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| ORIGINAL RESEARCH |
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| Year : 2020 | Volume
: 9
| Issue : 4 | Page : 131-134 |
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Comorbidities in children with epilepsy
Larissa Dabre, N Revathi, Harshita Shah
Department of Pediatrics, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India
| Date of Submission | 16-Dec-2020 |
| Date of Decision | 01-Mar-2021 |
| Date of Acceptance | 16-Mar-2021 |
| Date of Web Publication | 22-Dec-2021 |
Correspondence Address:
N Revathi
Department of Pediatrics, MGM Medical College and Hospital, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpai.jpai_32_20
Aims and Objectives: Children with epilepsy can have other coexisting issues related to the disease, drugs, or social factors. The spectrum and prevalence of these comorbidities are seldom considered. The aim of this study was to study the presence and type of comorbid factors in epileptic children and to determine the association between the age at diagnosis, duration, and type of epilepsy with comorbidities. Materials and Methods: It is a cross-sectional observational study conducted over a period of 18 months in a tertiary care hospital in Navi-Mumbai. Children with epilepsy, satisfying the inclusion criteria, were examined for the presence of comorbidities such as developmental delay, sleep disorders, hyperactivity, autism, and school performance. Standard screening questionnaire were used for each of the above conditions. Results: Sixty children with epilepsy were enrolled in our study. Fifty-two percent of these children were found to have multiple comorbidities, the most common being autism. Younger age at onset of epilepsy, polytherapy with anticonvulsant medications, generalized tonic-clonic seizures, higher frequency, and prolonged duration of epilepsy were found to be risk factors of comorbidities. Conclusion: From our study, we demonstrate that the risk of multiple comorbidities in children with epilepsy is high. Identifying these comorbidities can improve the quality of life in epileptic patients and hence should be a part of epilepsy management.
Keywords: Comorbidities, epilepsy, quality of life
How to cite this article:
Dabre L, Revathi N, Shah H. Comorbidities in children with epilepsy. J Pediatr Assoc India 2020;9:131-4 |
| Introduction | |  |
Epilepsy/seizure is the most common neurological emergency in children. According to the International League Against Epilepsy (ILAE), “a person is considered to have epilepsy if they meet any of the following criteria:
- At least two unprovoked (or reflex) seizures occurring >24 h apart
- One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
- Diagnosis of an epilepsy syndrome.”[1]
The prevalence of epilepsy varies with age and sex of the child, but the overall prevalence of all types of epilepsy all over the world is about 1%. Comorbidity is an additional disorder or disease. Comorbidities in a child with epilepsy can be neurological, psychological, or physical. These comorbidities could be due to the epilepsy itself or could be due to underlying factors contributing to epilepsy. Most antiepileptics are also known to have side effects. Furthermore, children with epilepsy are vulnerable to social withdrawal and discrimination which may lead to psychological problems. Hence, it is essential to study the comorbidities which can sometimes be more restricting than the epilepsy itself.
| Materials and Methods | | |
This is a cross-sectional observational study. Children in the age group of 6 months to 12 years diagnosed with epilepsy for a period of at least 3 months were included in the study. Children with preexisting developmental disorder and those with no permanent care taker were excluded from the study. The study was conducted in a tertiary care hospital with specialty services over a period of 18 months.
Details of patients enrolled in the study were entered in a predesigned pro forma. Details regarding the age at onset of convulsions, type, duration, frequency of convulsions, and antiepileptic therapy were recorded. Risk factors for epilepsy such as intrauterine infections, maternal illness, birth asphyxia, perinatal infections, hypoglycemia, and trauma were studied to classify the epilepsy. The children and parents were asked questions using various standard questionnaires to assess the presence of comorbidities.
Developmental assessment in children from 6 months to 66 months was done using the Ages and Stages Questionnaire (ASQ). Sleep problems were assessed using simple screening questionnaire which has questions related to Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, Snoring (BEARS). Risk for autism was assessed using modified checklist for autism in toddlers (M-CHAT) questionnaire. Details of school academic performance were obtained from the school report card. After recording the relevant details and screening the child for comorbidities, an attempt was made to find an association between the type of epilepsy and the comorbidity. Data were entered in MS-Excel© and MS office and analyzed using Stata version 15© StataCorp, Texas, U.S.A. We calculated the means and standard deviation for linear variables and proportions for categorical variables. The proportions were compared using Chi-square test or Fisher's exact test for low expected cell counts. P < 0.05 was considered statistically significant.
| Results | | |
We analyzed the presence of comorbid factors such as developmental abnormalities, sleep problems, intellectual disability, and autism and found that 51.7% (31) of the epileptic children had one or more comorbid conditions. About 16.7% (10) children were diagnosed to have moderate-to-high risk for autism using M-CHAT, 11.7% (7) patients had sleep problems according to BEARS score, and 5% (3) had developmental abnormalities in one or more field as assessed using ASQ. 18.3% (11) patients had multiple comorbidities.
Comorbidities in different age group
This study shows younger the age group of epileptic children, more are the chances of child developing comorbidities. All three infants in our study group had single or multiple comorbidity. About 33.3% (8) of children in 1–5-year age group had at least one of the comorbidities studied and 16.7% (4) had multiple comorbidities. The presence of multiple comorbidities was higher – 23.3% (3) in children between 5 and 10 years of age [Table 1].
Children with generalized tonic-clonic seizures (GTCS) had higher chance of developing one or more comorbidities as compared with other seizure types. The result, however, was not statistically significant (P = 0.29). Furthermore, children with poor seizure control were more prone to one or more comorbidity. More than half the children – 57.1% (4) with multiple daily convulsions had one or more comorbidity whereas only 10% (3) of children with infrequent seizures, 6–12 monthly seizure, had multiple comorbidity. It was noted that as the duration of epilepsy increased, the comorbidities are also increased.
The overall percentage of children developing comorbidities was more in children on antiepileptics – with more chances of children developing multiple comorbidities 21.3% (10), 17% (8) had positive autism screening tests, 12.8% (6) had sleep disturbances, and 6.4% (3) had developmental abnormalities. Almost 17.6% (3) of children in the upper middle class showed developmental disorder in one or more domains of development. Sleep problems and autistic tendencies were seen at a higher rate in children born in lower middle class family.
Comorbidities and its relation to speech
Eighty percent of patients who reported delayed speech in history had associated comorbid condition. If a child with epilepsy reports with delayed speech, the chance of the child having additional comorbidity is significant.
About 25% of children with abnormal electroencephalogram (EEG) had multiple comorbid conditions, whereas only 15.8% of children with normal EEG were found to have multiple comorbid conditions. The difference, however, is not statistically significant. Autism was the single common comorbid condition.
| Discussion | | |
Several population and hospital-based studies have found that the prevalence of epilepsy in children is lower than in adults.[2],[3] Most of the childhood epilepsy has their onset in the 1st year of life.[4],[5] We found similar pattern in our study, wherein, 42% children had the first seizure in their 1st year of life. Nearly half of the children included in our study were <5 years old. Focal seizures were the most common type of seizures in children.[6],[7],[8],[9] We noticed that most children in our study reported with GTCS. However, when EEG was done in them, it was found that the most common abnormality was focal.
Various studies have shown that biological factors associated with a greater risk of comorbidity in epilepsy include younger age at seizure onset, temporal or frontal lobe onset, and intractability [Table 2]. Social factors correlating with greater risk include lower socioeconomic status, lower parental education level, and poorer family function.
A study conducted by Reilly et al.[10] proved that factors significantly associated with intellectual disability in children with epilepsy were nonwhite ethnicity, weekly seizures versus monthly/yearly seizures, and duration of ≥8 years versus <4 years. In his work on pediatric epilepsy and its association with psychiatric comorbidities, Nagaraj et al.[11] found that males were having more psychiatric problem as compared to females. Furthermore, there was a correlation found between high frequency rate of seizures and psychiatric problems.
In our study, we found that GTCS convulsion was more commonly associated with comorbidities. Longer the duration of epilepsy and higher the frequency of seizures, higher were the chances of developing comorbidities. Fifty-three percent of children with epilepsy lasting more than 5 years had one or more of the comorbidities studied as against 38% of those with epilepsy <1 year. Fifty-seven percent of children with frequent convulsions had multiple comorbidities.
Studies by Berg et al.[12] and Fastenau et al.[13] concluded that young age at onset, symptomatic cause, epileptic encephalopathy, and continued treatment of antiepileptic drugs (AEDs) were independently associated with cognitive outcome. Regarding the antiepileptics, Bourgeois[14] was of the opinion that older AEDs (before 1990), such as phenobarbital, can produce greater cognitive impairment. However, carbamazepine, phenytoin, and valproic acid are comparable in their cognitive effect. Our study also proved that the use of AEDs itself increases the incidence of comorbidities. 23.1% children on antiepileptic medication had multiple comorbidities. Seventeen percent had positive screening for autism. 12.8% had sleep problems.
Evidence by Bazil[15] suggests that both the occurrence of seizures and AEDs are associated with significant sleep disruption. Persistent daytime drowsiness in children with epilepsy is not always due to the side effects of AEDs and may arise from sleep fragmentation. In our study, we noticed that only 11.7% children had sleep problems and this was not significantly associated with the type, duration, and frequency of convulsion or antiepileptic medication.
Studies have shown that children and adolescents with epilepsy and adults with childhood-onset epilepsy have higher incidence of learning difficulties, behavioral problems, and higher rate of social isolation. These problems may be of multifactorial etiology. It could be related to structural brain anomalies, type of epilepsy, medication, social stigma, etc.
Studies show that learning disabilities are reported more frequently in children with epilepsy, and these children are at higher risk of repeating a year in school. A study by Parisi et al.[16] on attention-deficit hyperactivity disorder (ADHD) in children with epilepsy reported that several factors may contribute to ADHD comorbidity including underlying brain pathology, chronic effects of seizures, epileptiform brain activity as seen on EEG, and effects of AEDs.
In our study sample, 16.7% (10) children were diagnosed to have moderate-to-high risk for autism using M-CHAT. Epilepsy is one of the disorders that have been studied frequently in children with autism. Several studies in this regard put the prevalence of epilepsy in autism in the range of 22%–30%.[17],[18],[19],[20],[21]
In our study, we found that, 48.3% (29) of epileptic children had none of the comorbidities studied. Overall in all age groups, about one-third of the children (35%) had at least one comorbidity and 18.3% had multiple comorbidities. No significant correlation was found between younger age and comorbidity.
| Conclusion | | |
This study revealed that more than half the children with epilepsy had one or multiple comorbid conditions that were likely to affect their quality of life. Younger age at onset, poor seizure control, and polytherapy were conditions associated with comorbidities. Antenatal and perinatal factors did not have a direct association with the comorbidities. However, the above factors determine the type of epilepsy and so indirectly contribute to the same. The study emphasizes the need for a multidisciplinary approach in the treatment of epilepsy as the comorbidities may be more restricting than the epilepsy itself.
Limitations
The study was conducted in a single center with patients belonging to similar demographic profile. Furthermore, it was mainly based on screening questionnaire. Tests for confirmation of the comorbidities were not employed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Scheffer IE, Berkovic S, Capovilla G, Connolly MB, French J, Guilhoto L, et al. ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsia 2017;58:512-21.  |
| 2. | Aaberg KM, Gunnes N, Bakken IJ, Lund Søraas C, Berntsen A, Magnus P, Lossius MI, Stoltenberg C, Chin R, Surén P. Incidence and Prevalence of Childhood Epilepsy: A Nationwide Cohort Study. Pediatrics 2017;139:e20163908. doi: 10.1542/peds.2016-3908. Epub 2017 Apr 5. PMID:28557750. |
| 3. | Hauser WA. The prevalence and incidence of convulsive disorders in children. Epilepsia 1994;35:S1-6. |
| 4. | Sidenvall R, Forsgren L, Heijbel J. Prevalence and characteristics of epilepsy in children in Northern Sweden. Seizure 1996;5:139-46. |
| 5. | Harvey AS, Cross JH, Shinnar S, Mathern GW; ILAE Pediatric Epilepsy Surgery Survey Taskforce. Defining the spectrum of international practice in pediatric epilepsy surgery patients. Epilepsia 2008;49:146-55. |
| 6. | Kwong KL, Chak WK, Wong SN, So KT. Epidemiology of childhood epilepsy in a cohort of 309 Chinese children. Pediatr Neurol 2001;24:276-82. |
| 7. | Wirrell EC, Grossardt BR, Wong-Kisiel LC, Nickels KC. Incidence and classification of new-onset epilepsy and epilepsy syndromes in children in Olmsted County, Minnesota from 1980 to 2004: A population-based study. Epilepsy Res 2011;95:110-8. |
| 8. | Lavados J, Germain L, Morales A, Campero M, Lavados P. A descriptive study of epilepsy in the district of El Salvador, Chile, 1984-1988. Acta Neurol Scand 1992;85:249-56. |
| 9. | Camfield CS, Camfield PR, Gordon K, Wirrell E, Dooley JM. Incidence of epilepsy in childhood and adolescence: A population-based study in Nova Scotia from 1977 to 1985. Epilepsia 1996;37:19-23. |
| 10. | Reilly C, Atkinson P, Das KB, Chin F, Aylett SE, Burch V, et al. Neurobehavioral comorbidities in children with active epilepsy: A population-based study. Pediatrics 2014;133:e1586-93. |
| 11. | Nagaraj N, Berwal PK, Sharma M, Berwal A. A study on pediatric epilepsy and its main psychiatric comorbidities. Indian J Neurosci 2016;2:60-3. |
| 12. | Berg AT, Langfitt JT, Testa FM, Lvey SR, DiMario F, Westerveld M, et al. Global cognitive function in children with epilepsy; A community based study. Epilepsia 2007;49:608-14. |
| 13. | Fastenau PS, Johnson CS, Perkins SM, Byars AW, deGrauw TJ, Austin JK, et al. Neuropsychological status at seizure onset in children: Risk factors for early cognitive deficits. Neurology 2009;73:526-34. |
| 14. | Bourgeois BF. Antiepileptic drugs, learning, and behavior in childhood epilepsy. Epilepsia 1998;39:913-21. |
| 15. | Bazil CW. Epilepsy and sleep disturbance. Epilepsy Behav 2003;4 Suppl 2:S39-45. |
| 16. | Parisi P, Moavero R, Verrotti A, Curatolo P. Attention deficit hyperactivity disorder in children with epilepsy. Brain Dev 2010;32:10-6. |
| 17. | Bolton PF, Carcani-Rathwell I, Hutton J, Goode S, Howlin P, Rutter M. Epilepsy in autism: Features and correlates. Br J Psychiatry 2011;198:289-94. |
| 18. | Viscidi EW, Triche EW, Pescosolido MF, Mclean RL, Joseph RM, Spence SJ, et al. Clinical characteristics of children with autism spectrum disorder and co-occuring epilepsy. PLoS One 2013;8:e67797. |
| 19. | Tuchman R, Cuccaro M, Alessandri M. Autism and epilepsy: Historical perspective. Brain Dev 2010;32:709-18. |
| 20. | Canitano R. Epilepsy in autism spectrum disorders. Eur Child Adolesc Psychiatry 2007;16:61-6. |
| 21. | Amiet C, Gourfinkel-An I, Bouzamondo A, Tordjman S, Baulac M, Lechat P, et al. Epilepsy in autism is associated with intellectual diability and gender: Evidence from a meta-analysis. Biol Psychiatry 2008;64:577-82. |
[Table 1], [Table 2]
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