Factors associated with the severity of motor impairment in children with cerebral palsy seen in Enugu, Nigeria

Background. Cerebral palsy (CP) is a heterogeneous condition that is well known to cause impairments with varying degrees of severity. The gross motor function classification system (GMFCS) is widely used to assess ambulatory function in CP, but little is known about the factors that account for the variations in gross motor function in children. The purpose of this study was to assess the relation between the severity of gross motor dysfunction (GMD) and certain factors such as the type of CP, aetiology of CP, nutrition, socioeconomic class (SEC), and the frequency of these accompanying impairments like visual, auditory, cognitive and speech impairments.Methods. This was a cross-sectional observational study of 100 consecutively recruited CP patients aged 9 - 96 months, who attended the paediatric neurology clinics (PNCs) in Enugu between April and October 2010. Each patient's clinical history was recorded, a neurological examination conducted and GMFCS level ascertained. Statistical analyses were done to determine the association between the categorical variables.Results. The type of CP (p=0.000), aetiological factors (p=0.016), the presence of malnutrition (p=0.004) and the frequency of accompanying impairments (p=0.001) were significantly associated with the severity of GMD, while SEC (p=0.649) had no significant association.Conclusion. The type of CP, aetiological factors, the presence of malnutrition and the number of accompanying physical, mental or physiological impairments, were positively associated with the severity of GMD and walking ability in children with CP

Behavioral problems of siblings of epileptic children in Enugu.

BACKGROUND AND OBJECTIVE: The existence of a psychosocial dysfunction in the siblings of children with chronic illness has been documented. There are very few reports on siblings of children with epilepsy. The aim of this study is to investigate to what extent the children's epilepsy has affected their healthy siblings in our own center. MATERIALS AND METHODS: Epileptic patients who consecutively referred to the Pediatric Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu, from October 1999 to September 2000 were recruited. Demographic data were obtained, with a questionnaire administered to the parents. Information on the behavior of the school-age siblings and control was obtained by the class teachers using Rutter's behavior scale (B2) for children (Teacher's Scale). RESULTS: One hundred and fifty-six children with epilepsy, of age four to fifteen years, 124 males and 32 females, with a Male: Female ratio of 4: 1, were recruited; and 156 school-age siblings of the epileptic children (index children) and 156 controls were studied. Prevalence of behavioral problems was 38.5 and 15.4%, respectively, among the index and control children ( P < 0.001). There was no significant sex difference in the two groups. There was a significant difference in the distribution of the types of behavior problems between the index and controls ( P < 0.05). The duration of epilepsy did not affect the prevalence of behavior problems ( P < 0.05), but seizure control had a significant effect on the prevalence of behavior problems ( P < 0.001). CONCLUSIONS: Siblings of children with epilepsy have more behavioral disturbances than controls. A strong association was found between poor seizure control and the prevalence of behavioral problems.

Academic performance of school children with epilepsy.

BACKGROUND: Studies in developed countries show conflicting reports on effect of epilepsy on academic performance. There is also a dearth of information on the academic performance of Nigerian children with epilepsy. OBJECTIVE: This study is aimed at determining the academic performance of children with epilepsy with the hope that the findings will help in formulating policies that will be used in their educational programme. METHODS: The academic performance of 50 epileptic children attending normal primary school was compared with those of non-epileptic classmates matched for age, sex and socioeconomic status. The academic performance was assessed using the overall scores achieved in the terminal examination in the 2001/2002 academic years, as well as the scores in individual subjects. RESULTS: There were 36 males and 14 females. The most common seizure type among the epileptic children was generalized tonic-clonic seizure. Thirteen (26%) of the epileptic children had a low overall score, and therefore poor academic performance, compared to 16% of the controls. (p = 0.35). However, the mean score of the epileptic children was significantly lower than that of the controls in English (p = 0.02), Science (p = 0.02) and Social studies (p = 0.02). CONCLUSION: The overall academic performance of epileptic children without other chronic disorders attending normal schools is not different from that of normal children in the same setting, though they are under-achieving in some subjects.

Factors influencing the academic performance of school children with epilepsy.

The academic performance and intelligence quotient (IQ) of 50 children with epilepsy aged between 5 and 14 years, attending normal primary schools in Enugu, were compared with those of their non-epileptic classmates. The academic performance was assessed using the overall scores achieved in terminal examinations in the 2001-2002 academic year. IQ was assessed using the Draw-A-person Test. The influences of school absence rate, Rutter behavioural scores, socio-economic status and seizure-related variables on academic performance were then determined. Twenty-six percent of the children with epilepsy had a low overall score, and therefore poor academic performance, compared with 16% of the controls (p = 0.35). The mean IQ of the children with epilepsy was significantly lower than that of the controls (p = 0.02). The mean school absence rate for the children with epilepsy was significantly higher than that of the controls (p = 0.001). The mean Rutter score of the children with epilepsy was significantly higher than that for the controls (p < 0.001). On multiple linear regression analysis, only IQ (p = 0.01) and seizure type (p = 0.03) had significant predictive effects as risk factors for low overall scores and poor academic performance. It is concluded that the academic performance of epileptic children is influenced by their IQ and type of seizures rather than by other seizure variables or socio-demographic characteristics.

Ethosuximide induced lymphadenopathy--a case report.

A wide range of adverse effects has been reported following prolonged use of anticonvulsant drugs. More commonly reported adverse effects for ethosuximide include gastric disturbances, psychiatric disorders and Systemic Lupus Erythematosus (SLE). Rare instances of leukopenia and pancytopenia have been noted. A case is presented of a 12 year old girl who developed generalized lymphadenopathy with progressive weight loss and leukopenia following prolonged use of ethosuximide for simple absence seizures. The enlarged lymph nodes regressed with withdrawal of the drug but re-appeared when the drug was recommenced. Sodium valproate was then introduced and ethosuximide discontinued. The seizures were successfully controlled with sodium valproate. Histopathology report of the lymphnode biopsy showed marked reactive lymphnode hyperplasia.

Paediatric neurologic emergencies at the University of Nigeria Teaching Hospital, Enugu.

Four hundred and sixty-seven children, aged from birth to 16 years (mean age:35.9 months), presented with emergency neurological problems to the Children's Emergency Unit (CHER) of the University of Nigeria Teaching Hospital, Enugu over a 12-month period. This accounted for 11.1% of all the cases seen in the Unit during that period. There was a male:female ratio of 1.55:1. A significantly higher number of cases presented during the rainy season (May to October) than during the other months of the year. Febrile convulsion was the most common problem, with 132 cases (28.3%), followed by meningitis (18.2%) and afebrile seizures (15.8%). One hundred and ninety-two patients (37.7%) were discharged home, while 36 (7.7%) died. The findings from the study are discussed and compared with data from other centres. Recommendations that may help to reduce mortality from neurologic emergencies in children, are made.

Childhood migraine in Nigeria--I: A community-based study.

The prevalence rate and other aspects of migraine were investigated among school children (aged 6-13 years) in Enugu. The diagnosis of migraine was made by means of a questionnaire completed by parents which was based on the criteria proposed by Prensky and Sommer, and was further confirmed by personal interview of the parents in their homes. A prevalence rate of 6.8% was found among the 4,398 schoolchildren studied. More girls were affected than boys (158 and 140 respectively). Most (88.4%) of the children had their first attack by 10 years of age. Attacks occurred mostly in the afternoon, with sunlight and exercise as the most important trigger factors. Headache of a throbbing nature, sensory aura and relief after sleep were the commonest symptoms. Clinical examination was abnormal in only one child who had paralytic poliomyelitis, but EEG abnormalities were found in 51.1% of the children who had the test. The study revealed a hitterto unrecognised high level of morbidity from migraine among school children in Enugu, resulting in a disturbingly high incidence of school absenteeism.

Childhood migraine in Nigeria. II: Psychosocial aspects.

The Social class of 298 children with migraine, together with the prevalence of psychiatric morbidity among them was studied, as part of a Community-based survey of childhood migraine in Enugu. A significantly greater proportion of the children belonged to the uppermost social classes. Also, a higher incidence of neurotic disorders occurred among the migraineurs than among age and sex-matched controls. Behavioural disorder was not significantly influenced by social class. With regard to intelligence, the migraineurs were not intellectually superior to the controls and none of them was mentally retarded.

Serum calcium, phosphate and alkaline phosphate levels in epileptic children treated with phenobarbitone.

A longitudinal study to estimate the serum calcium, phosphate and alkaline phosphatase levels of 89 ambulatory epileptic children, aged between 3 years and 12 years, and having generalised tonic-clonic seizures, was carried out. None was on any form of medication for the treatment of seizures prior to presentation. Each patient received only phenobarbitone during the period of study. Serum levels of the biochemical parameters were determined at presentation, 6 months and 12 months, while serum phenobarbitone levels were estimated at 6 months and 12 months. Mean serum calcium, phosphate and alkaline phosphatase of the patients remained within the normal range. Using the paired 't' test, the differences in the levels of the parameters at the three measurements were not statistically significant (P > 0.05). Serum phenobarbitone levels remained within the therapeutic range during the period of study. Our results show that over a 12-month period, serum levels of calcium, phosphate, and alkaline phosphatase, remain normal in ambulant epileptic children treated with phenobarbitone.

Measurement of muscle tone in children with cerebellar ataxia.

An electro-mechanical device has been used to measure muscle tone in 12 children with cerebellar ataxia and in 12 healthy children matched for age and sex. All the children also had their tone assessed clinically. The machine measurement showed that six (50%) of the 12 ataxic children had hypotonia, one was hypertonic, while five had normal tone. There was significant correlation between estimation of muscle tone by the machine and by clinical examination. The machine will serve as a valuable addition to other devices already being used to measure the other motor deficits encountered in children with cerebellar disease--such as devices that measure gait ataxia, truncal balance, intention tremor and incoordination of the limbs. It is re-emphasized that assessment or confirmation of clinical signs by reliable and reproducible instrumentation, offers a more objective basis for management and follow-up of patients, than clinical testing alone, and eliminates the often-encountered inter-tester discrepancies.

Compliance by cerebral palsy (CP) patients attending a child neurology service, in a developing country: a preliminary study.

In an attempt to determine the extent to which cerebral palsy patients complied with doctors' recommendations, by regularly attending the follow-up clinics of the Paediatric Neurology Unit of the University of Nigeria Teaching Hospital (UNTH) Enugu, the records of the CP patients seen in the Unit during three years (1985-1987) were scrutinized. A very high default rate of over 88% was noted. Of the 155 CP patients registered during the period, only 18 were still attending the clinic by the end of 1988, the follow-up period ranging from 12 to 47 months. Default from follow-up correlated significantly with the socio-economic status of the patients. There was no correlation between compliance and the type of CP, or the presence of other concurrent neurological disorders. It is thought that early recognition of factors that are associated with poor compliance is important. It will result in early identification of the group at risk for default, and in efforts being made to give them the support and advice that will enable them to benefit fully from the available services.

Rutter's Behaviour Scale (B2) for children (Teacher's Scale): validation and standardization for use on Nigerian children.

Nigerian teachers were asked to place the children in their classes in either of two groups: Group I, comprising children of normal behaviour, and Group II, children who, in their opinion, had significant behavioural problems. Validity of the teachers' grouping was confirmed, using as reference measure the findings from traditional psychological assessment of the children. The teachers then completed the Rutter Child Behaviour Questionnaire (Teachers' Scale) for the same children. The children's scores on the Rutter Scale were matched against the teacher's grouping, the aim being to identify the Rutter Score that separates the children into two 'behaviour' groups that agree most closely with the teachers' own grouping. Results show that this was achieved at the Rutter Score of 10 (k = 0.66). Children scoring 10 or more on the Rutter scale appeared mostly in Group II, while those scoring less than 10 were mostly in Group I. Rutter's scale was also found to be a highly valid instrument for identifying Nigerian children with behavioural problems. It is recommended that Nigerian children scoring > or = 10 on Rutter's Behaviour Questionnaire (Teacher's Scale), should be regarded as children with behavioural disorder. This is one point higher than the score of > or = 9 recommended for British children.

Cerebellar ataxia in childhood: a review of clinical features, investigative findings and aetiology in 30 cases.

The symptoms, neurological deficits and aetiology of cerebellar ataxia were reviewed in 30 children aged from 4 to 16 years, who had been extensively investigated. Fourteen (46.6%) children had perinatal problems, and in 6 (20%), ataxia resulted from these perinatal events. Besides unsteady gait, a common presenting complaint was delayed motor milestones, noted in 15 (50%) patients. In most children (76.6%), clinical examination indicated involvement of more than one of the three main cerebellar divisions, viz archicerebellum, paleocerebellum and neocerebellum. Hypotonia, found in 11 (36.6%) children, was the third most common sign after gait and truncal ataxia. A variety of aetiological factors was identified, the two most frequent being hydrocephalus in 7 (23.3%) children, and perinatal problems in 6 (20%). The findings are discussed against the background of current literature on the subject.

PIP: A pediatric neurologist analyzed the case histories of 30 4-16 year old children diagnosed with cerebellar ataxia in the pediatric neurology unit at the Royal Hospital for Sick Children in Edinburgh, Scotland to examine its clinical features, investigative findings, and etiology. Previous unfavorable events happened to 14 children (46.6%). Yet only 6 (42.8%) of these 14 children had unfavorable events of etiological significance. These previous unfavorable events occurred during the perinatal period (48%). These events in order of significance were asphyxia, prematurity, neonatal jaundice, and trauma. 66.6% of all children had an unsteady gait. The 2nd and 3rd most common signs of cerebellar ataxia were truncal ataxia (53.3%) and hypotonia (36.6%). The next most common symptom was considerable delay in reaching gross motor milestones (50%) such as not sitting until 2 years old. 23 (76.6%) of the children had dysfunctions in 1 of the cerebellar divisions. Clinical examination found dysfunctions most often in the paleocerebellum (86.6) followed by the neocerebellum (70%) and archicerebellum (56.6%). The paleocerebellum and the archicerebellum were the only divisions involved in 6 and 1 of the remaining children, respectively. The most common cause of ataxia was hydrocephalus (23.3%) followed by perinatal problems (20%). 70% of the patients also experienced other central nervous system conditions such as macrocephaly and mental retardation. 5 children had normal investigative findings, 3 of whom had cerebellar ataxia syndrome, 1 had congenital ataxic cerebral palsy, and 1 had familiar ataxia.

Psychiatric morbidity among children with sickle-cell disease.

The prevalence of psychiatric morbidity was investigated among 84 children with sickle-cell disease (SCD) and 84 healthy matched controls, using Rutter's Behaviour Questionnaires. The prevalence of psychiatric morbidity on the parents' and teachers' scales, respectively, was 26.2 and 22.6 per cent for children with SCD and 4.8 and 6.0 per cent for controls. Boys with SCD had significantly higher mean scores than girls, with older children having higher scores than younger ones. Behavioural deviance in seven children occurred both at home and in school, while in 27 it was situational. 34 children had psychiatric morbidity: 14 were neurotic, 11 were antisocial, six were antisocial and neurotic, and the diagnostic category for each of the remaining three differed. Behavioural problems among children with SCD and implications for therapy and prevention are discussed.

Febrile convulsions in a rural and an urban population.

By means of personal interview of parents in their homes, using a questionnaire, the prevalence rate and some other factors associated with febrile convulsions, were determined in a rural and an urban population of Anambra State of Nigeria. Significantly different rates of 11.61% and 8.05% respectively were obtained for the rural and urban population surveyed. Other factors examined included age of onset and sex distribution, family history, recurrence rates, and severity of seizures. Clinical examination of affected children revealed that 2.9% of the children in the urban population had postictal neurological deficits, while the corresponding figure for the rural population was 5.5%.

The pattern and prognosis of speech disorders among children in Enugu, Nigeria.

Of 965 children with neurological disorders seen in the Child Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu over a 3-year period (1985-87), 80 (8.3%; 41 boys and 39 girls) had speech problems. The most common speech disorder was dyslalia. Twenty-six (32.5%) of the 80 children were mentally retarded. Besides speech problems, some of the children had other neurological disorders such as hyperactivity, recurrent seizures, microcephaly and deafness. Varying degrees of improvement in speech were observed in only eight girls and four boys, amounting to 24% of the 50 who were followed up for a period ranging from 3 months to 3 years (mean follow-up period 12.26 months). Eight of those who improved (66.6%) did so within the first 18 months of follow-up. There was a disturbingly high rate of default from follow-up, 30 of the patients (37.5%) failing to keep appointments at the clinic after the first assessment. Also, there was a long delay between onset of symptoms and presentation to hospital (mean delay 45.3 months). With the recent acquisition of the services of a speech therapist by the hospital, it is hoped that the prognosis for children with speech problems will be considerably improved.

Gross motor development of Nigerian children.

A prospective study of 320 Nigerian children was undertaken to determine their pattern of motor development by recording the age at attainment of 12 gross-motor milestones. The children were all born full term and were neurologically normal at birth. They were recruited in the first week of life and seen at regular intervals in a well-baby clinic, where their parents were questioned about the ages at attainment of milestones. Results show that most gross-motor milestones were attained at earlier ages by these children than by children studied to establish norms for the traditional tests of motor development that have long been in use. Our findings confirm several previous reports which emphasize the more rapid attainment of motor milestones such as 'sit without support', 'crawl', 'stand well alone' and 'walk well alone' by black as compared with white children. But, conversely, a number of transitional milestones such as 'roll over', 'pull self to stand' and 'stand holding on' were achieved later by children in this study than by their non-African counterparts. Girls in this study were slightly advanced, relative to boys, in their attainment of most milestones. The results of this study have been incorporated into a chart which can be used in well-baby clinics to detect children with motor delay.

A review of neurological disorders seen at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu.

A review of 965 children with neurological disorders, seen at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu, over a 3-year period (1985-1987), revealed that epilepsy was the most common neurological problem affecting 60% of the children, followed by cerebral palsy (16%), speech disorders (8.3%), mental retardation (7.2%), behaviour disorders (2.2%), paralytic poliomyelitis (1.55%), premature craniosynostosis (1.0%), visual and auditory impairment (1.0%) and muscle disorders (0.72%). Perinatal problems such as birth asphyxia, severe neonatal jaundice and infections were the most common aetiological factors identified. Facilities for rehabilitation of the children were inadequate and this, together with the people's ignorance of the natural history of some of the neurological disorders, may account for the high rate of default from follow-up observed in this study. The need for improved maternal and perinatal health services and vigorous health education strategies is emphasized by this review. The positive effect of the Expanded Programme on Immunization (EPI) is reflected in the sharp decline in the proportion of children with neurological disorders owing to paralytic poliomyelitis, from 9.2% in the period 1978-1980, to 1.55% in the present study.

Pyridoxine therapy on Nigerian children with infantile spasms.

Nine Nigerian children, with infantile spasms, 4 boys and 5 girls age 2.5-15 months, were treated with high doses of vitamin B6. Unlike results from some European and Japanese centres, our results have not been encouraging. Possible reasons for this poor response are suggested.

The pattern of childhood epilepsy with mental retardation in Nigeria.

Of 580 epileptic children, 353 males and 227 females, seen at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital Enugu, from 1985 to 1987, 18 per cent were mentally retarded, a much higher prevalence rate than in the general population. Nine different seizure types were seen, with generalized tonic-clonic seizures (grand mal) leading in frequency. The highest incidence of mental retardation occurred among the children with infantile spasms (51 per cent). For all the seizure types, there was a long delay in seeking medical attention (mean interval, 1.7 years). The mean interval for epileptics with mental retardation was even higher (2.77 years). Factors found to increase the chances of an epileptic child having mental retardation include episodes of status epilepticus, early age at onset of seizures, and long delay before presentation to hospital for treatment. There is need for increased efforts aimed at the elimination of these factors and also for a well organized programme to educate the population about the nature of epilepsy, and the importance of compliance with the treatment schedule.