Dr Mohamed Osman Eltahir Babiker, Consultant Paediatric Neurology, Dr Sulaiman Al Habib Hospital, talks about how properly diagnosing epilepsy in children is the most important step towards treatment
What are the types of patients you see as a paediatric neurologist?
Paediatric neurology is a sub-specialty branch in paediatrics and child health that essentially covers medical conditions that affect the brain, spine, nerves and muscles of children from the first day of life up to the age of 16. Common conditions that a paediatric neurologist sees, diagnoses and treats include epilepsy, headaches, cerebral palsy, developmental delay, disorders of movement, muscle weakness and nerve problems to name a few.
What is epilepsy and what are epileptic seizures?
Epilepsy is derived from a Greek word that literally means a “state of being overcome, seized or attacked”. Interestingly, the Arabic word al saraa is translated in English as “to be knocked down”, which reflects the ancient name “the falling sickness”, so called because the patient suddenly falls to the ground during a fit. Epilepsy is one of the commonest conditions affecting the brain.
Paediatric neurology is such an intellectually stimulating branch of medicine.
There are billions of cells on the brain’s surface and these cells communicate with each other by sending tiny electrical currents at very calculated levels to execute the different body functions such as raising an arm, talking and walking. An epileptic seizure occurs when a localised area in the brain or the brain in its entirety is dominated by an out-of-control burst of this electrical activity.
There are different types of seizures depending on where in the brain this aberrant electrical activity is coming from. Epilepsy is the individual’s tendency to have recurrent “epileptic seizures”.
How do you diagnose epilepsy in children?
Properly diagnosing epilepsy in children is perhaps the most important first step towards the best possible treatment outcomes. Many conditions in children may present in a manner similar to epileptic seizures. Hence, it is paramount that we take adequate history that describes the episodes in question in as much detail. Nowadays, almost everyone has a mobile phone with a camera. Taking videos of the episodes as they happen can prove very helpful when they are reviewed by the neurologists. The next step is to perform a test called electroencephalogram (EEG for short), which involves application of wires over the head to record the patterns of the brain’s electrical waves and circuits.
The EEG can be run for about an hour or so but sometimes we may need to extend the recording for 24 hours or even longer to gain more information. The EEG usually serves to give supporting evidence before we can confidently diagnose epilepsy but it can also give valuable information about the type of epilepsy the child has.
Epilepsy can result from a wide range of causes and that is why other tests might be needed to understand why the child has developed epilepsy. These may include brain imaging via magnetic resonance imaging, or MRI. Nowadays we are relying on genetic testing more and more. It is worth pointing that it is not always feasible to find a direct cause for the child’s epilepsy despite our best efforts.
What are the treatment options for patients with epilepsy?
There are three main levels of treatment. These are medications, brain surgery and the ketogenic diet. Often, we start with an anti-epileptic medication that has been appropriately chosen based on the child’s characteristics and the type of epilepsy he or she has. A balance has to be struck between the effectiveness of the medicine and its side effects. In children, we tend to start with smaller doses then build them up slowly over time to ensure safety and tolerability.
Up to 70 per cent of patients respond well to one or two medications and we will be able to successfully withdraw the medicine within a couple of years. In cases whereby medications do not work satisfactorily or when there is a diseased part of the brain, the surgical option is then considered. There are different surgical options and these are chosen after careful consideration and planning on a case-by-case basis.
Does a ketogenic diet help in epilepsy?
The role of the ketogenic diet in epilepsy treatment has been recognised for nearly a century now. Essentially, it is a strict type of diet that consists of low-carbohydrate, high-fat and calculated protein content. In the face of low carbohydrate and sugar intake, the body is forced into producing chemicals known as ketones that the brain uses as its main source of energy. This is thought to be the mechanism through which the ketogenic diet works although this does not seem to be the whole story thus far.
In cases where medication or brain surgery do not seem to fully control the epileptic seizures, the ketogenic diet may be a reasonable option. We know from research that the chance of response can be as high as one in three. It must be remembered that the selection for and administration of the ketogenic diet should be under strict medical supervision. This is because this type of diet can potentially cause problems such as low blood sugar levels, tummy upset, kidney stones, poor body growth and so forth.
What is the hardest part of being a paediatric neurologist and what are the challenges of looking after children with neurological problems?
Paediatric neurology is such an intellectually stimulating branch of medicine. Many of the conditions we deal with are rare and, needless to say, serious. Most share similar symptoms and some require time, patience and sometimes a lot of detective work before they are diagnosed. Given that several neurological problems may last for a long time, paediatric neurologists are privileged to have the opportunity of establishing long-term trusting relationships with the children and their families. Transparent, honest and responsive communication with the families all the way through is the foundation of these relationships. Although many of the conditions we see and manage have no cure because of their very nature, the satisfaction for us comes from the mere fact that we can always care!