The Right Child, the Right Treatment, the Right Time: Rethinking Referral in Pediatric Drug-resistant Epilepsy

Review ARticleManagement extends beyond optimizing ASMs.Rational pharmacotherapy remains important, but unnecessary polytherapy often increases adverse effects without improving seizure control.Dietary therapies, particularly the ketogenic diet and its variants, are valuable options in selected epilepsy syndromes and younger children.Neuromodulation, including vagus nerve stimulation, offers meaningful seizure reduction when curative surgery is not feasible.7,8 However, epilepsy surgery remains the most effective treatment for appropriately selected children with focal DRE. 4 Resective and disconnective procedures can achieve sustained seizure freedom Despite remarkable advances in pediatric epileptology, nearly onethird of children with epilepsy continue to have seizures despite appropriate antiseizure medication (ASM) therapy. 1 Drug-resistant epilepsy (DRE) is associated with substantial neurodevelopmental, cognitive, psychosocial, and mortality burdens during childhood.Yet, many of these children have potentially effective treatment options.The challenge today is no longer simply controlling seizures-it is ensuring that children are identified early and receive the right treatment at the right time.The International League Against Epilepsy (ILAE) defines DRE as the failure of two appropriately selected, tolerated, and adequately dosed ASMs, used either sequentially or in combination, to achieve sustained seizure freedom. 1 Beyond this point, the likelihood of achieving sustained seizure freedom with further ASM trials decreases substantially, underscoring the need to reconsider the treatment strategy rather than continuing prolonged sequential medication trials.Drug-resistant epilepsy is not merely a failure of medications-it is the point at which the treatment strategy must change.[2][3][4] Pediatric DRE encompasses a heterogeneous group of disorders, including focal cortical dysplasia, developmental brain malformations, perinatal brain injury, tuberous sclerosis complex, Rasmussen encephalitis, genetic developmental and epileptic encephalopathies, and metabolic disorders.5,6 Advances in high-resolution epilepsy protocol magnetic resonance imaging, prolonged video-electroencephalography, molecular genetics, and functional neuroimaging have improved etiological diagnosis, enabling individualized treatment and better prognostication.