|CHILD HEALTH IN THE HINTERLANDS
|Year : 2021 | Volume
| Issue : 3 | Page : 207-208
Managing a child with epilepsy: The value of primary care and three-stage assessment
Gargi Goel, Pavitra Mohan, Sanjana Brahmawar Mohan
Basic Health Care Services, Udaipur, Rajasthan, India
|Date of Submission||08-Aug-2021|
|Date of Decision||09-Aug-2021|
|Date of Acceptance||09-Aug-2021|
|Date of Web Publication||31-Aug-2021|
Dr. Pavitra Mohan
Basic Health Care Services, 39, Krishna Colony, Bedla Road, Udaipur - 313 001, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Goel G, Mohan P, Mohan SB. Managing a child with epilepsy: The value of primary care and three-stage assessment. Indian Pediatr Case Rep 2021;1:207-8
|How to cite this URL:|
Goel G, Mohan P, Mohan SB. Managing a child with epilepsy: The value of primary care and three-stage assessment. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:207-8. Available from: http://www.ipcares.org/text.asp?2021/1/3/207/325093
Epilepsy is defined as a condition characterized by recurrent (two or more) epileptic seizures, unprovoked by any immediate identified cause. It is estimated that, in India alone, about 10 million people suffer from epilepsy. The prevalence of epilepsy in rural areas is almost twice that seen in urban areas (1.9% vs. 0.6%). However, it is estimated that almost 70%–90% of epileptic patients are either untreated, inadequately treated, or noncompliant. Multiple factors contribute to this: nonrecognition that epilepsy is a medical illness, inability of families to access specialized care, challenges in managing epilepsy, and lack of coordination between primary care level and specialized health care.
In this issue, we discuss the case study of a child from a rural area, who presented to our clinic with a history of seizures. The purpose of highlighting this case is to illustrate the value of primary care and three-stage assessment in managing children with epilepsy.
| Case Study|| |
R, a 12-year-old girl, was brought to our clinic by her parents who resided in Morwal, a remote, rural village with no telephone connectivity, about 35 km from Udaipur city. Her presenting complaints were convulsions for 4 months; the episodes were associated with the loss of consciousness along with stiffening and jerky movements of the limbs, lasted for less than a minute, and occurred around 3–4 times/day. In between events, the child was alert, active, and had no difficulties in participating in her routine activities. There was no history of headaches, vomiting, fever, or ear discharge. There was no history of similar episodes, head injury, febrile illness with altered sensorium in the past, or febrile convulsions in childhood. She was born in a health center, had apparently attained all milestones at the appropriate age, and immunized. She had been living with her maternal aunt in the city for a year so that she could pursue her studies in class 6 in a school there but had been sent back to her village due to her illness. Her academic performance was average and was right-handed. Since coming home, she was spending a lot of time watching television or on the mobile. Menarche had not been attained. She was the second in birth order out of three siblings. There was no family history of epilepsy in the immediate family. Her father was an employee at the local liquor store, and her mother was a homemaker.
On examination, her height was 140 cm (−1.18 standard deviation [SD]), weight 28.9 kg (−1.52 SD), and body mass index 14.7 (−1.24 SD). Her vital parameters including blood pressure were normal. There was no overt dysmorphism or the presence of neurocutaneous markers. Her sensorium was normal and higher functions intact. There was no cranial nerve or focal neurological deficits or signs of meningeal irritation. Hearing and vision were normal.
We encouraged the family to seek a neurological consultation and to get an electroencephalogram (EEG) and magnetic resonance imaging (MRI) from a referral hospital. However, her father was unable to get leave for a few weeks. In view of these circumstances, a normal neurological examination, and the absence of history suggestive of any secondary illness, we kept a presumptive diagnosis of idiopathic generalized epilepsy and started her on sodium valproate. She was advised to limit her screen time. A few weeks later, an MRI of the brain (epilepsy protocol) revealed focal, abnormal, signal intensity in the right frontal lobe in the periventricular region that appeared hyperintense on T2-weighted and FLAIR images. An EEG showed paroxysms of generalized spike and wave, with an amplitude of 200–300 mV. The background activity was synchronous and symmetric, consisting of 8–9 Hz waves that were maximally seen over the posterior region. Hyperventilation and photic stimulation produced no significant changes. This confirmed our diagnosis, and she was asked to continue on the same dose of anticonvulsants and remain in close follow-up.
However, over the next few months, she was unable to visit regularly due to the distance, cost of travel, and inability of her father to get leave. This led to break in continuity in medication and poor seizure control. When she presented back to us 3 months later, she was still having 2–3 convulsions/day, each lasting for a few minutes. We decided to take over the prime responsibility of managing the child by ensuring the availability of antiepileptics and fortnightly follow-up visits to our clinic. With proper counseling and assurance that her antiepileptic drugs will be provided at the clinic (which was close to her home), her compliance improved, and seizure frequency decreased to one episode every 2–3 days.
A three-stage assessment was conducted to understand the family and social circumstances and determine factors that may have an impact on her condition. This included the details that had been ascertained from her clinical assessment (history, examination, and established diagnosis), assessment of R (her thoughts, ideas, feelings, concerns, and fears), and contextual assessment (with respect to her family and home). R had been living away from her family, with her aunt in the city for a few months. Even after returning to the village, she was staying with her maternal grandmother and not her own family, due to a stressful environment at home. R felt that she was neglected because she was the second consecutive girl child. This resentment emerged in the form of anger and aggression directed at her family members. Her parents complained that she did not help with the household chores and that she had to be reprimanded often.
The clinic team and visiting physician consistently counseled and sensitized the family members individually about the condition and challenges that R faced. Extra efforts were obtained to actively listen to R and support her emotionally. Gradually, we noted that this resulted in her gaining more confidence and the family members becoming more aware of her emotional needs and displaying greater empathy toward her. Her compliance with the medication became absolute. Her screen time reduced significantly with gentle but repeated counseling at each visit. She has been seizure free for 6 months. Improved compliance, family support, and improvement in the home environment, all appear to have contributed to this. Her mood appears uplifted and her attitude positive when she comes to the clinic. She has resumed her studies. Her family reports that she is much calmer and helps out at home. The image on the front cover (social pediatrics) shows the child, her grandmother and one of our team members.
| Discussion|| |
In the 21st century India, the status of children with epilepsy in rural areas is just not acceptable. In 2015, the World Health Assembly passed a resolution to address the treatment gap in epilepsy and exhorted the member states to integrate epilepsy management in primary care. This case study illustrates the value of primary care that is closer to the families, affordable, responsive to their needs, and understand their circumstances, with context to the management of epilepsy in children. In this case, the primary healthcare service (our clinic), was able to diagnose, treat, and follow-up R, in conjunction with the referral hospital. If the child had been dependent only on the latter, she would have remained inadequately treated. Better coordination between two levels (e.g., appropriate back-referral from the specialist care to primary care) can definitely improve the treatment course.
A three-level assessment is the basic principle and practice of family medicine and primary care. It includes clinical assessment (all aspects needed to establish the diagnosis), individual assessment (thoughts, ideas, feelings, concerns, and fears of the concerned patient), and contextual assessment (with respect to family and the work context). In this case, the three-level assessment revealed the identification of anger of the child as well as lack of understanding and empathy of the family toward her. Supporting the child and counseling the entire family helped us address the underlying household stress and likely contributed to the improvement in compliance to treatment and improved clinical outcomes. It is well-established that stress can trigger convulsions and hamper seizure control in epileptic patients.
Moving ahead, to meet the treatment gap for childhood epilepsy, there is an urgent need to equip primary care providers with skills to identify and manage, to ensure the availability of antiepileptic drugs, and to improve the coordination between specialist care and primary care. It is a moral imperative for pediatricians and neurologists to decentralize the management of epilepsy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Santhosh Subbareddy N, Sinha S, Satishchandra P. Epilepsy: Indian perspective. Ann Indian Acad Neurol 2014;17 Suppl 1:S3-11.
Fehrsen GS, Henbest RJ. In search of excellence. Expanding the patient-centered clinical method: A three stage assessment. Fam Pract 1993;10:49-54.
World Health Organization. Global Burden of Epilepsy and the Need for Coordinated Action at the Country Level to Address its Health, Social and Public Knowledge Implications. Geneva: WHA (68.2); 2015.