Cheryl Martin (Host): This is Children's Health Checkup, where we answer parents most common questions about raising healthy and happy kids. I'm Cheryl Martin. We are continuing our series on epilepsy in children. In the previous episode, we answered the question, what is epilepsy? Today, our topic focuses on treatment options for epilepsy in kids. And our expert is Dr. Andrea Lowden, a Pediatric Neurologist and Epilepsy Specialist at Children's Health and Associate Professor at UT Southwestern.

If your child is diagnosed with epilepsy, making sure they get the best treatment possible is one of the most important things you can do. As we briefly discussed in the first episode of this Epilepsy Series, there are various treatment options. In this episode, we explore what those treatments are. Dr. Lowden, first, please give us an overview of the various treatment options available for children with epilepsy.

Andrea Lowden, MD: Thank you so much, Cheryl. So when we talk about the different treatment options for kids with epilepsy, throughout the years there has been a lot of development and various treatments for epilepsy. And this is mainly to help people to achieve seizure control. First line treatment for epilepsy is trying to find the right anti-seizure medicine for the patient.

Many drugs have been approved throughout the years, in the United States and we have approximately 30 anti-seizure medications, prescriptions, on the market. And in about 70 percent of people with epilepsy, anti-seizure medicines can successfully control the seizures. If, despite trying two different anti-seizure medicines, if seizures continue to happen, then other treatmens, can be considered, which may include diet therapies or, Neurostimulation devices, and, also we can consider surgery to help control seizures.

Host: So what factors should parents consider when deciding on a specific approach?

Andrea Lowden, MD: There are many pharmacological and non-pharmacological options and these all need to be considered when we're trying to find the right therapy for the patient. But the most important factors that we take into account are going to be the seizure type of the patient. For example, if the patient has what we call a focal type of seizures, or if they have generalized type of seizures that affect both areas of the brain, or many times, one individual can even have both types of seizures.

We also take into account if the patient has a specific type of epilepsy, and also the cause of the epilepsy. So, is it caused by a structural abnormality of the brain or is it secondary to a genetic condition that the patient might have? We will also decide on the approach depending if the patient is now being refractory to medicines, which means that they have not responded to two or more anti-seizure medications. We also look at does the patient suffer from other conditions, or do they have other comorbidities, because this will be important also to choose the right medicine. We also look at the side effects of the medicines or of the specific therapeutic option, because if the patient does have either a different medical condition, we want to make sure that the medication we're starting is either not interacting with other medicines that the patient might have, or might not worsen a specific comorbidity that also the patient will have.

So we take many different things into account and deciding on the specific approach for the patient.

Host: Just to follow up on what you just shared, what else can you tell us of how you work with parents to customize their treatment plan for the child, take into account factors like age, seizure type, and potential side effects of medications? Anything else on that?

Andrea Lowden, MD: I always tell my patients and families that when we're treating epilepsy, we're a team. The best therapy and the best court of action is going to be a joint decision between the parent, the patient, and specialist, because this is going to be very important for compliance of the therapy that is chosen.

So a detailed history is very important, not only regarding the seizures, but also for the physician to learn and understand the social circumstances of the family. As I mentioned previously, we're going to look at the epilepsy type, the other medical conditions, if the patient is on any other specific medications that might possibly interact with what we prescribe.

But also we need to consider the social circumstances. Is the family able to afford the medication? Do they have insurance? Is it easy for them to obtain the medicine? So, I always encourage my patients and parents and caregivers to ask questions, to voice their concern, so that way we can develop together the best treatment plan for the patient.

Host: As you know, many parents are concerned about the side effects of epilepsy medication. So what information and advice can you offer to help parents navigate these concerns so they can make informed decisions?

Andrea Lowden, MD: So, communication is just key in the treatment of epilepsy. It's important for the families and parents to ask questions. They need to ask questions to their physician. They need to also let them know if there are any specific concerns with the treatment or with the medication. Every piece of information is important.

And, if a specific medication or therapy is prescribed, prior to initiating, it's important for them to ask what side effects or what should they be looking out for. Very often the specialist will talk in detail and explain in detail those possible side effects and also may provide patient education handouts about the medication to the families.

If this doesn't happen they can always ask their physician for more information, and also in the pharmacy, they should have those handouts for each medicine in different languages, and also not only ask the questions when the medication is started, but once the medication is initiated and the patient is on the medicine, if they notice anything or they suspect any side effects, they can always ask their physician and I do encourage to do so because sometimes we might see that they might just stop the medicine and this is not safe because this can lead to withdrawal seizures. So, it's important if they have any concerns with the medication or any difficulty obtaining the medicine that they talk with their doctor.

Host: So you mentioned surgery before. When would surgery be an option for epilepsy in children and how does it it work?

Andrea Lowden, MD: In about 70 percent of people, medications will be effective in controlling seizures. But in 3 of 10 people with epilepsy, seizures might not respond to anti-seizure medicines. When that happens, when a patient does not respond to two or more seizure medicines, that's what we call drug resistant or refractory epilepsy.

And this interferes with the patient's quality of life, because if someone is having multiple seizures, that can limit their ability to learn or ability to if they're driving, to drive. And when we see that, then epilepsy surgery can be an option. However prior to considering epilepsy surgery, the specialist needs to perform different testing.

And the testing, mainly what we're trying to determine is this patient a candidate for surgery? Can we help identify or can we identify what is the area or the site of the brain that is generating the seizure? And also with each test that we do as part of our pre-surgical workup, we're trying to understand the area of the brain that is generating the seizure, but also is that area and the areas around it, does it have a function?

So does it control language or sensation or your motor skills or does it have any other important function. Because all this information will create let's say, a map and help us and the neurosurgeon talk about what would be the prognosis after the procedure and what would be the outcome regarding seizure free of an epilepsy surgery.

Host: So how common is surgery among children?

 Andrea Lowden, MD: So it all depends on the causes of epilepsy and also depends on their response to medications. At Children's Health, we do have a multidisciplinary epilepsy surgery team where we do perform different type of epilepsy surgeries and our team, we have our Epilepsy specialists, our neurosurgeon, neuroradiologist, neuropsychologist. So we have a multidisciplinary team as this will take a team effort.

Host: What non-pharmacological interventions have shown promise in treating children with epilepsy?

Andrea Lowden, MD: Most people with epilepsy, a first line of therapy will be anti-seizure medicines to try to control their seizures. However, we do have many non-pharmacological

treatments of epilepsy. We have dietary therapies, for example, the ketogenic diet, modified Atkins diet, low glycemic index. And these are high fat, low sugar, or low carbohydrate diets. Sometimes these type of therapies can be first line therapies for specific conditions. For example, GLUT1, glucose transporter deficiency, where the glucose cannot be transported into the brain itself. If this is the case, then a dietary therapy with ketogenic diet, could be first line.

We also have, what we call neurostimulation devices, which may include vagal nerve stimulator. There's also another one called responsive nerve stimulation and deep brain stimulation. These are also surgical procedures in which, we give stimulation to different areas of the brain in order to help with controlling the seizures.

And then we also have different type of epilepsy surgeries, which may include a resective surgery, in which we will remove the area of the brain that's generating the seizures, or we can also disconnect the area of the brain that's generating seizures from a healthy portion of the brain. And this also may help controlling seizures. So there are many different types of epilepsy surgery. There's also clinical trials for gene therapy for epilepsy, which is an evolving area with promising signs. And what gene therapy is, it's a medical approach with the goal to treat or prevent either a known genetic cause procedures. And what the scientists do, they're trying to alter the person's gene and target those areas in the brain where seizures may originate. However, these gene therapy options are still in infant stages.

Host: Well, clearly there are a lot of options for treatment. Well, Dr. Andrea Lowden, thanks for coming on and sharing your expertise on this topic. Very, very helpful.

Andrea Lowden, MD: Thank you so much, Cheryl.

Host: For more information, visit Childrens.com/epilepsy. And in the next episode of our epilepsy series, we'll discuss seizure first aid and precautions. Thanks for listening to Children's Health Checkup. If you found this podcast helpful, please rate and review it or share the episode. And please follow Children's Health on your social channels.