Since the 1920s, interest in this form of seizure control has varied, being revived periodically in centers caring for many children with intractable epilepsy. Despite the absence of controlled studies showing its efficacy or an agreed upon hypothesis for its mechanism, several trials in the first half of the twentieth century, and again more recently, demonstrated a reduction in seizures in half of the patients, including handicapped children with severe and sometimes intractable episodes. The diet is used mainly in children between the ages of 1 and 10 years. The regimen is initiated during hospitalization by starvation for a day or two in order to induce ketosis, followed by a diet in which 80 to 90 percent of the calories are derived from fat (Vining). The difficulties in making such a diet palatable leads to its abandonment by about one-third of children and their families.
A summary of experience from the numerous trials of the ketogenic diet can be found in the review by Lefevre and Aronson and in the report of its use in 58 children by Kinsman and colleagues. They both concluded that the diet is effective in refractory cases of epilepsy in childhood, reducing seizure frequency in two-thirds of children and allowing a reduction in the amount of anticonvulsant medication in many. It has also been commented that some benefit persists even after the diet has been stopped. Nephrolithiasis is a complication in somewhat less than 10 percent of children, and this risk is particularly high if topiramate is being used.
Keotgenic diet is the main treatment for children with GLUT1 deficiency syndrome, as discussed earlier.
For lack of a better place to comment, we note that cannabinoids are being introduced for the treatment of epilepsy, prominently in special cases such as Dravet syndrome, but as reviewed by Friedman and Devinsky, no firm conclusions as to their effectiveness can be made at this time.
Safety and Regulation of Physical
A person with incompletely controlled epilepsy should not be allowed to drive an automobile. Only a few states in the United States and most provinces of Canada mandate that physicians report patients with seizures under their care to the state motor vehicle bureau. Nonetheless, physicians should counsel such a patient regarding the obvious danger to himself and others if a seizure should occur while driving (the same holds for the risks of swimming unattended). What few data are available suggest that accidents caused directly by a seizure are rare and, in any case, 15 percent have been the result of a first episode of seizure that could not have been anticipated. In some states where a driver’s license has been suspended on the occurrence of a seizure, there is usually some provision for its reinstatement—such as a physician’s declaration that the patient is under medical care and has been seizure-free for some period of time (usually 6 months or 1 to 2 years). The Epilepsy Foundation website can be consulted for updated information regarding restrictions on driving, and this serves as an excellent general resource for patients and their families (http://www.efa.org).
The most important factors in seizure breakthrough, next to the abandonment of medication or a natural reduction of serum levels of medication, are loss of sleep and abuse of alcohol or other drugs. The need for moderation in the use of alcohol must be stressed, as well as the need to maintain regular hours of sleep. Advice to collegians about moderating alcohol is particularly important.
With proper safeguards, even potentially more dangerous sports, such as swimming, may be permitted. However, operating unguarded machinery, climbing ladders, or taking baths behind locked doors are not advisable; such a person should swim only in the company of a good swimmer. There is concern about epileptic mothers bathing their infants without additional safety guards.
Psychosocial difficulties are common and must be identified and addressed early. The stigma of epilepsy remains an issue in society. Advice and reassurance to attempt to pursue a normal life will aid in preventing or overcoming any feelings of inferiority and self-consciousness of many younger patients with epilepsy. However, the situation is rarely so simple and patients and their families may benefit from more extensive counseling.