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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 1  |  Page : 74-80

Outcome of treatment of children with epilepsy in a Nigerian tertiary hospital


1 Department of Paediatrics, Federal Medical Centre, Asaba, Delta State, Nigeria
2 Department of Paediatrics, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Nigeria

Date of Submission20-Nov-2020
Date of Decision19-Feb-2021
Date of Acceptance17-Mar-2021
Date of Web Publication3-Dec-2021

Correspondence Address:
Uzoamaka V Muoneke
Department of Paediatrics, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Enugu State.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_69_20

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  Abstract 

Background: Epilepsy, the most predominant noncontagious neurologic disorder affecting children and carrying profound levels of social stigma, is an important cause of childhood morbidity globally. Objectives: This study aims at describing the prevalence, etiological risk factors, seizure pattern/associated comorbidities, and outcome of treatment with antiepiletic drugs (AEDs) among patients with epilepsy attending the neurology clinic of Federal Medical Center, Asaba, Delta State, Nigeria. Materials and Methods: A 10-year review of all patients seen at the neurology clinic of the tertiary institution. Information including history/physical examination, socio-demographic variables, and electroencephalogram (EEG) findings was collected from the clinic records of the patients between January 2009 and December 2019. A total of 105 patients presented with clinical features of epilepsy classified based on the 2017 International League Against Epilepsy classification. All data obtained from the clinic records were analyzed using the SPSS, Version 23.0, software. Results: Of the 302 patients seen with different neurologic morbidities, 105 had epilepsy, giving a prevalence rate of 34.7%, occurring more in children aged 6 months to 3 years with a male predisposition (55.2%). Generalized tonic-clonic (GTC) seizure was identified as the most predominant type 9/105(8.6%), severe birth asphyxia and cerebral palsy were the most common cause, and comorbidity of epilepsy, respectively. Sodium valproate was the commonly used AED with 55.8% good outcome. Conclusion: Epilepsy is still an underreported childhood neurologic morbidity in our environment. Good outcome recorded can be attributed to high levels of adherence to medication and absence of associated metabolic disorders or intracranial structural lesions.

Keywords: Asaba, children, epilepsy, neurology clinic


How to cite this article:
Okike CO, Emeagui DO, Ajaegbu OC, Muoneke UV. Outcome of treatment of children with epilepsy in a Nigerian tertiary hospital. Int J Med Health Dev 2022;27:74-80

How to cite this URL:
Okike CO, Emeagui DO, Ajaegbu OC, Muoneke UV. Outcome of treatment of children with epilepsy in a Nigerian tertiary hospital. Int J Med Health Dev [serial online] 2022 [cited 2023 Feb 8];27:74-80. Available from: https://www.ijmhdev.com/text.asp?2022/27/1/74/331735




  Introduction Top


Epilepsy is a chronic disorder marked by intermittent, often unpredictable seizures which may be embarrassing and disruptive to the normal activity of daily living.[1] Epilepsy is the most predominant neurologic disorder affecting children, and World Health Organization reports that it is an important cause of childhood morbidity and that the global burden is 4–10/1000, with the highest annual periodic and life time prevalence seen in Asian, Middle East, and African countries.[2],[3],[4],[5] Africa contributes 37% of world epilepsy burden and most epileptics suffer the disease from early childhood.[6]

In some parts of Africa, childhood epilepsy carries unwarranted social stigma as children with this disease are often inappropriately labeled to have a contagious disease or are erroneously perceived to be possessed with evil spirit.[5] This may result in isolation in school and undue avoidance by peers. To this end, the true burden of childhood epilepsy in sub-Saharan Africa may be underreported because of social stigmatization that goes with the disease.[5]

Studies have shown that incidences and prevalence of epilepsy were higher in developing countries and among children living in rural areas.[7],[8],[9] For example, 59.4% of children seen at the neurology clinic of a teaching hospital in Calabar, Nigeria, had epilepsy with the highest prevalence occurring in children less than 5 years.[9] Similarly, high burden of epilepsy was reported among rural Sri Lankan children.[8] The authors found that children below the age of 5 years were most affected. A retrospective review of a hospital neurology clinic record in Sagamu by Ogunlesi et al.[10] showed that 75% of 183 patients seen within the period under review were diagnosed of epilepsy and 54.7% of these patients were aged 6 months to 3 years. They identified generalized tonic-clonic (GTC) seizure as the commonest type of epilepsy while birth asphyxia and brain infections were the leading etiologies. The same study showed that males were more affected than females. These findings were also corroborated by Langunju et al.[11],[12] On the other hand, Kandil et al.[13] documented that focal seizure was the most prevalent type among Egyptian children aged 0–18 years and only 31% of the patients showed demonstrable electroencephalogram (EEG) abnormality. Similarly, focal epilepsy was the most frequent type amongst children aged less than 18 years in Owerri, Nigeria.[14] Out of 10,218 children screened for epilepsy in Kenyan communities, 17% were found to be epileptic with the highest prevalence occurring in those aged 6–12 years.[6] The authors identified febrile seizure as an important etiological risk factor. Epileptic disorders were reported in 0.7%, 1%, 1.5%, and 1% of rural children, aged less than 18 years, selected from very few communities in South Africa, Uganda, Tanzania, and Ghana, respectively.[15] Adverse perinatal events such as birth asphyxia were the major risk factors contributing to the development of the disorder. But Duggan[16] reported a higher rate of 2.04% among urban children in Uganda aged less than 15 years. He found that GTC was the commonest seizure type and that 50.2% of seizures started in infancy while cerebral palsy was associated with complex partial seizure. The prevalence of epilepsy among children aged 7–17 years in Kayseri, Turkey, was 0.8% with febrile convulsion and prematurity being the leading risk factors.[17] In a more recent study in South Africa, it was documented that 51% of 4701 children managed at the neurology service center of a tertiary hospital had epilepsy. Focal seizure was the most prevalent seizure type. While the etiology in 54% of these epileptics was unknown, perinatal insults and infections of the central nervous system were among the identifiable risk factors.[18]

Screening of 3684 rural and urban North Indian children aged 0–18, for epilepsy yielded a prevalence rate of 0.6%. There was no gender predilection but prevalence was highest among children aged less than 10 years and generalized epilepsy was the most prevalent type.[19] Similar screening of 114,427 Norwegian children aged 3–13 years revealed epilepsy prevalence of 0.5% with equal male to female ratio and subjects aged less than 5 years had the highest prevalence rate.[20]

Concerning outcome of treatment, it is believed that 60–70% of patients on antiepilepsy drugs (AEDs) will have satisfactory control of seizure.[21] Niriayo et al.[22] reported that 50% of 270 epileptics who were on medication had poor response to treatment evidenced by poor control of seizure. They attributed treatment failure to poor adherence to medication and comorbidities among others. Nwani et al.[23] also corroborated that poor adherence to AEDs was responsible for poor response to treatment while suboptimal doses of antiepileptic drugs was associated with poor response in Uganda.[24] Xia et al.[25] documented that 71.8% of 204 patients who were on AEDs had 36 months seizure free period. They concluded that initial 6-month response to AEDs was a valuable predictor of long-term response and that frequent seizure before commencement of treatment and brain imaging abnormalities were indicative of poor prognosis. Drug resistance, hence treatment failure, was seen in 30%–40% of Norwegian epileptic children treated with AED while 60–70 responded well to therapy. Resistance was attributed to structural lesion of the brain, metabolic, and genetic abnormalities.[26] Out of 225 patients treated for epilepsy in Turkey, 67.5% responded well to treatment while 32.5% had treatment failure.[17] Fifty-two percent of children who were treated for epilepsy had good control.[8] Age at diagnosis, seizure type, etiology, and antiepileptic drug selection were considered as factors responsible for drug treatment failure in childhood epilepsy.[2] More than 57% of 171 epileptics enrolled for treatment at the University College Hospital Ibadan showed significant response to treatment with AEDs.[27] As high as 80.4% of 138 children with epilepsy seen at the neurology clinic of a tertiary health center in Shagamu, Ogun State of Nigeria, had a favorable treatment outcome.[10]

This study aims at describing the prevalence of epilepsy among patients attending the neurology clinic of Federal Medical Center, Asaba, Delta State of Nigeria, determining the etiological risk factors, identifying seizure pattern, and associated comorbidities, as well as describing the outcome for patients receiving AEDs.

The information obtained from this study will act as a guide for comparison of trends with previous studies and to consolidate on existing strategies to treat children with epilepsy in this region and beyond.


  Materials and Methods Top


This is a 10-year (2009–2019) review of all patients seen at the neurology clinic of the Federal Medical Center (FMC) Asaba, Delta State, Nigeria.

FMC, Asaba, is a tertiary health institution located within the capital city (Asaba) of Delta State of Nigeria. It serves the Northern part of Delta State and the neighboring Anambra, Edo, and part of Enugu States. All information concerning this study was obtained from the clinic records that were meticulously kept within the years under review.

A total of 305 patients were seen within this period but only 105 presented with features of epilepsy and were regular in clinic attendance. Diagnosis and classification of epilepsy was made clinically based on the definition and classification by the International League Against Epilepsy (ILAE).[28] Using the ILAE framework, all recurrent nonfebrile seizures were diagnosed as epilepsy. Patients who had only one afebrile episode of seizure but showed epileptiform discharges on EEG were also classified as epileptic. To further exclude possible structural abnormalities in these patients, cranial computerized tomographic scan was done for all suspected cases of epilepsy. All patients that presented with febrile seizure, neonatal seizure, syncope, psychogenic seizure, and cardiac arrhythmias were excluded.

Information obtained from the clinic records included, socio-demographic variables, diagnosis, perinatal history (such as history of jaundice and birth asphyxia), and findings on physical examination such as occipito-frontal circumference and central nervous system mal-development. Medications and EEG findings were also noted.

All data obtained from the clinic records were analyzed using SPSS, Version 23.0, software. Results are presented in tables and figures.


  Results Top


During the period under review, 302 patients with different neurologic morbidities attended the neurology clinic of FMC Asaba. One hundred and five patients had epilepsy, constituting a prevalence rate of 34.7%. Epilepsy was more prevalent in males (55.2%) than in females (44.8%) although the difference was not statistically significant. GTC seizure was identified as the most predominant type of epilepsy, 79/105 (75.2%). This is followed by focal aware seizure (simple partial seizure) 11.4%, absence seizure 2.9%, focal unaware seizure (complex partial seizure) 2.9%, myoclonic seizure 2.9%, and atonic seizures 2.9% [see [Table 1]]. About 50% of the patients had significant EEG findings suggestive of epilepsy.
Table 1: Gender disposition of various types of epilepsy

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Generalized GTC epilepsy occurred most in subjects aged greater than 6 months to less than 3 years. It also appears that, after the age of 6 months, the prevalence of GTC decreased with increasing age. Simple partial seizure (focal aware seizure) was found among subjects aged 6 months to 9 years but was most prevalent in children between the age of 6 and 9 years [Table 2].
Table 2: Age disposition of various types of epilepsy

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[Figure 1] shows that the cause of epilepsy in 61% of the subjects could be identified, while the etiology in 39% of the subjects was unknown. Severe birth asphyxia was identified as the leading cause of epilepsy followed by neonatal jaundice and head trauma.
Figure 1: Aetiology and seizure types in children with epilpesy

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[Figure 2] shows the comorbidities associated with epilepsy. Cerebral palsy was the commonest comorbidity, 9/105(8.6%), followed by mental retardation, 3(2.9%). Other comorbidities were attention-deficit hyperactivity disorder 1%, craniosynostosis 1%, deafness 1%, cataract 1%. Cerebral palsy and deafness were found to be associated with GTC seizure while 81.9% of the epileptics had no comorbidities.
Figure 2: Relationship between seizure type and comorbidities

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Concerning treatment outcome, a total of 104 of the 105(99%) patients had a good control of their seizure. About 55.8% of these patients were males while 44.2% were females. The only patient who responded poorly to treatment was a female who had GTC epilepsy [See [Table 3]].
Table 3: Outcome of treatment

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The most commonly used AED for the treatment of GTC was sodium valproate (53.2%) followed closely by carbamazepine (27.8%) and levetiracetam (13.9%) [See [Table 4]].
Table 4: Antiepilepsy drugs used for the treatment of various epilepsy types

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Ethosuximide was used to treat five patients with the absence of seizures while one patient responded well to sodium valproate. Pregabalin and topiramate were only used in combination with sodium valproate, as add-on for the treatment of recalcitrant GTC seizures.


  Discussion Top


The prevalence of epilepsy in this study is 34.7%, which is lower than 59.4% and 75% documented in hospital setting in Calabar[9] and Sagamu,[10] respectively. It is also much lower than, 17%, that was reported in Kenya[6] and in Turkey (0.8%).[17] The disparity in our prevalence rate compared to the cited studies could be due to variation in sample size. Both Turkish and Kenyan studies excluded subjects less than 6 years. Put together, children aged less than 5 years had the highest prevalence of epilepsy. This agrees with previous studies in Nigeria and Sri Lanka.[8],[9],[10] Amongst Norwegian children attending hospitals, the prevalence of epilepsy was reported to be about 0.65%[24] in contrast to the findings of our study that revealed that about 35% of children attending the neurology clinic had seizure disorder. Although the prevalence observed is not as high as that obtained from other parts of Nigeria.[7],[16] The results from our study, therefore, show that childhood epilepsy is still a predominant disease managed by the pediatric neurologists. Though, about 70% of people living with epilepsy can become seizure free after prompt and adequate treatment[19]; however, many African children are likely not to seek early health care. The patients with their parents/caregivers prefer or opt for traditional care, so that the 35% prevalence recorded in our environment may actually have been higher than that observed.

In developed countries, epilepsy is commonly associated with attention deficit, hyperactivity, and autism spectrum disorders,[23] but in our environment the predominant comorbidities coexisting with pediatrics epilepsy were cerebral palsy and mental retardation. The coexistence of learning problems, cerebral palsy, and epilepsy have been reported to lead to higher mortality.[25]

Severe birth asphyxia was the most significant cause of childhood epilepsy. This differs from some of the studies conducted in more developed countries. Aaberg et al.[26] observed that the most common causes of pediatric epilepsy were genetic, structural, metabolic, and infectious. There was no mention of birth asphyxia being a known cause. This absence has been attributed to the highly developed maternal obstetrics care in such countries. It is pertinent that if the prevalence rate in our environment would be reduced, then adequate maternal obstetrics care, presence of skilled birth attendants, and prompt neonatal resuscitation should be seriously promoted and applied appropriately.

The commonest type of seizure seen was GTC seizure which is a reflection of widespread involvement of neural tissues of the brain. Our findings were in keeping with other studies done in Nigeria[7],[16] and other reports from Asia.[19]

Concerning the outcome of treatment, about 99% of the children responded favorably to the prescribed anticonvulsants. This is far higher than favorable outcome rates recorded in other studies.[8],[17],[22],[25],[27],[29] However, the outcome in this study is comparable to 80.4% reported by Ogunlesi et al.[10] in Sagamu Ogun State. The high rate of response to treatment could be due to the fact that the patients had no associated metabolic disorders or intracranial structural lesions that have been documented to cause poor response to AEDs.[22],[25] The good outcome can also be attributed to commendable adherence to medication. As a matter of policy, members of the neurology teams regularly and closely interact with the patients every clinic day. The interactions include listening to the patients on their experience with the ongoing treatment, allowing them bare their minds on side effects of drugs and encouraging them to share their experiences. The members of the team, on the other hand, take time to explain to the patients, the possible consequences of stopping treatment or taking the medications erratically. Poor adherence to AED is a known impediment to good outcome.[24]

It is hoped that with the information obtained in this study, the development of appropriate treatment and management plan in this center will sustain the good outcome already obtained.

Recommendations

The study would give better prevalence results if, in the future, the study is made more of a community-based study. This would help pick up more of the patients who prefer to patronize the traditional healers but refuse to present themselves at the hospital.

It is equally recommended that a more collaborative study with other centers within the South Eastern part of the country be carried out. Results from this study will hopefully produce a uniform treatment/management platform.


  Conclusion Top


Epilepsy is still a common childhood neurologic morbidity that may be under reported in our environment. It is, therefore, imperative that deliberate efforts are made to reduce the burden of this disease through health education, training of birth attendants, and early presentation to a health facility for treatment.

Limitation

The study was hospital based and results obtained may not be quite comprehensive. There was also no room for long-term follow-up of the children.

Authors contribution

OCO: Conceptualization and design of the study, Data collection and writing of the manuscript; EDO: design of the study, data collection, and revision of the manuscript; ACO: Manuscript writing and revision of the manuscript; MVU: Manuscript writing, revision of the manuscript and correspondance.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflict of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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