|Year : 2016 | Volume
| Issue : 1 | Page : 1-4
Challenges in the management of pediatric epilepsy in Nigeria
Wilson Chukwuneke Igwe
Department of Pediatrics, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria
|Date of Web Publication||17-Dec-2015|
Wilson Chukwuneke Igwe
Pediatric Neurology Unit, Department of Pediatrics, Nnamdi Azikiwe University Teaching Hospital, PMB 5001, Nnewi, Anambra State
Epilepsy is a disorder that is associated with a lot of social stigma and diverse cultural beliefs as to its causation and management. Effective management often relies on the following: Clinical information obtained from the patient and corroborative eye-witness account/s; supportive ancillary laboratory investigations; use of appropriate drugs for sufficiently long periods; and adherence to the prescribed treatment. The valuable information and the supportive ancillary tests are often lacking in resource-poor countries, thus posing a lot of problems to the clinician managing epilepsy in these settings. This paper is based on the author's clinical experience and a review of relevant papers from 33 review articles sourced from PubMed using the search terms “pediatric epilepsy,” “management challenges/difficulties,” “sub-Saharan countries.” Practical solutions to overcome these difficulties are also proffered.
Keywords: Challenges, management, pediatric epilepsy
|How to cite this article:|
Igwe WC. Challenges in the management of pediatric epilepsy in Nigeria. Trop J Med Res 2016;19:1-4
| Introduction|| |
Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. It is the commonest chronic neurologic disorder in children, affecting about 10.5 million children in the world. The majority of these children live in developing countries, including Nigeria. Although about 80% of these children with epilepsy (CWE) reside in developing countries, the majority of these children receive little or no treatment. Pediatric epilepsy care in Nigeria is plagued by a weak health-care system, few available pediatric neurologists, and nonavailability of quality drugs with appropriate formulations for different pediatric age groups. The social stigma, myths, and misconceptions associated with epilepsy often prevent people with epilepsy from seeking orthodox medical help. As children depend on caregivers for decisions on medical treatment, a caregiver's perception and attitudes toward epilepsy will significantly influence both the choice of and compliance to treatment. These factors make the identification of children with epilepsy and the provision of effective care very challenging. This review highlights the challenges of pediatric epilepsy care in our local setting and suggests practical solutions to overcome these difficulties.
| Burden of Pediatric Epilepsy|| |
Studies have shown that epilepsy is the commonest childhood neurological disorder in Nigeria.,,, Across various hospital-based studies in Nigeria, the prevalence rate ranges 45.3-75.4%.,, A majority of these CWE were observed to belong to the low socioeconomic class., However, these studies, being hospital-based, are not truly representative of the burden of childhood epilepsy in our environment for many reasons. Epilepsy is regarded by many as a spiritual problem and hence not amenable to medical treatment. Moreover, social stigma, poverty, ignorance, and sociocultural beliefs and practices usually present challenges to the epidemiological study of epilepsy., Because of misconceptions, only a small fraction of CWE are brought for medical treatment, and thus health services are of limited value in conducting epidemiological research on epilepsy. The few community-based epidemiologic studies done so far in Nigerian communities have reported prevalence rates ranging 4.3-6.2 per 1,000 for active epilepsy.,, Even though these studies were inclusive of both adults and CWE, a higher percentage was noted in children. Community-based studies are, therefore, inevitable to correctly assess the true burden of pediatric epilepsy.
| Treatment of Pediatric Epilepsy|| |
Successful management of epilepsy begins with an accurate diagnosis, followed by treatment with an appropriate anti-epileptic drug (AED) in a manner that optimizes efficacy. The goals of pediatric epilepsy treatment include: Significant seizure reduction/complete seizure control, absence of adverse drug reactions that can affect the child's development, and ensuring the best quality of life for the child. The treatment of pediatric epilepsy often presents multiple challenges to clinicians in resource-poor countries for many reasons. Epilepsy is still considered by many today as medically incurable. As a result, many resort to various traditional and spiritual remedies that offer no proven efficacy. Moreover, many of the misconceptions about epilepsy prevalent in the local population are also held by some health professionals who are even unaware of the long-term treatment required in epilepsy care., In many cases where AEDs have been used, they are administered for sufficiently long periods and are often given in inadequate doses. Nonadherence to long-term treatment may partly explain the poor response and thus lack of confidence the population place in medical treatment of epilepsy., Moreover, many CWE are treated before referral with suboptimal doses of AEDs, thus leading to poor seizure control. Significant adverse effects occur when such patients receive relatively higher doses of these medications. This often results in caregivers discontinuing treatment. Weaning these patients off these AEDs and reverting to monotherapy with the appropriate AED often leads to fewer side effects and better seizure control.
Noncompliance is a serious barrier to successful treatment and a major cause of seizure breakthrough., Major reasons for noncompliance include inconvenient dosing, complicated regimens, costs of treatment, and adverse drug reactions. Once- or twice-daily dosing often ensures higher rates of compliance. Serum drug monitoring also helps in detecting and confirming poor compliance. This, however, is an additional financial burden to epilepsy care that is usually borne by the caregiver and it is not readily available in many centers in Nigeria.
Ideally, the choice of AED is based on seizure type/or syndrome. Some AEDs when given inappropriately may even potentiate some seizure types—for example, carbamazepine may increase seizure frequency for absence seizures. The nonavailability of drugs poses a challenge to effective epilepsy care. Even though about 80% of people with epilepsy live in developing countries, they have access to only about 20% of the available AEDs. The most commonly available generics of AEDs include phenobarbitone, clonazepam, diazepam, carbamazepine, phenytoin, and valproate.,,, Among these drugs only carbamazepine and valproate are currently readily available in liquid formulations for pediatric age groups. Effective care is thus limited by the lack of pediatric formulations. Sadly, many of these generics are of substandard quality, too. Efforts aimed at the provision of quality drugs with appropriate pediatric formulations will go a long way in achieving good seizure control.
Many patients with epilepsy do not receive appropriate treatment, a phenomenon known as the treatment gap.,,, The epilepsy treatment gap is the difference between the number of people with active epilepsy and the number whose seizures are being appropriately treated in a given population at a given point in time, expressed as a percentage. Nwani et al. in a local epidemiologic study observed an overall treatment gap of 76% in Southeast Nigeria: Those who were never diagnosed accounted for 38% (diagnostic gap), while those who were diagnosed but discontinued treatment at their own volition (therapeutic gap) accounted for another 38%. In the case of pediatric patients, decisions regarding treatment are usually taken on behalf of the patient by his/her caregiver/s. Thus, a caregiver's beliefs and perception will influence treatment decisions in pediatric epilepsy management. Moreover, many CWE despite being diagnosed and started on AEDs are soon lost to follow-up and thus discontinue treatment. The caregivers often stop treatment immediately seizures are controlled. Among the usual reasons given by these caregivers for discontinuation of treatment are an erroneous belief that the child have been cured, the high cost of drugs, and lack of information on the consequences of discontinuing treatment.,, Nwani et al. noted that the main reasons for discontinuing treatment included: Persistence of seizures despite use of AEDs, lack of adequate counseling on the need for regular medication, nonavailability of drugs in the community, high cost of drugs, fear of stigma, and fear of drug side effects. However, with adequate counseling on the need for regular medications, appropriate education to dispel misconceptions about epilepsy, and the provision of cheap and high-quality generics, the high rate of treatment gap can be reduced.
| Diagnosis|| |
The diagnosis of epilepsy is a clinical judgment based on detailed medical history obtained from the patient and a corroborating eyewitness account. The accuracy of the diagnosis often depends on the skill and the experience of the physician, and on the quality and reliability of the information provided by the patient and witnesses. Nonverbal children or even verbal children cannot fully express themselves or clearly describe their symptoms. The history has to be obtained from the caregiver, who often may not fully describe the child's presenting features. Video electroencephalographic (EEG) monitoring will be invaluable in such circumstances. CWE are brought for medical treatment when treatments in traditional and spiritual homes have failed. This is often one of the reasons for significant delays in making the diagnosis and the recognition of the etiology of epilepsy in our local settings. These delays may have an impact on the development and cognition of the children. The label “epilepsy” is, unfortunately, still socially unacceptable and mistakes must be avoided in the diagnosis. It is, therefore, necessary to accurately differentiate epilepsy from nonepileptic paroxysmal events, which are very common in children. Events that may be confused with seizures include syncope, transient ischemic attack, sleep disorders, and psychogenic nonepileptic seizures. A detailed medical history supported by video EEG, if available, will differentiate these nonepileptic events from seizures. Some seizure types, for example nocturnal and absence seizures, may be more easily overlooked than the generalized tonic-clonic seizures that are more obvious paroxysmal motor events. A wrong diagnosis of epilepsy in a patient who does not have epilepsy could condemn him/her to the long-term, even lifelong, inappropriate use of AEDs, with consequent adverse effects and at a considerable cost. In addition, the wrong diagnosis of a seizure type in a patient with epilepsy will also lead to similar consequences. As a result of the existence of only a relatively small population of pediatric neurologists in the country, errors often occur on the side of wrong or missed diagnosis in pediatric epilepsy care. The diagnosis of epilepsy is mainly clinical supported by diagnostic tests, primarily EEG and neuro-imaging studies. Unfortunately, these ancillary tests are not readily available and are very costly in places where they are available. The absence of readily available EEG diagnostics with quality recordings and interpretation poses a great challenge to the effective management of patients with epilepsy. In the few places where EEG services are available, there are no minimum standards for an EEG laboratory and no professional authorities to ensure quality control. Consequently, EEG is very frequently misinterpreted, leading to overdiagnosis. The provision of quality EEG machines and training on recordings with interpretations will help in epilepsy management. The knowledge of epilepsy and its management is limited among primary and secondary health staff professionals who see the majority of these patients before referral. These patients often receive inappropriate doses of medications and they are not given for sufficiently long time. The provision of continuing medical education on epilepsy management will significantly improve pediatric epilepsy care at this level of care.
| Social Issues|| |
Misconceptions about epilepsy and the resulting social stigma often cause Distress to persons with epilepsy and their families. The public reluctance to disregard such myths and misconceptions also poses a great challenge to epilepsy care in our local settings. Several misconceptions associated with epilepsy have been noted as one of the reasons why CWE are brought in late for medical treatment. The duration between the first attendances for treatment depends on these cultural beliefs and the caregiver's financial status. In general, it is only after many months or even years of failed attempts to control seizures, using many options, that the child is brought for medical treatment. Adolescents with epilepsy often fear rejection from their peers and struggle to be accepted, as they do not see themselves as different from their peers.,,
| Goals of Management of Pediatric Epilepsy|| |
Unfortunately, CWE in our local settings are yet to benefit from the scientific, medical, and social advances of meeting today's goals of “no seizures, no side effects of treatment.” Governments in developing countries should dedicate efforts to enable all persons at risk to achieve their full potential. Making progress in epilepsy care will require medical personnel and lay epilepsy organizations to work together to:
- Educate the public to promote awareness and dispel the misconceptions and stigma associated with epilepsy
- Ensure regular supply of quality AEDs with formulations appropriate for different pediatric age groups
- Provide continuous medical education for practitioners at the first and secondary levels of care to diagnose epilepsy and initiate the appropriate AED according to seizure type. Caregivers must be counseled on the need for compliance and adherence to treatment, which is often for a prolonged period
- Set up a standardized EEG laboratory with adequate training on recordings and interpretation to complement the clinical diagnosis of epilepsy
- Provide continuous training and retraining of neurologists and nurses on advanced epilepsy care
- Undertake community-based research to correctly assess the burden of epilepsy in our local settings. This will go a long way toward the planning and effective management of CWE, thus reducing the treatment gap.
| Conclusion|| |
The need for CWE in our environment to benefit from the tremendous progress in the social and clinical management of epilepsy that has been achieved in advanced societies cannot be overemphasized. Widespread poverty, illiteracy, and an inefficient health-care system still continue to pose challenges to effective pediatric epilepsy care in our environment. In addition, the social stigma and misconceptions associated with epilepsy often pose a great barrier to effective epilepsy care in our local settings.
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