Dr Joy Alejo, a pediatric neurologist at the University College Hospital that manages children with developmental disorders, epilepsy and neurological diseases says in this interview with SADE OGUNTOLA that epilepsy is not a spiritual or mysterious condition, but a medical one that is curable under certain conditions, and its treatment must be prompt to arrest limitations later in life.

What is epilepsy, and why is there a need to raise awareness about the condition as expected during World Epilepsy Day celebrations?

Epilepsy is a chronic medical disorder characterized by convulsions. These can be scary when observed and so it’s quite understandable that it has a lot of spiritual connotations, particularly in our culture. So people must understand that epilepsy is not a spiritual or mysterious condition, but a medical one. Epilepsy is defined as when a person has at least two unprovoked seizures more than 24 hours apart. This is a seizure that is not provoked by fever or any immediate medical problem. A child with a fever can have a seizure; this is not epilepsy. That is called febrile seizures, and that is common in children under 5 years. Other things like severe malaria, meningitis, or low blood sugar can cause seizures; these are all provoked, so they do not count as epilepsy.

A lot of things can put children at risk of epilepsy, but broadly speaking, there are three broad types of epilepsy: generalized onset epilepsy, focal onset epilepsy and unknown onset. In generalized-onset epilepsy, the entire body is involved in that seizure. The person is convulsing, foaming in the mouth, with jerking the hands and legs. Focal onset epilepsy is a bit more subtle and unusual because it may begin from one hand or starts with some abnormal behavior. You may see the some abnormal behavior or conduct.

Sometimes it will start with just one hand starting to jerk; the child might say, Mummy, my hand is shaking; I don’t know what is happening. From that hand, the child will now get to the point that he loses consciousness and then has a full convulsion. So with generalized onset epilepsy, the entire brain is involved, but the focal one is a particular side of the brain. But there is another group that is called unknown-onset epilepsy, in which case nobody was there to describe what happened to the child or it doesn’t fit into any of the other 2 types. However, based on a detailed assessment of the child and brain studies, we are also able to talk about other different types of epilepsy.

When a child has epilepsy, there is a particular set of neurons in the brain that are acting abnormally. The brain is the control center of the entire body, including those things that we do not control consciously, like the heartbeat or breathing. This control is through what is called neurons; they are like wires, and the brain is like the junction box that brings out wires to supply the whole house. When a group of neurons in the brain becomes damaged or injured, they begin to misfire or is hyper-excited. As such, the information is no longer organized enough to function properly.

When someone begins to jerk, what is happening in the brain? A lot of neurons in the brain are all excited at the same time but in the wrong way. You see the person jerking, the mouth foaming, and the person unconscious. It is from the brain; it is not from the mouth or the hand. So we see that these damaged/injured neurons result in epilepsy.

A key cause of epilepsy is injury to the brain when it is starved of oxygen at some point, what is medically termed “hypoxic injury.” Then, later on, those damaged neurons begin to release these abnormal discharges. Particularly in our environment, brain damage may occur when a newborn does not cry well because there is nobody there to ensure that the child breathes quickly. One or two years down the line, such children may wake up one morning and have a seizure. The parents are wondering why the child, who has no fever is convulsing. However, the injury to the brain due to a lack of oxygen at birth is just beginning to manifest. In our environment, it happens a lot at birth because women deliver at home, in mission houses, and with traditional birth attendants.

Also, when a child has jaundice as a newborn, what is medically termed neonatal jaundice, the bilirubin level of the blood becomes elevated. Normally, elevated blood bilirubin is not something that damages the brain. However, the blood-brain barrier that protects the brain from this toxin in newborns is not fully developed. So, if a newborn has jaundice in the first month of life, bilirubin can easily cross into the brain and damage particular areas of the brain. The jaundice may appear trivial but a few years down the line the child begins to manifest with epilepsy. That is another common cause in our environment.

Brain injury from accidents is a big problem, especially with motorcycle accidents. The person may have a head injury, be unconscious, get treated, wake up, and go home. Then, a few months later, he started to have seizures. This is one of the main causes of seizures in adults. Also, the injury to the head can be due to falling from a height. Even though the child or adult survives the fall, they can begin to have seizures later on because any injury to the brain from trauma can also lead to epilepsy.

Another cause is genetics. Certain genes are inherited that predispose to epilepsy. If you observe closely, epilepsy can run in families. However, many genetic diseases can now be corrected. But in the African population, these are largely unexplored. We don’t have a lot of data on our genes but African scientists are now working on to see how this can be explored in our environment.

We also have metabolic causes for epilepsy. Sometimes people’s bodies are not properly processing certain types of chemicals, and this might cause them to have metabolic seizures. Similarly, it can be due to immune causes. Sometimes, when someone is exposed to particular diseases, their body produces what is called antibodies to fight them. After fighting the disease, the remaining antibodies begin to fight against the body’s system. And this can eventually cause epilepsy. We have a few cases of this type of epilepsy in young children, but it is more common in older children and adults.

Some structural abnormalities of the brain can also lead to epilepsy. This occurs when children are born with a malformation in their brain. Once the brain is not well developed, it means that the neurons are also not well developed, and they can cause epilepsy. One of the things that can help prevent this is for women to take folic acid before they get pregnant, especially in the first trimester of pregnancy. Folic acid is important for the development of the brain in the unborn baby. It is most important in the first 4 weeks of the pregnancy. At that time, the woman may not even know she is pregnant. Also important to prevent malformation of the brain are pregnant women avoiding alcohol, smoking, and unnecessary use of drugs. If the brain is malformed, there is a limit to what brain surgeons can do to repair it. So it is better prevented. And finally there is the group of patients with epilepsy in whom we really cannot identify the cause.


Can epilepsy be cured?

The cure for epilepsy takes a while, and it is also dependent on its cause. But epilepsy can be managed with medications to stop the seizures and stop them for long enough for the neurons to, in a way, heal to a reasonable extent. Sometimes, when we treat that person, they will never have seizures again. But in about 3 out of 10 cases, they may relapse after the treatment. If you think about the fact that some are due to malformations, it may be difficult to cure a seizure arising from a malformation. In such cases, when medications are stopped, the seizures return. Generally, we usually want to treat them for at least two and a half years. Even though the seizures had stopped, they are continued on their medications for the neurons in the brain to heal. After one year of being seizure-free, we say that the patient is in remission, but we continue treatment and observe the situation. If a patient remains seizure free for 5 years, the likelihood of a seizure recurring is minimal but a patient is believed to be cured after 10 years of seizure freedom without medication.

Why is treatment for epilepsy important, particularly early in life?

Each time a child has a seizure, some neurons are lost due to excessive stimulation without rest. Once they are lost, they cannot be regenerated. Unfortunately, the number of brain cells individuals are born with is fixed, and they only keep improving their activity. So if, during a seizure, a child loses some neurons, he cannot get them back. That is the danger of seizures.  We don’t want that because the child is still growing. These brain cells are supposed to help him master skills, learn, adapt and so on to progress in life. Children can therefore become intellectually impaired because of epilepsy if nothing is done about it. That is why we particularly push for it to be treated early so that it does not limit them as adults. Individuals with epilepsy cannot drive, do some jobs, swim nor operate machinery. This limits their quality of life significantly.


What lifestyle changes are people with epilepsy required to make to cope? better with this condition?

They should be on medications prescribed by the right doctors so that they do not have seizures. If the seizures are not controlled with medications or other means, they will continue to damage their brain cells. It is also important to avoid too many flashing lights. It is a trigger for a seizure in people with photosensitive epilepsy. Also, for the period, they are in remission, we don’t want them swimming, driving, or driving machinery for safety purposes. A lack of sleep also tends to trigger seizures. Getting at least 8 hours of sleep is essential. I have had some patients whose lack of sleep because of a night vigil triggered seizures in them the next day. They also must avoid stimulants like alcohol, smoking, and hard drugs. These can trigger seizures even in people who don’t have epilepsy and so must be avoided in epileptic patients.


Source: tribuneonlineng.com, Sade Oguntola