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Children with intractable epilepsy are a therapeutic challenge. In meeting that challenge it is important to have constantly in mind what it is hoped to achieve. The aim must be significant improvements in quality of life for the child and the family. Fairly minor reductions in seizure frequency may not achieve that aim. By mechanisms that are not known, stimulation of the left vagus nerve reduces seizure frequency in experimental animals. Studies in adults have led to this procedure being approved in the USA for patients over the age of 12. Now the paediatric data (19 patients) from two multinational trials, which mostly contained adults, have been reported together with data on 41 children treated in an uncontrolled fashion (Jerome V Murphy and the Pediatric VNS Study group. Journal of Pediatrics1999;134:563–6; see also editorial,Ibid: 532–3). A stimulator is implanted under the skin of the chest wall with an electrode on the left vagus nerve in the neck. Standard practice is 30 seconds on and 5 minutes off continuously. In children aged 3–18 with various types of seizure there was a reduction in seizure frequency by 23% at 3 months, rising to 42% by 18 months. No correlation was found between seizure type or cause and response. In some patients stimulation caused cough, fever, headache, or voice change. The device eroded through the skin in one patient. This report serves to emphasise the importance of paediatric trials, performed on children and designed to provide the answers that patients, their families, and their doctors want and need. It does not answer the most important question; were they better off for the intervention? It seems unclear whether vagal stimulation might provide real benefit for some children or whether, like the cerebellar stimulation briefly in vogue some 25 years or so ago, it will prove just another fad.
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