¹Assistant Professor, ²Resident, Department of Pediatrics, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Beed, Maharashtra, INDIA.

³Associate Professor, Department of Pediatrics, Vilasrao Deshmukh Government Medical Medical College, Latur, Maharashtra, INDIA.

Email: nagargojeramchandra@gmail.com

Table 1: Distribution of the Study subjects according to Age and gender

Maximum numbers of children were born after 37 weeks gestation (term pregnancy) while 5% children born before 37 weeks (pre-term), more commonly known as premature. Most of the children 55% were born as 1^st child followed by 2^nd order of birth were 35%. Institutional birth was most common in 99% cases. NICU candidate were 60% and most common factor for addition in NICU was respiratory distress syndrome (RDS) 16% followed by neonatal sepsis (NNS) 13% and early onset sepsis (EOS) 11%. Duration of breastfeeding <6 months was in 44% cases and 6-12months in 45%.

Table 2: Distribution of study subjects according to Birth characteristics

History of iron deficiency anaemia was observed in 5% cases, Stroke in 11%, space occupying lesion in 6%, CNS Malformation 6%, Immunization appropriate in 96%, milestones appropriate for age in 73% and delay in 27%. History of failure to thrive observed in 24% and vitamin/micronutrient deficiency was observed in 20%.

Table 3: Distribution of study subjects according to Past history

In present study, in majority of cases age of 1st onset of seizure was 6-12 months (23%) followed by 2-6 months (22%) and 5-10 years (21%). GTCS was the commonest type of seizure seen in 97 cases (97%) and focal seizure with secondary GTCS observed in 3(3%) cases. In most of the cases (24%) 2-4 times recurrence of seizure was observed since 1st diagnosis followed by 10-20 times in 15%, 5-10 times in 14, <2 times in 9 and >20 times in only one child. Focal Neurological deficit was seen in 24% cases, Positive family history in 11%, preceding aura 46%. The maximum number of children presented with fever of 100-104 F (53%) and 8% child with 105-106 F. Duration of fever was <2 days in 40% cases, between 4-8 days in 14%, 2-4 days in 13% and in one child duration of fever was >8days.

Table 4: Spectrum of clinical presentation

Prehospital resuscitation was done in 31% cases. Most common symptom was vomiting (35%) followed by fever with URI (22%) and ALOC (20%) while the commonest sign was pallor (70%) followed by abnormal skull shape in 19% and syndromic appearance (10%). Majority of patients had- CBG in the ranged from 120 to 200 mg/dl (50%) followed by from 54 to 120 mg/dl. Sodium, potassium and calcium were low in 18%, 21% and 33% of cases respectively. Ongoing NCSE was present in 66% patients and intracranial pressure in 36%, clinical meningeal signs in 31%, involuntary movements was seen in 38%, Cerebellar signs in 6%. Urinary incontinence (Incontinence bowel/bladder) occurs in 38% child with status epilepticus.

Table 5: Clinical examination profile of study population

Most common etiology associated with status epilepticus in children was seizure disorder 44% (44 cases), next being acute CNS infection 34% (34 cases), fever provoked seizures 24% (24 cases) and Quadriplegia 19% (19 cases).

Table 6: Etiology and diagnosis profile

SEPSIS Screen was positive in 93% cases, TORCH Screen positive in 8%, Viral Serology positive in 13% and Blood culture positive in 11%. CSF analysis was done for 81 children, cytology positive in 25%, Biochemistry positive in 30%, Culture/Sensitivity positive in 25% and CBNAAT positive for TB in 1 child. USG imaging study was done for 32 cases and USG abnormal in 26% cases, CT brain was done for 84 cases and 48 cases had abnormal findings. MRI done for 52 cases, 43% showed abnormal findings. Majority of children had abnormal epileptiform activity (73%). Out of 20 children with abnormal neuroimaging, 7 children had refractory status epilepticus (RSE). Among the structural abnormality, most common was cystic encephalomalacia seen in 30% cases followed by porencephaly 20%, space occupying lesion-DNET 20%, polymicrogyria cortex 20 and arachnoid cyst in temporal region seen in 10% cases.

Table 7: Investigation profile of study population

Mean duration of hospital stay was 7 days and 16 . 10 children (10%) were discharged within 5 days after admission. 59 children (59%) were discharged within 15 days and 29 (29%) children were discharged within 25 days after admission. Prolonged hospital stay of >25 days observed in 2 cases.

Table 8: Number of days of hospital stay

Out of 100 cases, 76 cases (76%) recovered. Among those recovered, 6 cases (6%) recovered with new neurological sequel; 13 cases (13%) died and 5 cases (5%) discharged against medical advice (AMA).

Table 9: Final outcome

DISCUSSION

Status epilepticus is a common paediatric neurological emergency with an estimated incidence of 18–23 per 100,000 children per year and a mortality of 2%–7%.⁵ In developing countries, optimal management of status epilepticus is associated with major barriers such as poor health care infrastructure, delay in transportation, lack of ambulance services, intermittent availability of drugs and economic affordability.⁶In present study male predominance was noted, which was not statistically significant Similar findings were noted by Thandavarayan et al.,⁷ study out of 92 children, male children were 46 (50%) and female children were 46 (50%).. Likewise, in Vafaee-Shahi et al.,⁸ study the prevalence of S.E in male and female children was 57.1% and 42.9%, respectively. Male to female ratio in our study was found to be 1.38:1. Predominant involvement of younger age group has been reported previously in many studies.^3,5,9 The reason for this predominance is probably, mechanisms for control of seizure activity are fragile in younger children and may get disrupted with minimal abnormalities in neurofunction. Also, younger age is more vulnerable for acute etiologies including febrile seizures. 54% of our cases presented as SE without prior history of seizures. Purusothaman and Kumar¹⁰ reported 40.7% children presented as SE without a prior history of seizures. 53.3% by Gulati et al.¹¹., in Kumar et al.³ study 74.2% cases presented with SE without any prior history of seizures and 18 patients (25.7%) had one or more seizure episodes in the past. Therefore, it was observed that association of prior seizure episodes with occurrence of SE was not significant (p>0.005). GTCS was the commonest type of seizure seen in 97 cases (97%) and focal seizure with secondary GTCS observed in 3(3%) cases which is comparable with study done by Purusothaman and Kumar¹⁰ where a generalized tonic-clonic seizure was the most common type 77.7% and Focal seizures observed in 2(3.7%). The most common seizure type observed in the Gulati et al.¹¹ study was GTCS (63.3%), which is similar to the present study. The aetiological spectrum of SE in developing countries is distinctly different when compared to developed countries. In present study, the most common etiology associated with status epilepticus in children was seizure disorder (44 %), next being acute CNS infection (34 %), fever provoked seizures (24 %) and Quadriplegia(19 %). In developing countries CNS infections accounted for 28–67% of aetiological spectrum^6,12 and this was much more so in the paediatric age group^12,13. In the studies from developed countries, the reported frequency of CNS infections as the risk factor varied from 4% to 19%¹⁴. In Thandavarayan et al.,⁷ study the most common etiology associated with SE in 92 children was remote causes 27.2%, next being acute CNS infection (19.6%), febrile seizure (18.5%) and cryptogenic/idiopathic SD (16.3%). Murthy et al.,¹⁴ reported CNS infection accounts for significant number of cases. The etiology of seizures is usually analysed because this has been shown to affect the morality of SE and can affect the duration of seizures.¹⁵ Neuroimaging of children with status epilepticus showed that out of 20 children with abnormal neuroimaging, 7 children had refractory status epilepticus (RSE). In Purusothaman and Kumar¹⁰ study, structural abnormality was seen in 10 (18.5%) cases of them 7 children (12.2%) presented with refractory status epilepticus. Out of 100 cases, 76 cases (76%) recovered. Among those recovered, 6 cases (6%) recovered with new neurological sequele; 13 cases (13%) died and 5 cases (5%) discharged against medical advice (AMA). In Thandavarayan et al.,⁷ study out of 92 cases, 74 cases (75%) recovered. Among those recovered, 5 cases (5.5%) recovered with new neurological sequele; 13 cases (14%) died and 5 cases (5.5%) discharged against medical advice (AMA). In current study, the overall mortality rate among children with SE was 13 per 100. The studies from developed countries reported mortality between 9-24%.^16,17 Morbidity and mortality from status epilepticus seems to be related to three factors: CNS damage due to the underlying illness or acute insult causing the status epilepticus, CNS damage caused by repetative electrical discharge of the seizure itself and Systemic and metabolic factors related to repeated Generalized tonic-clonic seizures (GTCS) type of seizures.¹⁷The major determinants of fatal outcome identified by Sagduyu et al.¹⁹ were increasing age, longer duration of SE before initiating therapy, CNS infection as a cause for SE. These factors correlate well with our study. However, in current study the mortality associated with SE was greatest (46%) in children between 2 to 5 years of age followed by 5 to 10 years (28%), less than 2 years (20%) and in children between 10 to 12 years of age (6%). This age difference was statistically significant with p value of 0.039. Proper prehospital therapy, early referral, proper care while transporting, anticipating risk factors involved, and protocol based approach uniformly at all hospital can reduce the mortality due to status epilepticus in children. Also considering the large number of referrals, upgradation of intensive care facilities even in tertiary care hospital is much sought to improve the overall outcome of SE.

CONCLUSION

Seizures are not only the cause of high morbidity and mortality in children but also are the reasons of physical, mental and financial distress for their parents. Male preponderance and younger age at presentation were the highlights. The commonest type of seizure was a generalised tonic-clonic seizure. Seizure disorder, acute CNS infections, and febrile seizures were commonest etiological. A good clinical evaluation and if required CSF analysis, Neuroimaging and EEG have the important role in diagnosis. We suggest a long term follow-up study in patients with seizures with regards to their neuro-behavioral outcomes.

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