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Tag: epilepsy

  • Common diseases of children Seizure syndrome, epilepsy and epilepticus in status

    Continued from last week

    There has been a stream of traffic since the article on the above subject emerged. Many people have sent texts and e messages asking questions and for assistance in one area or the other. Most of the questions have been persistent on drug treatment and permanent cure, and I felt it was necessary I clarified a few of these issues. Please be informed that relevant medical professional regulatory bodies do not allow prescription of drugs by text or e messages. You may have all sorts of information on the internet, but just as you have pictures on face book, what ever ways you use the information accessed on the internet and the results you get are entirely your responsibility. If a patent medicine shop attendant picks up something from a book and hastens to apply it to any patient who comes along, he may not have issues, but those who have passed through formal systems of doing things are more careful not to play heroes with precious human lives, because there are sanctions put in place

    Apart from seizures associated with fever, you really don’t want to talk about cure

    Emphasis rather is on knowing the medical history of your parents, brothers sisters, uncles etc, to the best possible. Knowing your own medical background and that of your husband, wife or the person you intend to marry, and on recognizing patterns of the different types when they occur, particularly when the patient is a child (up to age 14)

    During attacks, drugs are given in order to stop(abort) the seizure-this usually is the first thing a Doctor does, as he tries to find out possible causes and associations by asking so many questions. Stress had to be placed on the fact that you must be ready to answer these questions and not compound the efforts of the Doctor who in our environment is forced to rely on clinical judgment because, he does not have the benefits of expensive but very useful diagnostic machines. When seizures are due to obstructive lesions in the pathway for circulation of cerebrospinal fluid (CSF) for instance leading to hydrocephalus and the brain of an affected child becomes very large, abscess in the brain occupying space, tumor growing rapidly some where in the brain, abnormal metabolic patterns in the brain, injury to brain tissues etc – can very quickly be diagnosed with the aid of machines such as computed axial tomography (CAT) scan, positron emission tomography(PET)-for seizures where derangement in EUC and other metabolites is suspect, electroencephalogram(EEG), Multi analyzer etc all of which can give you results within minutes of arrival in Hospital,

    The drugs administered in respect of, how, when, where, -route of administration are all important .Equally important is knowing what not to give; these conditions are about the only ones in children where Doctors prefer the veins, the muscle, skin and the rectum/anus as safer routes to administer their drugs. They are also the conditions where they don’t rush to give drips( intravenous fluids)-here I am referring to medically qualified persons.

    Two or three people wanted to know about surgical treatment of these conditions in India-There is no doubt that Neuro surgeons in that country have made giant strides in the past few years, but we also need to stress that success or failure of surgical interventions involving the brain can only be assessed on individual basis.

    The reality of it all, is that results of surgery involving the brain in Children are not as forthcoming as the ease with which they are performed. Revision surgery is unavoidable in some cases and when they are seen the outcome are often talked about in whispers.

    Many people have also come to discover that not all persons who seek medical treatment overseas have success stories to tell – the death of the wife of a former Nigerian head of state in the hands of an experienced surgeon and in one of the best Hospitals overseas should drive the need to establish good health facilies here in Nigeria.

    Unfortunately those who should listen are not doing so-even when it is obvious that you can’t fly every one out. Nelson Mandela as President of South Africa did well to put the best facilities you can find on earth in South Africa ,and so when he developed respiratory problems, probably from reactivation of foci of M. Tuberculosis contracted during his prison years, he checked into one of such facilities, doing so with unalloyed confidence. Current information is that he has done so well he now views television will soon be discharged home – contrast that with the situation in here. Not too long ago, a prominent Nigerian went overseas after he had been given the not very pleasant diagnosis of late stage brain tumor and after taking him through several high medical tech machines, they couldn’t fault the diagnosis that was made here in Nigeria. They then asked him to come back here and undergo palliative care for the period left for him to live. He then began to ask questions, one of which was ‘where in Nigeria was he going to stay?” Officials of the Hospital then reminded him that dying in a hospital overseas from a terminal condition was a liability not a privilege.

    The huge problems facing the health sector and education have their origin in Godlessness, such that people in position do not consider the interest of ordinary people once they get to positions of authority. If those in charge of running the various systems adhered to the basic prescription for peace, love and harmony as provided by Jesus Christ-do unto others as you would have them do unto you, this country would have since swum out of the present situation of hopelessness, and as a result of this problem of arrant insincerity, the poor continue to die young, while the rich continue to buy every thing including health and education.

    Take for instance the current situation where Students in Public Universities are forced to idle way at home while their fellow Nigerians in private universities in their own country have continued to enjoy the academic momentum, because someone somewhere insists that an agreement signed over three years ago should be disrespected. Is it not egregious that a formidable constituency in the present dispensation like ASSUU is being treated with so much disdain and yet some labor unions known to be reasonably vocal and participatory at foreboding times like these have suddenly become amnesic? Why are those complaining about falling standards of education in this country, and who can not provide the yardstick employed not talking? It is for the reason that is now obvious; their children are studying overseas and so let the rain continue to fall into the houses of the other Nigerian students until Jesus comes back . So for majority of adult Nigerians the literacy score continues to drop, 68% before 2010, it is now below 50%, and with it the level of health education, in particular education concerning maternal and child care.

    Therefore in situations where survival is the matter, and one CT scan of the brain costs #60,00.00 (probably about 2 times total family income), parents are advised to be more concerned about preventing attacks of seizure or epilepsy – prompt treatment of malaria, typhoid, mouth, throat and ear infections etc, avoid creating unnecessary stressful conditions for other people, that way you don’t have it your self. A few days after the introductory part of this article was published, the pop music star, Chris Brown suffered a seizure said to have been caused by stress. Older children(teenagers 13,14) in this computer age are exposed to intra psychic conflicts, some of these arising from intuitive perceptions-social media, school work, house chores, family, peer pressure and so on, parents are expected to be involved in the lives of their children, one very successful way of doing this is fellowship with God.

    There is no over flogging the importance of taking children hospital in these conditions. One can only mention a few things on paper so that misunderstanding does not cloud good intentions. Once observed, you must be very warm and sympathetic to the affected child. He must receive love, attention and have access to all that there is to know about his illness Basic steps have been mentioned when attacks begin-lie patient face down, head turned to one side, don’t sit him up, so secretions will come out.

    Some one talked about hot sand or clay-these are dangerous in situations that subsist during attacks.

    Another person claims to have developed permanent herbal cure for seizures and epilepsy with guarantee, and says he is willing to engage who ever is interested for details, contact address will be provided to those interested.

    As concerns some maintenance drugs, do not adjust dosage or change drugs on your own, even if you have moved and a different Doctor has taken over.

    As regards dosage in children not working as expected – you must allow your Doctor titrate the dosage in graduated pattern until your child no longer has seizures-patience is important.

    About foaming in the mouth mixed with blood—This does not mean situation is getting out of hands, and it may arise when the tongue is trapped between the teeth. Very strong tonic contractions of the throat muscles can also cause it, more so if the condition goes into status epilepticus.

    I am awfully sorry I don’t have the time to reply text messages. You can call or send e mail.

    For the pastor who sought permission to use three previous articles and was given the go ahead at no cost. Kindly return this favour; send a copy of the magazine as you promised, please the spirit of God lead you to do what is right.

  • Common diseases of children: Seizure syndrome, epilepsy and epilepticus in status

    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