BNF for Children 2011-2012

BNFC 2011–2012 4.8.1 Control of the epilepsies 217Young women who have seizures in the second half ofpregnancy should be assessed for eclampsia before anychange is made to antiepileptic treatment. Status epilepticusshould be treated according to the standardprotocol, see section 4.8.2.Routine injection of vitamin K (section 9.6.6) at birthminimises the risk of neonatal haemorrhage associatedwith antiepileptics.Withdrawal effects in the newborn may occur with someantiepileptic drugs, in particular benzodiazepines andphenobarbital, and can take several days to diminish.Epilepsy and Pregnancy RegisterAll pregnant women with epilepsy, whether takingmedication or not, should be encouraged to notifythe UK Epilepsy and Pregnancy Register (Tel: 0800389 1248).Breast-feeding Breast-feeding is acceptable with allantiepileptic drugs taken in normal doses, with thepossible exception of the barbiturates and some of thenewer antiepileptics (see under individual drugs).Focal seizures with or withoutsecondary generalisationCarbamazepine, lamotrigine, oxcarbazepine, andsodium valproate are the drugs of choice for focalseizures; second-line drugs include clobazam, gabapentin,levetiracetam, tiagabine, and topiramate.Generalised seizuresTonic-clonic seizures The drugs of choice for tonicclonicseizures are carbamazepine, lamotrigine, levetiracetam,and sodium valproate. For children whohave tonic-clonic seizures as part of the syndrome ofprimary generalised epilepsy, sodium valproate is thedrug of choice. Second-line drugs include clobazam,oxcarbazepine, and topiramate.Absence seizures Ethosuximide and sodium valproateare the drugs of choice in typical absenceseizures; lamotrigine can be used if these are unsuitable.Sodium valproate is also highly effective in treatingthe generalised tonic-clonic seizures which can co-existwith absence seizures in idiopathic primary generalisedepilepsy.Myoclonic seizures Myoclonic seizures (myoclonicjerks) occur in a variety of syndromes, and response totreatment varies considerably. Sodium valproate is thedrug of choice, and clobazam, clonazepam, ethosuximide,lamotrigine, levetiracetam, or topiramate aresecond-line drugs.Atypical absence, atonic, and tonic seizuresAtypical absence and atonic seizures can be managedwith sodium valproate, lamotrigine, or ethosuximide.Tonic seizures can be treated with sodium valproate.Second-line drugs for atypical absence, atonic, and tonicseizures include clobazam, clonazepam, levetiracetam,and topiramate; tonic seizures are rarely aggravated bybenzodiazepines.Epilepsy syndromesInfantile spasms Vigabatrin is the drug of choice forinfantile spasms associated with tuberous sclerosis. Inspasms of other causes, high doses of corticosteroids,such as prednisolone (section 6.3.2) or tetracosactide(section 6.5.1), may be more effective. Second-linealternatives include clobazam, clonazepam, sodium valproate,and topiramate; nitrazepam is used but it issedating.Lennox-Gastaut syndrome Lamotrigine, sodiumvalproate, and topiramate are first-line drugs for treatingLennox-Gastaut syndrome. Clobazam, clonazepam,ethosuximide, levetiracetam, and rufinamide are alsoused.Landau-Kleffner syndrome Prednisolone, lamotrigine,and sodium valproate are commonly used totreat Landau-Kleffner syndrome. Alternatives includeclobazam, levetiracetam, and topiramate.Neonatal seizures Seizures can occur before delivery,but they are most common up to 24 hours afterbirth. Seizures in neonates occur as a result of biochemicaldisturbances, inborn errors of metabolism, hypoxicischaemic encephalopathy, drug withdrawal, meningitis,stroke, cerebral haemorrhage or malformation, orsevere jaundice (kernicterus).Seizures caused by biochemical imbalance and those inneonates with inherited abnormal pyridoxine or biotinmetabolism should be corrected by treating the underlyingcause (section 9.6.2). Seizures caused by drugwithdrawal following intra-uterine exposure are treatedwith a drug withdrawal regimen.Phenobarbital can be used to manage neonatal seizureswhere there is a risk of recurrence; phenytoin isan alternative. Benzodiazepines (such as clonazepam(p. 232) and midazolam (p. 234)) and rectal paraldehyde(p. 234) may also be useful in the managementof acute neonatal seizures. Lidocaine (p. 86) maybe used if other treatments are unsuccessful; lidocaineshould not be given to neonates who have receivedphenytoin infusion because of the risk of cardiac toxicity.Severe myoclonic epilepsy of infancy Stiripentolis licensed to treat severe myoclonic epilepsy of infancy(Dravet Syndrome).Carbamazepine and oxcarbazepineCarbamazepine is a drug of choice for simple andcomplex focal seizures and for tonic-clonic seizuressecondary to a focal discharge. It can exacerbate myoclonicand absence seizures. It is essential to initiatecarbamazepine therapy at a low dose and build this upslowly in small increments every 3–7 days. Some sideeffects(such as headache, ataxia, drowsiness, nausea,vomiting, blurring of vision, dizziness, unsteadiness, andallergic skin reactions) are dose-related, and may bedose-limiting. These side-effects are more common atthe start of treatment. They may be reduced by alteringthe timing of medication or by using a modified-releasepreparation.Oxcarbazepine is licensed as monotherapy or adjunctivetherapy for the treatment of focal seizures with orwithout secondary generalised tonic-clonic seizures.4 Central nervous system