastaut Syndrome, Rett
syndrome and tuberous sclerosis. The KD may be more effective
in generalized epilepsies, particularly those with a myoclonic
component. Contraindications to the KD include hyper-
lipidaemia, pyruvate carboxylase deficiency, porphyria and fatty
acid oxidation disorders.
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 SYMPOSIUM: NEUROLOGY
Neuromodulation therapies: currently, neuromodulation thera-
pies are estimated to provide seizure control in a minority of
cases and are considered a palliative second line treatment
strategy to reduce seizure burden for those who are considered
not amenable to epilepsy surgery. Nonetheless, neuromodulation
therapies are continuing to develop and the last decade has
ushered in a few novel techniques.
Vagal nerve stimulation (VNS) is the best known neuro-
modulation therapy. Evidence of its efficacy is mainly based on
larger adult controlled studies, and data is more limited in chil-
dren. A recent randomized controlled trial of 41 children (35 with
focal and six with generalized epilepsy) reported an overall result
of more than 50% reduction in seizure frequency in 26%, which
was not significantly different to the control group. Expert
assessment is needed prior to offering implant.
Amongst other neuromodulation therapies, transcranial
magnetic stimulation has had mixed results and is rarely used.
Deep brain stimulation is the most invasive of the neuro-
modulation therapies and its use is usually restricted to severe
epilepsies. Newer modalities of neuromodulation therapy with
encouraging results include transcutaneous vagal nerve stimu-
lation, closed loop systems such as responsive neuro-stimulation
and transcranial direct-current stimulation.
Conclusion
Epilepsy in children can be challenging. Nevertheless, the paedi-
atrician needs to be aware that diagnostic advances in the last
decade, including pragmatic classification, can lead to identifica-
tion of aetiology in a far greater number of children, allowing,
better targeted management. In the near future, we can anticipate
that further development of targeted AED therapy, minimally
invasive surgery, palatable diets and new neuromodulation tech-
niques will continue to improve prognosis for many children. A
FURTHER READING
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and epilepsy: denitions proposed by the International League
Against Epilepsy (ILAE) and the International Bureau for Epilepsy
(IBE). Epilepsia 2005; 46: 470e2.
2 Berg AT, Berkovic SF, Brodie MJ, et al. Revised terminology and
concepts for organization of seizures and epilepsies: report of the
ILAE Commission on Classication and Terminology, 2005e2009.
Epilepsia 2010; 51: 676e85.
3 International League Against Epilepsy. Epilepsy diagnosis. 2015.
Available from: https://www.epilepsydiagnosis.org/ [cited 30.11.16].
4 McTague A, Howell KB, Cross JH, Kurian MA, Scheffer IE. The
genetic landscape of the epileptic encephalopathies of infancy
and childhood. Lancet Neurol 2016; 15: 304e16.
5 McTague A, Cross JH. Treatment of epileptic encephalopathies.
CNS Drugs 2013; 27: 175e84.
PAEDIATRICS AND CHILD HEALTH --:-
Please cite this article in press as: Ngoh A, Parker Alasdair PJ, New developments in epilepsy management, Paediatrics and Child Health (2017),
http://dx.doi.org/10.1016/j.paed.2017.03.010
6 Nice Guideline 137. The epilepsies: the diagnosis and manage-
ment of the epilepsies in adults and children in primary and sec-
ondary care. London: National Institute of Clinical Excellence,
2012, January (revised December 2013).
7 Pearl PL. Amenable treatable severe pediatric epilepsies. Semin
Pediatr Neurol 2016; 23: 158e66.
8 Ryvlin P, Cross JH, Rheims S. Epilepsy surgery in children and
adults. Lancet Neurol 2014; 13: 1114e26.
9 Cross JH, Jayakar P, Nordli D, et al. Proposed criteria for referral
and evaluation of children for epilepsy surgery: recommendations
of the subcommission for pediatric epilepsy surgery. Epilepsia
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10 Suleiman J, Dale RC. The recognition and treatment of autoim-
mune epilepsy in children. Dev Med Child Neurol 2015; 57:
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11 Marson AG, Al-Kharusi AM, Alwaidh M, et al. The SANAD study of
effectiveness of valproate, lamotrigine, or topiramate for gener-
alised and unclassiable epilepsy: an unblinded randomised
controlled trial. Lancet 2007; 369: 1016e26.
12 Engel Jr J, McDermott MP, Wiebe S, et al. Early surgical therapy
for drug-resistant temporal lobe epilepsy: a randomized trial.
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Practice points
C Microarray (genetic) testing is now a routine diagnostic
investigation for children with epilepsy
C There is no convincing evidence to suggest that the newer
generation drugs are significantly superior to the older
AEDs but new drugs have distinct profiles with advantages,
such as better pharmacokinetic properties, which are
helpful in selected patients.
C The indications for epilepsy surgery have broadened in the
last decade, and patients who are drug resistant should be
referred early for assessment at a tertiary centre.
C The ketogenic diet is estimated to be helpful for approxi-
mately 50% of children who try it and variations offer more
flexibility and palatability. Neuromodulation therapies such
as vagal nerve stimulation have limited evidence of efficacy
in children and are currently palliative procedures, but
newer therapies are being developed.
6 2017 Published by Elsevier Ltd.