Prevalence and Risk Factors for Epilepsy in Children with Cerebral Palsy – A Prospective Observational Study
Karuppiah Pandi 1, Kumaran SS 2*, Gayathri S M 3
1 Associate Professor in Pediatrics, Sri Lakhsmi Narayana Institute of Medical Sciences, Puducherry – 605 502.
2 *Associate Professor in Pediatrics, Sri Lakhsmi Narayana Institute of Medical Sciences, Puducherry – 605 502.
3 AssociateProfessor in Pediatrics, Sri Lakhsmi Narayana Institute of Medical Sciences, Puducherry – 605 502.
Corresponding Author:
Dr. Kumaran SS,
AssociateProfessor in Pediatrics,
Sri Lakhsmi Narayana Institute of Medical Sciences, Puducherry Email Id: [email protected]
ABSTRACT
Objectives: to find the prevalence of epilepsy in children with cerebral palsy and assess the risk factors for epilepsy in children with cerebral palsy
Design: Prospective observational study
Setting: Pediatric OPD of Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry Subjects :79 children under 12 years of age with cerebral palsy were enrolled in the study Methods
Mothers or Caretakers of children with cerebral palsy who attended the pediatric OPD were interviewed to fill a printed structured questionnaire after consent. The details were recorded by the principal investigator. All children with cerebral palsy who had seizures were taken as cases.
Children with cerebral palsy who did not have seizures were taken as controls. The data collected were tabulated in a Microsoft Excel data sheet and analysed. The percentage of risk factors was estimated in both the cases and controls. Chi square test was done to calculate p value. Statistical analysis was carried out using SPSS 20.0. P value less than 0.05 was taken as statistically significant
Results
The total number of children with cerebral palsy recruited in our study is 79.Out of these 79 children, 46 (58.2%) had seizures and the remaining 33 (41.8%) children did not have seizures.
Hence the prevalence of seizures/epilepsy in children with cerebral palsy as per our study is 58.2%. Among the various risk factors analysed, 5 factors were found to be statistically significant between both the groups namely consanguinity (p value < 0.036) , age of the mother less than 20 years at conception (p value < 0.032), low birth weight (p value < 0.001), NICU stay for more than 48 hours (p value < 0.02) and spastic quadriplegic type of cerebral palsy (p value <
0.04).
Conclusions
The prevalence of epilepsy in children with cerebral palsy in our study is 58.6%. Consanguinity , age of the mother less than 20 years at conception , low birth weight, NICU stay for more than 48 hours and spastic quadriplegic type of cerebral palsy are the risk factors for epilepsy in children with cerebral palsy.
Keywords: cerebral palsy, epilepsy, Risk factors Introduction
Children with cerebral palsy have seizures frequently but not all children will experience them.
Brain damage is usually the cause for seizures in children with cerebral palsy. The type of seizure will depend upon the location of the brain injury. After a brain injury seizure may start in early infancy but may be hard to detect as infants have the tendency to make unexpected movements (1). Seizure occurrence and their control is one of the important determinants for better neurodevelopmental outcome in children with cerebral palsy. Some children with cerebral palsy despite having a brain injury do not have seizures. Understanding the risk factors for epilepsy in these children in a resource limited setting is vital as it would enable us in improving our management plan optimizing their neurodevelopment. Hence it is very important for us to understand the risk factors for occurrence of epilepsy in children with cerebral palsy in our setting. So this study was done with the objective to find the prevalence of epilepsy in children with cerebral palsy and assess the risk factors for epilepsy in children with cerebral palsy.
Materials and Methods
a) Study design : Prospective observational study
b) Place of study : Sri Lakshmi Narayana Institute of Medical Sciences c) Study Period : January 2017 to August 2018
d) Target Population : All children attending Pediatric OPD of Sri Lakshmi Narayana Institute of Medical Sciences
e) Study Population : All children with cerebral palsy upto 12 years of age with recurrent episodes of seizures
Inclusion criteria : All children with cerebral palsy under 12 years of age attending Pediatric OPD /admitted with any issue
Exclusion criteria : Children whose parents refuse to give consent for the study.
f) Sample size: All consecutive children with cerebral palsy within the study period were enrolled in the study. Based on the previous year statistics, the sample size was 42.In our study period, final sample recruited is 79.
g) Ethical considerations: Institutional Review Board clearance was obtained and the written informed consent was obtained from parents before recruitment of the children into the study.
METHODOLOGY
Mothers or Caretakers of children with cerebral palsy who attended the pediatric OPD were interviewed to fill a printed structured questionnaire, after obtaining their consent. The details were recorded by the principal investigator and it included basic demographic details , antenatal ,natal and postnatal details. The clinical details of the child was recorded after examination along with enquiry regarding other risk factors and development history. The collected data were filled up by the principal investigator on the data entry form. All children with cerebral palsy who had seizures were taken as cases. Children with cerebral palsy who did not have seizures were taken as controls. The data collected were tabulated in a Microsoft Excel data sheet and analysed. The percentage of risk factors was estimated in both the cases and controls. Chi square test was done to calculate p value and analyse if there was statistical significance of those risk factors descriptively between the cases group and control group. Statistical analysis was carried out using SPSS 16.0. P value less than 0.05 was taken as statistically significant.
Results
The total number of children with cerebral palsy recruited in our study is 79.Out of these 79 children, 46 (58.2%) had seizures and the remaining 33 (41.8%) children did not have seizures.
Hence the prevalence of seizures/epilepsy in children with cerebral palsy as per our study is 58.2%.Out of these 79 children, 47 (59.4%) are boys. There are 27 (58.6%) boys among the children with cerebral palsy who had seizures and 20 (60.6%) boys among the children with
cerebral palsy who did not have seizures. The various risk factors which are analysed and compared between both the groups and statistical significance measured with the p value is depicted in Table 1. Among the various risk factors analysed, 5 factors were found to be statistically significant between both the groups namely consanguinity (p value < 0.036) , age of the mother less than 20 years at conception (p value < 0.032), low birth weight (p value < 0.001), NICU stay for more than 48 hours (p value < 0.02) and spastic quadriplegic type of cerebral palsy (p value < 0.04). Presence of neonatal seizures , birth asphyxia, NICU admission, hypoglycemia in newborn, neonatal meningitis, neonatal jaundice, presence of microcephaly and squint were found to be statistically not significant between both the groups.
Risk factors studied Cerebral palsy with seizures
N=46 (58.2%)
Cerebral palsy without seizures N=33 (41.8%)
P value
Consanguinity 13 (28.2%) 3 (9.09%) 0.036
Boys 27 (58.6%) 20 (60.6%) 0.864
Maternal infection during pregnancy
22 (47.8%) 0 2.911
Age of mother at conception less than 20 years of age
17 (36.9%) 5 (15.1%) 0.032
History of epilepsy in family
0 0 0
GDM 0 0 0
PIH 1 (2.1%) 0 0.393
Maternal anemia 3 (6.5%) 1 (3.03% 0.485
Poor maternal weight gain during pregnancy
3 (6.5%) 1 (3.03%) 0.485
Normal vaginal delivery
36 (78.2%) 27 (81.8%) 0.698
Home delivery 6 (13.04%) 6 (18.1%) 0.530
Prematurity 0 2 (6.06%) 0.090
Low birth weight 31 (67.3%) 10 (30.3%) 0.001
Birth asphyxia 40 (86.9%) 27 (81.8%) 0.353
Hypoglycemia in newborn period
1 (2.1%) 0 0.393
Neonatal seizures 19 (41.3%) 8 (24.2%) 0.114
Neonatal jaundice 2 (4.3%) 2 (6.06%) 0.732
Neonatal meningitis 2 (4.3%) 0 0.225
Newborn admission 20 (43.4%) 13 (39.3%) 0.716
NICU stay for more than 48 hours
41 (89.1%) 23 (69.6%) 0.029
Microcephaly 9 (19.5%) 10 (30.3%) 0.270
Squint 7 (15.2%) 6 (18.1%) 0.725
Abnormal vision 0 0 0
Anbormal hearing 0 0 0
Spastic Quadriplegia 34 (73.9%) 17 (51.5%) 0.040
Spastic Diplegia 6 (13.04%) 9 (27.2%) 0.111
Spastic Hemiplegia 2 (4.3%) 3 (9.09%) 0.393
Atonic 1 (2.1%) 3 (9.09%) 0.166
Dyskinetic 3 (6.5%) 1 (3.03%) 0.485
Table 1 : Risk factors for epilepsy in children with cerebral palsy analysed in our study Discussion
Epilepsy is an important comorbidity in children with cerebral palsy and addressing this issue is vital. The prevalence of epilepsy in children with cerebral palsy is 58.6% in our study and it is higher than the average prevalence of 10 to 40 % as per other studies (2).59.4% were boys in our study and it is similar to 63.2% as reported by Rajeshkannan B et al (3). Prematurity and neonatal seizures which were found to be statistical significant risk factors in other studies (3,4,5,8) were not found to be statistically significant in our study. This is possibly due to better newborn care available around this region. Antental factors like GDM ,PIH ,maternal anemia, maternal weight gain were found to be statistically insignificant in our study. This is possibly due to the lower complication rates prevalent in this area due to better obstetric care services available in this region. Home delivery which was found as an independent risk factor in other studies (3,4,6,7,8) was not found to be statistically significant in our study. This may be due to the lower prevalence of home delivery in this region and high rates of institutional delivery in this locality which is possibly boosted by the incentives given in various government schemes like JSY and JSSK. Risk factors found to be statistically significant in our study were consanguinity, age of the mother less than 20 years at conception , low birth weight, NICU stay for more than 48 hours and spastic quadriplegic type of cerebral palsy. Consanguinity as a risk factor needs to be addressed more in detail and further work up is required in these children before we make inference as we have not evaluated for neuro metabolic causes in detail due to financial constraints. However thyroid screening was done in all the children. Low birth weight and Spastic quadriplegic cerebral palsy which were found as risk factors in our study is comparable to other published studies (2,8). The chances of hypoxia and brain damage are more in low birth weight babies compared to normal weight babies due to higher risk of complications.
The brain insult in Spastic quadriplegic cerebral palsy is more compared to the other types of cerebral palsy and hence this could possibly be the reason for the high risk to develop epilepsy as we know any abnormal area in brain can be epileptogenic. The limitation in our study is the small sample size and matching was done between cases and control as most of the children enrolled in the study had seizures and hence it was difficult to match the control group equally which needed more enrollment of children with cerebral palsy without seizures. All the risk factors which are identified to be statistically significant in our study are preventable by an efficient health care delivery system and good health education strategies.
Further improving neonatal and obstetric care to greater heights would help in reducing these risk factors. This would enable us to reduce the prevalence of seizures in children with cerebral palsy which would help us to improve the neurodevelopmental outcome.
Conclusion
The prevalence of epilepsy in children with cerebral palsy in our study is 58.6%. Consanguinity, age of the mother less than 20 years at conception, low birth weight, NICU stay for more than 48 hours and spastic quadriplegic type of cerebral palsy are the risk factors for epilepsy in children with cerebral palsy.
Acknowledgement: We would like to thank the staffs of Pediatrics department for spending their valuable time and for their co-operation in completing the study.
Funding for the study: Nil Conflict of interest: Nil References
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