Synopsis Proforma for Registration Of

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA

SYNOPSIS PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK

“A good teacher is like a candle. It consumes itself to light the way for others”

• Bruke Adams

INTRODUCTION

India is the country with the largest number of children. India has more children of school age than China. Newly released data from a Demographic and Health Survey (DHS) show that primary school attendance rate has increased by more than one percentage point annually since the beginning of the decade .In 2000, 76 percent of all children of primary school age (6-10 years)were in school. By 2006, this value had increased to 83 percent.1

Children spend a significant proportion of their day in school. Schools are in compliance with many of the recommendations for emergency preparedness. Pediatric emergencies are likely to arise in the schools mostly the conditions like cardiac arrest, over dose, seizures, heat illness, accident and head injury.2

Seizures are the most common pediatric neurologic disorder. 4% to 10% of children suffer at least one seizure in the first 16 years of life. The incidence is highest in children less than 3 years of age, with a decreasing frequency in older children. Epidemiologic studies reveal that approximately 150,000 children will sustain a first time unprovoked seizure each year, and of those, 30,000 will develop epilepsy. 3

The cross sectional study in Andhra Pradesh showed that the prevalence rate of epilepsy is 6.2/1000 population, and in Kerala it is 4.9/1000population.23% of all symptomatic epilepsies with onset below the age of 3 years in tertiary care. School age children are most affected with a slight male preponderance.4 In America 300,000 people have a first convulsion each year.120,000 of them are under the age of 18.5

Seizures occurring in association with fever affect approximately 4% of all children. In children with a seizure associated with fever the probability of bacterial meningitis, ranging between 0-4percent.6 Psychiatric disorders were identified in 34.6% of children with seizures compared to 6.6% in the general population and 11.6% in children with other chronic illnesses. Some of the more common emotional and behavioral difficulties seen in these children include increased anxiety, depression, irritability, hyperactivity, aggression, and in some cases, irrational periods of rage. In a more recent study of behavior in children in the 6 months before a first recognized seizure, 24.6 % of the children had higher than expected rates of behavioral problems, particularly attention difficulties. This finding suggests that epilepsy is a more complex disorder that may manifest itself with behavioral disturbances, as well as seizures.7

The disease enrobed in superstition, discrimination, and stigma. There is a clear cut lack of information programmes in the developing world about seizure and its management.33The child with seizure has an impact on many aspects of a child’s development and functioning. As a result many of these children are at risk for unsuccessful school experiences, difficulties in social engagement with peers, inadequate social skills and poor self esteem.7

As many as 325,000 school-age children, ages 5–14, have epilepsy. It is important for parents and schools to work together to create a safe and supportive environment for students with seizures to grow, learn and achieve their full academic potential.8In a country like India teachers have pivotal role with substantial influence on the society. In fact they are often the torchbearer for most of the social and educational concepts regarding health in the community.9The plan should be specific for each student and should include instructions for both basic first aid as well as appropriate emergency responses to ensure the child's safety in the event of an acute seizure emergency. Many action plans include the following instructions for what do if someone is having a seizure to reduce mortality and morbidity.10

6.1. NEED FOR THE STUDY

One of the earliest descriptions of a secondarily generalized tonic-clonic seizure was recorded over 3000 years ago in Mesopotamia. Epileptic seizures were described in ancient cultures, including those of China, Egypt, and India. An ancient Egyptian papyrus described a seizure in a man who had previous head trauma. Hippocrates wrote the first book about epilepsy almost 2500 years ago. He rejected ideas regarding the divine etiology of epilepsy and concluded that the cause was excessive phlegm that caused abnormal brain consistency.11 English neurologists--John Hughlings Jackson, defines a seizure as "an occasional, an excessive, and a disorderly discharge of nerve tissue on muscles." He also recognizes that seizures can alter consciousness, sensation, and behavior.12

Modern investigation of the etiology of epilepsy began with the work of Fritsch, Hitzig, Ferrier, and Caton in the 1870s. In 1929, Berger discovered that electrical brain signals could be recorded from the human head by using scalp electrodes; this discovery led to the use of electroencephalography (EEG) to study and classify epileptic seizures.12

Prevalence of seizure disorders are, in India it is 360/100,000,in Japan it is 89/1000 in children younger than 13 years ,in Peru it is 2016/100,000 in children younger than 15 years and 10.1% is estimated to be Life time prevalence of febrile convulsion in India. In Iranian journal of public health says that in a study the Life time prevalence of febrile convulsion was 32/1000 population, approximately 60% of case reported febrile convulsion as the presumptive cause.13

Seizure is a paroxysmal, uncontrolled episode of behavior that results from an abnormal electrical discharge from the brain.14 This may affect the child’s consciousness associated with uncontrolled jerky movements of the limbs or the face, stiffening of the arms and legs, loss of control of the bladder, and twitching may be present. The children with seizures will have altered sensorium and responsiveness that will lead to an increased risk of drowning, burns, fractures, accidents etc.15

Seizures associated with fever occur in 1 in every 30-50 children, and those unassociated with fever occur in about 1 child in 200.About 5% of children experience one or more seizures before they reach adulthood. Seizures activity often involves the diagnosis of potential for injury, physical& psychosocial. A potential for injury can be minimized with first aid measures. Thus school teachers should possess skills in observational assessment and first aid.16

First aid is an emergency care and treatment of an injured person before complete medical and surgical treatment can be secured. It is the most important branch of medical science, one in which a lay man has a useful and rewarding play. It requires progressive acquisition of knowledge. Though first aid was being practiced from ancient time, the recorded history of first aid dates to 1099, where religious knights trained to administer medical treatment. An organized world wide effort came in 1877.17

A teacher faced with children having a seizure may experience fear, embarrassment and a feeling of inadequacy. The teacher has a vital role to play in ensuring the student with seizure is safely managed within the school environment. And have an important role in encouraging the student with seizures to develop a healthy, positive adjustment to living with the disorder. Teachers can also model appropriate attitudes and behaviors about epilepsy, which can be a powerful means of ensuring the student’s acceptance by his or her peers. The responsibility of the school community to provide first aid knowledge to teachers will support and assist all students to reach their full potential academically, socially and emotionally.7

A small study found that finding a bite to the side of the tongue was very helpful when present, while only a quarter of those with seizures had such a bite that is sensitivity of 24, the finding was very specific for seizures, with only 1% due to other causes that is specificity of 99%.18

Brain damage occursif seizures are severe and last longer than 60 minutes. Death can result during convulsive status epilepticus if the patient suffers a prolonged lack of oxygen or neuronal exhaustion.19

The first aid for a seizure depends on the type of seizure occurring. Generalized seizures will cause the person to fall, which may result in injury. A tonic–clonic seizure results in violent movements that cannot and should not be suppressed. The person should never be restrained, nor there by any attempt to put something in the mouth. Regarding morbidity trauma is common among people with generalized tonic-clonic seizures. Injuries such as ecchymosis; abrasions; and tongue, facial, and limb lacerations often develop as a result of the repeated tonic-clonic movements. Atonic seizures are also frequently associated with facial and neck injuries. Worldwide, burns are the most common serious injury associated with epileptic seizures. Regarding mortality, seizures cause death in a small proportion of individuals. Sudden unexpected death in epilepsy (SUDEP) may occur even when patients are resting in a protected environment, e.g. in a bed with rail guards.11

Some myths about seizure management are:

1. Person will swallow their tongue during a seizure.

2. Force something into the mouth of someone having a seizure.

3. We should restrain someone having a seizure. 20

One of the difficulties with first aid and seizures observation is the prompt recognition that the seizures is occurring. This is more of a problem when there is no pre existing history of seizures and when the school teachers are relatively inexperienced observers of seizures. Other paroxysmal events that occur in childhood can be mistaken for seizures activity. The nature of this can range from benign events to those life -threatening nature. The school teachers should also be familiar with this in order to help the children to the deliver appropriate first aid. Thus this measure taken by school teachers can help in reducing morbidity and mortality among school children suffering from seizures.14

A study was conducted on the effectiveness of a knowledge-based intervention in increasing levels of knowledge about epilepsy and reducing negative stereotypes toward people with epilepsy in Australia.131 psychology students completed measures of knowledge of and familiarity with epilepsy and attitudes toward people with epilepsy before and after watching a first aid educational video. Results showed that the video was effective in both enhancing the level of knowledge of epilepsy. The video was rated highly on measures of acceptability. They recommended that presenting first aid educational video to the public, specifically those who are most likely to encounter someone with epilepsy e.g., teachers, future health professionals, may be particularly fruitful .This study illustrates the effectiveness of using a simple, cost-effective educational intervention, with specific knowledge-based information incorporating the viewer's emotional involvement, to improve knowledge and reduce stigma regarding epilepsy in a targeted influential group.21

Based on the above fact the school teachers are having inadequate knowledge regarding first aid management of seizures. The fear and fright experienced on confronting a seizing child in the classroom should be eradicated and a sense of confidence is essential among the teachers. Clearly this indicates incorporation of adequate knowledge regarding first aid management in all school curricula.

The investigator in her previous experience meet with the child undergoing seizures who was managed by her school teacher by giving key bunch in her hand which is the superstitious belief followed by most of the people in developing countries. Teachers are the familiar accessible and resourceful person in the society. If teachers are well familiar with first aid knowledge of management of seizure they can easily tackle such situation in schools and reduce morbidity and mortality rate. Hence this video assisted teaching will provide adequate knowledge regarding first aid management of seizure in children for school teachers who are most likely to encounter someone with seizure.

6.2 REVIEIW OF LITERATURE

Review of literature is mainly divided into three headings:

1. Studies related to incidence and prevalence of seizures

2. Studies related to investigations and outcomes

3. Studies related to knowledge of school teachers towards seizures.

1. STUDIES RELATED TO INCIDENCE AND PREVALENCE OF SEIZURES

A study was conducted on the prevalence of epilepsy in school going children between the age group of 6- 18 years in Kashmir valley, India. The results revealed that rural and urban specification prevalence of 3.49/1000 and 2.96/1000 respectively. It included 55.1% males with the prevalence of 3.74/1000 and 44.9% females with the prevalence of 3.13/1000. Age-specific prevalence was found to be 3.82/1000 among 6-10 years, 3.44/1000 among 11-14 years and 2.33/1000 among 15-18 years. Higher prevalence of 3.38/1000 was observed in children from government run educational institutions. Generalized tonic-clonic seizures -73.5%was the commonest type of seizure observed.22

A retrospective observational study was done on 250 000 pupils attending secondary school with epilepsy over a 1-year period in West Cheshire Health District. The prevalence of epilepsy was 4.1 per 1000, being 10 times higher among adolescents who had special educational needs. They concluded that health and education professionals working across the range of secondary school environments need to be able to support pupils with challenging epilepsy, many of whom will also have special educational needs and some a physical disability, as an increasing number of adolescents with these difficulties are being placed in mainstream schools.23

A home based survey was done on psychiatric disorders in 8 to12 year old children in Calicut District, Kerala, India. One thousand one hundred and ninety-two consecutive children underwent neurological and psychometric assessments. The projected number of children with a history of febrile seizures was 120 giving a lifetime incidence of 10.1%. Recurrent febrile seizures predominated and these were strongly associated with a history of perinatal adversity. Febrile seizures were independently association with indices of infective illness and mothers' education. Epilepsy developed in 2.7% of children with febrile seizures.24

2. STUDIES RELATED TO INVESTIGATIONS AND OUTCOMES.

A study was conducted to find the epileptic syndromes in childhood on clinical features, outcomes, and treatment in Canada, using a review of the literature and personal experience, with most references to authoritative texts in the children aged from 2 to 12 years of age. Results showed that 50% of children with cryptogenic partial seizures have a very benign course. Generalized epilepsy with febrile seizures plus (GEFS+) has a dominant inheritance. The catastrophic epilepsies in childhood all have an inconsistent response to anti epileptic drug and include continuous spike-wave in slow sleep, Landau-Kleffner syndrome, the Lennox Gastaut syndrome, and myoclonic-astatic epilepsy. They concluded that many of the epilepsies that begin in childhood are benign. Others interfere seriously with cognitive and social development.25

A retrospective cross-sectional study was conducted to find the etiologies and outcomes of status epilepticus in childrenin Iran among 135 patients (76 boys, 59 girls) were studied from 1 month to 15 years old, between 1999 and 2004 .Outcomes were rated according to the Glasgow Out Score (GOS).Results revealed that the most common cause of status epilepticus[ SE] was fever. Etiology of SE did not differ significantly between various age groups and also between boys and girls, fourteen patients died in hospital and 81 were discharged in good health. Outcome did not differ significantly between the age groups; outcome was significantly correlated with etiology of SE. The study concluded that prolonged febrile seizures had the best and symptomatic SE the worst, outcome. Status epilepticus (SE) is a medical emergency with significant associated mortality and morbidity.26

A study was conducted on febrile seizures and about current views and investigations in Canada. Febrile seizures (FSs) are seizures that occur during fever, usually at the time of a cold or flu, and represent the most common cause of seizures in the pediatric population. Up to 5% of children between the ages of six months and five years-of-age will experience a FS. Clinically these seizures are categorized as benign events with little impact on the growth and development of the child. There are many unanswered questions about FSs, such as the mechanism of their generation, the long-term effects of these seizures, and their role in epileptogenesis. Answers are beginning to emerge based on results from animal studies. This review summarizes the current literature on animal models of FSs, mechanisms underlying the seizures, and functional, structural, and molecular changes that may result from them.27

Aretrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration was conducted,to perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) in Australia. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. Data were obtained from 542 eligible episodes of CSE. Results revealed that Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and rapid sequence induction of anesthesia and intubation [RSI] in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. The study concluded that Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the pre hospital and hospital phases. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy.28