Etiology and Management of Pediatric Seizures: A Descriptive Cross-Sectional Study

 

Vinodkumar Mugada^*, Raj Kiran Kolakota

Department of Pharmacy Practice, Vignan Institute of Pharmaceutical Technology, Duvvada, AP, India

 

ABSTRACT:

The aim of the study was to know the etiology and types of various seizures in all children of age less than six years and to determine the type of management of seizures. This was a descriptive cross-sectional study carried out on 109 pediatric patients. Purposive sampling technique was employed for sampling. Patients of age less than six years and who are willing to cooperate were included in the study. Children with other diseases and critically ill patients were excluded from the study. 40.3% (44) children experienced their first seizure when they are less than one year of age (26 were males and 18 were females). 62.3% of children had common generalized tonic-clonic seizures. Febrile seizures were the most common cause among the children. Monotherapy was administered to the majority of patients (58.7%). Phenytoin was the most commonly used antiepileptic drug in patients receiving monotherapy. Febrile seizures are common and they can be effectively managed by using Phenytoin as monotherapy.

 

 

 

INTRODUCTION:

Epilepsy is a condition characterized by recurrent (two or more) unprovoked seizures occurring 24 hours apart.¹ Seizures in a newborn are one of the few neonatal neurological emergencies where prompt diagnostic and therapeutic plans are necessary; a delay in therapy results in poor neurological outcome.² Focal seizures are often preceded by certain experiences, known as an aura.³ These may include sensory, visual, psychic, autonomic, olfactory or motor phenomena. In a complex partial seizure, a person may appear confused or dazed and cannot respond to questions or direction. A focal seizure may become generalized.⁴

 

Jerking activity may start in a specific muscle group and spread to surrounding muscle groups—known as a Jacksonian march. Unusual activities that are not consciously created may occur. These are known as automatisms and include simple activities like smacking of the lips or more complex activities such as attempts to pick something up. ^[5] Generalized seizures, There are six main types of generalized seizures: tonic-clonic, tonic, clonic, myoclonic, absence, and atonic seizures. ⁶

 

They all involve a loss of consciousness and typically happen without warning. Tonic-clonic seizures present with a contraction of the limbs followed by their extension, along with arching of the back for 10–30 seconds. A cry may be heard due to contraction of the chest muscles. The limbs then begin to shake in unison. After the shaking has stopped it may take 10–30 minutes for the person to return to normal. Tonic seizures produce constant contractions of the muscles. The person may turn blue if breathing is impaired. Clonic seizures involve shaking of the limbs in unison. Myoclonic seizures involve spasms of muscles in either a few areas or generalized through the body.⁷ Absence seizures can be subtle, with only a slight turn of the head or eye blinking. The person often does not fall over and may return to normal right after the seizure ends, though there may also be a period of post-ictal disorientation.⁶ Atonic seizures involve the loss of muscle activity for greater than one second. This typically occurs bilaterally (on both sides of the body).⁵

There are many possible etiologies of the first attack of seizure in children, including infection, neurologic/developmental causes, traumatic head injury and metabolic disturbances. ⁸ The common etiologies of seizures are determined by the geographical variations. Febrile seizures (FS) are reported in many studies to be the most common type of seizures seen in the pediatric population, and the majority being less than five years of age.⁹ Infections are the most associated causes and have a good outcome.¹⁰

 

The conventional antiepileptics are still the main modality of epilepsy treatment in Asian children even after the availability as well as the safety of newer antiepileptics, like Valproate (about 40%). Valproic acid was advised mostly followed by carbamazepine and benzodiazepines. The newer antiepileptics are increasingly being prescribed 26.9% nowadays.¹¹ Monotherapy is recommended because of fewer adverse drug effects, absence of drug-drug interactions, better compliance, and lower cost compared to therapy with multiple AEDs.^12-15 Studies in developed countries with adequate resources for treatment have however shown that 17-40 % of children do not respond to the first drug used and may require multiple AEDs.^16-17 It has been suggested that the patients’ clinical characteristics such as frequent, focal and long duration of seizures, symptomatic or syndromic epilepsy, history of status epilepticus, and the presence of neurological deficits, is the primary reason for failure of the first AED, rather than drug related factors such as efficacy and adverse effects. The answers to these questions are important because the inadequate response to initial treatment with the first AED and subsequent treatment with multiple AEDs is believed, in itself, to be a poor prognostic factor in epilepsy.^18-20 The aim of the study was to know the incidence, aetiology, and types of various seizures in all children of age group 5 months to 6 years and to determine the type of management of those seizures in pediatric I.C.U/ward in a tertiary care hospital.

 

MATERIALS AND METHODS:

Study site: Inpatient department of Pediatrics, Visakha Institute of Medical Sciences, Hanumanthawaka, Visakhapatnam.

Study Duration:

March to August 2018(6Months).

 

Study Design:

Descriptive cross-sectional study.

 

Sample Size:

The sample size n and margin of error E are given by

x = Z ( ^C / ₁₀₀)²r(100-r)

n = ^Nx/((N-1) E² + x)

E = Sqrt[^(N-n)x/_n(N-1)]

Where N is the population size N = 150, r is the fraction of responses that you are interested in r = 50%, Z(C/100) is the critical value for the confidence level c, Z(C/100) = 95%. By applying the above formula the Sample size obtained is 109.

 

Source of data:

Patients, Patient caretakers, case sheets. A data collection form which suits our present study was framed. It contains demographic data like name, gender, child’s age, location, and age of the first onset of seizure, symptoms, duration, and type of seizures, the cause of seizure, final diagnosis, clinical data, and treatment. The questions were asked to the patient or their caretaker regarding their past history, family history, symptoms regarding the seizures.

 

Sampling Technique:

Based on the nature and aim of the study, a purposive sampling technique which involved using a predefined group of study subjects was used. This sampling technique would enable to obtain specific and relevant information about a group of the pediatric population with seizures. The selection process can be described as purposive, judgmental based on strict selection criteria for the participants.

 

Ethical committee approval:

The study was approved by the Institutional Ethics Committee. Patient consent was taken from the subjects who were willing to cooperate.

 

Participants:

Inclusion criteria:

1.    Pediatric patients, aged between 5 Months to 6 years and of either sex who presented with seizures with any etiology.

2.     Those who are willing to participate in the study.

 

Exclusion criteria:

1.    Children who are having diseases other than seizures.

2.    Children with age less than 5 Months and more than 6 Years.

3.    Seizure cases who expired immediately after hospitalization (before diagnosis).

4.     Not willing to give consent.

Data collection and analysis:

The data was collected from the case sheet and from patient caretakers wherever applicable. If the data was collected from patient caretakers, then the aim and objective of the study were explained clearly. A data collection form which suits the present study was prepared and data was collected accordingly. Collected data was tabulated and analyzed at the end. Frequency and percentage were calculated.

 

RESULTS:

 

Table 1: Age at which first seizure occurred

Age at which first seizure occurred	Males	Females	Total	Percentage
<1 Year	26	18	44	40.3%
1-2 Years	18	15	33	30.3%
2-3 Years	9	7	16	14.6%
3-4 Years	5	3	8	7.3%
4-5 Years	2	1	3	2.7%
5-6 Years	2	3	5	4.5%
Total	62	47	109	100%

 

In our study the majority of children suffered first seizure at age less than one year (40.3%) as shown in Table 1. This was followed by children of age between 1-2 years (30.3%)

 

Table 2: Type of seizures diagnosed in children

Type of seizures	Males	Females	Total	Percentage
GTCS	39	29	68	62.3%
Tonic	14	12	26	23.8%
Clonic	2	2	4	3.6%
Partial	5	4	9	8.2%
Absence	1	0	1	0.9%
Myoclonic	0	1	1	0.9%
Total	61	48	109	100%

 

In our study, as shown in Table 2, majority of children (62.3%) are diagnosed with Generalized Tonic Clonic seizures. This was followed by Tonic seizures (23.8%).

 

 

Table 3: Etiology of Seizures

Etiology	Males	Females	Total	Percentage
Febrile seizures	19	14	33	30.2%
CNS Infections	19	13	32	29.3%
Cerebral palsy	10	9	19	17.4%
Neurodegenerative disorders	5	1	6	5.5%
Metabolic disorders	2	2	4	3.6%
Intracranial hemorrhage	0	2	2	1.8%
Drug withdrawal seizures	0	2	2	1.8%
Tumors	2	0	2	1.8%
Idiopathic	2	3	5	4.5%
Others	3	1	4	3.6%
Total	62	47	109	100%

 

 

 

In our study, febrile seizures were found to be the common etiology for seizures in children (30.2%). This was followed by CNS infections (29.3%) as another etiology of seizures.

 

Table 4: Type of therapy

Type of Therapy	No. of patients	Percentage
Monotherapy	64	58.7%
Phenytoin	30	27.5%
Clobazam	23	21.1%
Sodium valproate	8	7.3%
Levetiracetam	3	2.7%
Combination therapy	45	41.2%
Dual therapy	30	27.5%
Triple therapy	11	10.1%
>3 Drugs	4	3.6%

 

In our study majority of children are treated with monotherapy only (58.7%). Among monotherapy, Phenytoin was the most commonly prescribed antiepileptic drug (27.5%) followed by clobazam (21.1%). Dual therapy was prescribed in 27.5% patients.

 

DISCUSSION:

Seizures have been found to have a higher incidence in younger children in many studies with a decreasing frequency in the older age group, and are found to be more common in males. Similar results were observed in our study wherein out of a total of 109 subjects ( 62 males and 47 females), 44(40.3%) children experienced their first seizure when they are less than 1 year of age (26 were males and 18 were females). 33(30.3%) children had their first seizure between the age of 1year to 2 years (18 were males and 15 were females). 16(14.6%) children experienced their first seizure in between the age of 2years to 3years (9 were males and 7 were females). Beslow et al ²¹ reported that 60 percent of subjects with ICH has their seizure incidence during their perinatal period. Naik et al ²² reported 4.4% cumulative incidence of febrile convulsions and are more common in males than females with a male to female ratio of 1.3:1. Inamdar et al ²³ reported a higher incidence of seizure cases in neonates when compared to the other age groups of children. Singh et al ²⁴ reported a decrease in Incidence of seizures with increasing age 6 months to 5 years age group seems to be more susceptible because this is the age group which has a high incidence of febrile seizures as well they are more prone to CNS infections and metabolic derangements. Jan et al ²⁵ observed that the age-specific incidence for meningitis presenting as seizures was highest in the first year of life.

 

The most common type of seizures observed during our study period were generalized tonic-clonic seizures followed by generalized tonic seizures. 68(62.3%) children had the most common generalized tonic-clonic seizures. 26(23.8%) had generalized tonic seizures. Similar findings were reported by Singh et al ²⁶, Arpita et al ²⁷. Mwipopo et al ³¹ reported generalized seizure mostly tonic-clonic was the predominant type of seizures seen in 98.0% children while 98.4% of them were febrile. Children with focal seizures were only (2%) and (50%) of them had status epilepticus.

 

Febrile seizures accounted for 30.2% of pediatric seizures in our study and are the most common cause among children less than 5 years of age. The next most common etiology was CNS infections which accounted for 32 cases (29.3%). CNS infections were also the most common causes of seizures in our study almost similar to the febrile seizures. Sudhir et al ²⁵ stated that febrile seizures (53.0%) were the main etiology of the first attack of seizure in children less than 5 years of age. CNS infections and febrile convulsions were common causes of seizures in febrile children. Chun et al ²⁸ found that febrile seizures (62.1%) were the main etiology of the first attack of seizure in patients presenting at the ED, and upper respiratory tract infections and systemic viral infections (45%) were the main underlying diagnoses in this group of children. Shetty et al ²⁹ reported that most of the acute symptomatic seizures are caused by febrile seizures, CNS infections like meningitis and encephalitis, neurocysticercosis. Sahin et al ³⁰ stated that CNS infections were also the most common causes of seizures among children in their study.

 

Management of seizures requires the use of antiepileptic drugs and selection of the antiepileptic drug depends on the type of seizure. Initially, a single drug (monotherapy) is given to abort the seizure and if not successful a combination (dual or triple therapy) is given until the required therapeutic outcome is obtained. In our study monotherapy was found to be given in more patients compared to the combination therapy. Monotherapy was given in 64(58.7%) patients while a combination therapy is given in 45(41.2%). Phenytoin was the most commonly used antiepileptic drug in monotherapy (27.5) patients. Next commonly used antiepileptic drug was clobazam in 23(21.1%) patients, followed by sodium valproate in 8(7.3%) patients and levetiracetam in 3(2.7%) patients. The most commonly used drug combinations were phenytoin and midazolam, phenytoin and clobazam and others.

 

 Ragnar et al ³² reported that monotherapy was sufficient in controlling the majority of pediatric seizures. In his study, 77% were on monotherapy. Rita et al ³³ reported 42 patients were on dual therapy while three were on triple therapy. The most common drug combination was sodium valproate and carbamazepine, (75.5 %) followed by carbamazepine and phenobarbitone, (13.4 %) and sodium valproate and phenobarbitone, (4.5 %). Of the 94/139 participants on monotherapy, 38.8 % were on carbamazepine only, 26.6 % were on sodium valproate only, two were on phenobarbitone and one was on phenytoin only. Children using multi AEDs had a higher number of daily seizures compared to children on monotherapy. Children on multi AED were also less likely to have attained good seizure control (p < 0.001). Nagendra et al ³⁴ reported that phenytoin was the most commonly preferred antiepileptic drug (58.3%) in treating seizures followed by valproate (32.7%). The reason for widespread use of phenytoin could be because of its easier availability and cheaper cost in developing countries like India. Abend et al ³⁵ reported that the most commonly administered first AEDs were levetiracetam in 38%, Phenobarbital in 31%, phenytoin–fosphenytoin in 28%, and valproate in 4%. Sahin et al ³⁰ reported that intravenous midazolam was administered to 48.9% of the patients in first-line therapy consistent with the literature. Saz et al ³⁶ reported that most cases of Status Epilepticus can be treated successfully with first-line medications (e.g., diazepam, lorazepam, phenytoin, and Phenobarbital). However, approximately 15% to 30% of the episodes are refractory to this conventional therapy. In our study, we also found that continuous midazolam infusion up to 1.2 mg/kg/min was effective in 89% of the children with refractory Status Epilepticus without significant side effects.

 

CONCLUSION:

The most common type of seizures observed during our study period were generalized tonic-clonic seizures followed by generalized tonic seizures. Febrile seizure accounted for 30.2% and is the most common cause seen among children less than 5 years of age. In our study monotherapy was found to be given in more patients compared to the combination therapy. Monotherapy was given in 64(58.7%) patients while a combination therapy is given in 45(41.2%). Phenytoin was the most commonly used antiepileptic drug in monotherapy (27.5) patients.

 

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Accepted on 04.11.2018            © A&V Publications All right reserved