Part three Common causes of seizures and epilepsy
Many factors have been identified as etiological for epilepsy, depending on the type. It has earlier been mentioned that some individuals are born with reduced threshold for aggregates of neuronal excitation to become excitable by normal and abnormal neuronal firing, while that for inhibition is actually elevated, This also partly explains why a medication like Tegretol for instance will control epilepsy in one individual while in another person of the same age, biological sex and body mass index (BMI) twice the same dose will be required to produce favorable outcome. Doctors therefore use their professional discretion to titrate anti seizure drugs used for the purpose of aborting attacks and carefully select the ones needed for maintenance.
In general some of the causes are as enumerated below;
First year of life
Problems that will give rise to convulsion in infancy may actually have begun in the mother (while child was still in the womb)
Particularly in the third trimester(last three months of pregnancy), any febrile illness from viral and bacterial infections such as Hepatitis B, Syphilis, HIV/AIDS particularly with organopathies (evidence of disseminated disease) severe maternal malarial parasitaemia
Drug use and abuse during pregnancy—alcohol (withdrawal), coccaine, caffeine,
Meatabolic diseases affecting mother…. Such as Diabetes mellitus, Hypertension, Preeclampsia, Eclampsia(pregnancy associated seizure disorder with or without elevated blood pressure )
Underage pregnancies, Grand multiparity (successful pregnancies up to five or more), old primigravid (getting pregnant at age 35and older), multiple pregnancy(twins, triplets, quadruplets ,quintuplets, etc especially with use of fertility enhancing drugs and assisted reproductive technology(ART)
Obstetric complications(problems in pregnancy severe enough to require medical intervention outside of routine antenatal care) leading to instrumental deliveries. Bleeding problems in pregnancy such as major degree Placenta praevia, abruptio Placentae( premature separation of a normally situated placenta)
All sorts of problems associated with disproportion –feto pelvic (FPD), cephalopelvic (CPD), premature, prelabour rupture of membranes (PPROM)—burst and leakage of liquor before actual labour begins creates an unprotected passageway for ascending infection right up to the fetus, Trial of labour with excessive use of Oxytocin, popularly referred to as hot ‘injection
Babies born small for date, Small for age, with low APGAR scores (babies unable to cry, grip a finger, breathe spontaneously as he takes the first breathe outside mothers womb, babies born to un booked, malnourished mothers. Trauma …birth injuries involving the head, neck and trunk, in half of cases affect the rest of the central nervous system, but manifestation may not be immediate. Metabolic disorders such as Hypoglycemia leading to low blood sugar could occur in children born to diabetic mothers. They may also occur on their own as part of inherited disorders arising from errors of metabolism. Hypoglycemia could also arise in concert with hypocalcemia, as secondary complications of birth trauma
Infections of the brain—meningitis, infestation by cysts of tape worms(cysticercus)
Infections from the eyes, ear and mouth spreading into the brain
CNS abnormalities – include medical conditions of the head, neck and brain present at birth –hydrocephalus, when eyes are set low , chin receding or unusually small, head flat like bread loaf, or had shaped like electric bulb, sometimes with a horn pointing upwards at the point of glabella , double heads, or collapsed scalp where eyes stick out like a frog – all these should warrant special attention, because, the brain substance itself may have taken it’s own share of the congenital abnormality—even those found down below at the genital region.
Others: Seizures due to inborn errors of metabolism
•Convulsion in the first few days of life may arise in families known to have other inherited brain disorders as can be demonstrated via procedures using genetic linkage analysis
•Vitamin B deficiency such as Pyridoxine (vitamin B6) deficiency and abuse of multivitamin supplements.
•Babies of mothers using drugs such as cocaine, heroin, or ethanol apart from damage to the brain, these babies are also at very high risks of developing drug-withdrawal seizures in the first few days after delivery.
Adolescence Many of the conditions capable of causing seizures in early childhood can also give rise to seizures and epilepsy in older children up to the age of 14, many of these can still be traced back. In this period and most of the teen years, accidents from various sources can affect the brain and cause permanent damage. Acquired conditions of the central nervous system(CNS ):- head trauma, infections –fungal, viral .-encephalitis, parasitic infections such as cysticercosis, brain tumors, congenital CNS abnormalities, use of hard drugs(Indian hemp, cocaine, heroin alcohol(abuse and withdrawal). Stress is diabetogenic and can induce hyperglycemia to blood levels outside the capacity of endogenous insulin. Stress on it’s own can cause direct insult by its effect on the cholinergic pathways, particularly in young teenagers using combination of hard drugs—they first stimulate the CNS and then depress the neurons. Up to ten years or more may pass before the first attack of seizure and the more severe the injury ,the higher is the risk of developing epilepsy later in life. Metabolic disturbances such as electrolyte imbalance, hypo- or hyperglycemia, renal failure, and hepatic failure may cause seizures at any age. Similarly, endocrine disorders and problems of abnormal hemoglobin and many other systemic diseases may cause seizures over a broad age range.
Febrile Seizures
Febrile seizures may be defined clinically as seizures associated with fevers but without evidence of infection of the brain and its branches of nerves.
Though an overall prevalence of 3–5% has been reported, this is likely to be higher in some parts of the world, such as Africa, Asia and Latin America. Febrile illness occurs more in males than females, infection common cause.
Family history of febrile seizures or epilepsy is often present though recall is always a problem.
Usually occurring between 3 months and 6years of age, peak incidence is between and include 18 and 24 months. Absence of previous attack, may be helpful in the diagnosis and management-if one remembers to ask .There is associated delay in milestones of development – smiling to mother, holding neck erect sitting, crawling all coming late compared to other children of the same or other families
How do they present?-pattern recognition.
Two main types have been observed ;
Typical form of febrile seizure has a duration usually less than ten minutes, may occur once and is never experienced again for rest of the child’s life .
Atypical febrile seizures type on the other hand lasts more than 15 minutes and several episodes may occur in a 24 hour period; affected kids are usually less than I year old on the average and, risk of epilepsy later is real. Most patients have a family history of convulsion and in a few cases of epilepsy. Some groups use the words simple and complex to describe typical and febrile seizures respectively.
Febrile convulsion may begin with what appears to be mild fever in association with malaria. Its commonly seen with other common childhood infections of the ear, nose throat, and with gastroenteritis, measles, meningitis, and eyes, and then without warning, the picture changes very quickly as the child stretches out (usually generalized, tonic-clonic seizure )during a febrile illness with eyes rolling upwards ,face turned to one side (contralleteral gaze). The seizure is likely to occur during the rising phase of the temperature chart of a febrile illness such as malaria, typhoid or bronchopneumonia
An episode of febrile convulsion is most likely to be missed in cases where subclinical doses of drugs are given and other forms of management are poor due to poverty . Watch the child closely during the periods of temperature spike when the child wants to be left alone, he is hot to touch, skin is dry, eyes are glassy and face is dull.
Status Epilepticus
This condition is usually diagnosed when a seizure attack continues for about half an hour or more without the patient regaining consciousness. It is usually a medical emergency because in a small but significant number of cases, patients quickly go into respiratory arrest and consequently respiratory failure. They can also develop renal shut down and eventually kidney failure from the ceaseless muscle contractions and breakdown of muscle protein.
When a child who is convulsing ceaselessly not making urine in between attacks, you should worry about kidney shut down
Brain death is almost inevitable if the convulsion continues without proper medical attention
In such situations, there are a few things you can do before the Doctor arrives or before you get to the Hospital, as packaged under the acronym ABC- ensure patient has enough air going in and coming out – an individual usually breathes in oxygen and sends out carbon dioxide, whereas too much oxygen can damage brain structures, retaining carbon dioxide patient is far more dangerous. The brain substance in itself does not produce pain and so patient may die by simply from going into deep sleep.
When you pour crude oil down the throat of a convulsing person or child, you block both breathing and movement of air, and when you sit the patient up instead of allowing him to lie down, you help the saliva and other slimy secretions and your crude oil to enter the lungs and kill the child, Crude oil irritates the eyes and can permanently damage the cornea. Oil also increases the probability of developing dangerous lipoid pneumonia and the time it takes for food to digest and so the child becomes congested and dies from a combination of problems ,some arising from bad management.
Where it is not possible get proper medical attention , you can not avoid going to the chemist nearest to you, but the temptation of drip(intravenous fluids) should be avoided , because something that narrows the blood vessels and prevents the child urinating is already being produced in excess and there is congestion every where most importantly congestion in the brain. Doctors may put special kinds of drips but leave that for pediatricians; children are much too delicate to try things you are not too familiar with.
What to do when there is a seizure?
Remain calm and don’t panic—will help you ponder over possible questions the Doctors might ask you when you eventually get to the Hospital .
What do you know? what can you really remember about your family medical history? What about your husband? Did he tell you any thing about seizure disorders or epilepcy concerning himself, family members? Social history of alcohol abuse , Indian hemp, if he has stopped, there could still be a connection. For the girl child, When did she see the last normal menses ? What about abnormal vaginal discharge ?
Has the child had appetite problems? Did you have to force him to take breakfast?
Watch and note important elements of the crisis -the way it all began; was there a cry? Strange smell?, picture of something no one else could see? Check position of head, trunk, limbs, pattern of cry. Eyes ,direction of gaze…eyes point and look in the direction of site of lesion in brain abscess, CVAS etc Check and note presence of saliva, urine, and fecal matter around the mouth, genitalia and anal region respectively. You must keep the child under close watch
Get someone to remove objects that can harm the patient from the place where convulsion is taking metal, planks, buckets, lantern and others. Ensure that nose and mouth are not blocked ,so child can breathe properly . Ensure breathing is not obstructed and blood is flowing freely——you can suck out saliva, cough and catarrh from the child’s mouth and nose if there is nothing available to use. Doctors and nurses do these freely without holding back when they have cases that require them to ,so you can do the same thing for your child
Remove whatever you see that can increase temperature or strangulate the child such as pieces of clothing, scarf or native amulets .Check that there is nothing in the mouth, because muscles of swallowing may be tightening. Take note of the movements ,the sound, position of the eyes, call child from time to time, pinch him to gauge his response .Do not apply hot objects to burn the child –it will trigger more seizure . Don’t put spoon in the mouth, YOU CAN CUT HIS TONGUE TO SHREDS .
What ever the child has taken that you find suspicious, drugs or mushroom etc, keep to show the Doctors
Bring the temperature down by dabbing and sponging the child in gentle stroke starting with the head, DO NOT USE COLD WATER, you can bring temperature down but you can hardly succeed in bringing it up when it goes down below 35 degrees in a child— It is much safer for blood to flow in the blood vessels to nourish violently contracting muscles and remove metabolic wastes from actively metabolizing tissues than to slow down the flow of blood in the tiny blood vessels, so use look-warm(slightly warm) water(tepid water)
MANAGEMENT
Management of these conditions usually will follow the established pattern of knowing the history, carrying out physical examination and laboratory investigations before drug treatment. One may not have to wait until the other one is completed. Parents and family members are advised to take note as events unfold because in places where resources are not readily available , much will depend on how much relevant information is obtained and how thoroughly, physical examination is achieved. The success of treatment also partly depends on adequate history and physical examination, especially in cases of febrile convulsion. The ultimate is to take the Child to the Hospital for thorough physical examination and laboratory tests including lumbar puncture.
GENERAL PREVENTIVE MEASURES
Governments can create awareness and encourage the empowerment of women via health education and improve primary health care so that malaria prevention methods are amplified. They can improve and monitor the supply of treated nets, supervise the clearing of compounds, provide anti malaria combination therapy drugs freely to children and solicit involvement of multinational companies. Detection of early cases of injuries and infections will enable early recognition and treatment of febrile illnesses and treatment of common injuries .
Provision of basic amenities such water, electricity, food, essential medicines, and attention to pharmaco vigilance makes sense of the presence of Government and improves confidence of ordinary people in the health care delivery system.
For Parents and Guardian know your history, including your family history, live by example, if you must drink and smoke, keep them away from your kids
Pregnant women should be encouraged to register for ANC and attend ante natal clinics regularly and to ask questions each time they go to clinic to clinic
Except prescribed by your Doctors, do not ingest any drugs because someone else used it for some other problem and it worked . Do also be careful about massage. Go to BTAS that are registered with appropriate authorities
The following actions are commonly brought to bear upon children who have no power to stop them ; they do not make children happy; but torture them and should be discouraged, because a child may go into seizure/convulsion or simply stop breathing and you will be shocked
· .holding a child vertically head down, except during birth for medical reasons
· .tickling a child for prolonged periods
· .closing the two ears of a child for too long
· shaking and throwing up a child
· .scare tactics with dogs, cats, lizards, snakes, live fish and birds, including domestic chicken
· Shaking of babies, throwing them up or tickling them.
· Rubbing dirt onto the face of a child
· Kissing another person’s child in the mouth or putting his mouth on your face , even when your personal hygiene cannot be vouched for and skin harbors bacteria like Staphylococcus aureus and fungi like Candida Albicans- they become harmful when they enter the delicate structure that kids have
· Punishing children by making them stoop, kneel, sit with hands behind or stand for long periods.
Ensure enough food. For children but don’t over feed…give your kids enough water
Control play activities of your kids and don’t rebuke each time a child has injuries; he will end up a recluse or hide away from you when he has wounds ; which can then become infected and cause other problems. Don’t allow sitting down to watch television for extended period of time.
Give your children enough room so they can confide in you without being disrespectful.
Observe normal behavior so you know when there are deviations from normal that herald the appearance of a seizure illness
For further reading and additional information, please see Harisson17, high yield Neuroanatomy, pediatric emergencies Mede books, Isilo etc
