Consultant paediatric neurologist in the Department of Paediatrics, University College Hospital, Ibadan, Joy Alejo, tells EMMANUEL OJO about the triggers of convulsion and how it can be avoided or managed
What is convulsion?
The first thing to say is that convulsion is like a symptom of an ailment just like you have fever, headache and the likes. It’s a symptom that something is going on in the body. It’s not like a condition per se. It’s just like a manifestation of something that is happening, usually within the body.
How can you describe the situation?
The brain is a mass of nerves that still sends nerves down to all parts of the body. Everything moves like an electric current. Whenever there is an injury to the brain from whatever cause such that all these connections are damaged or injured or suffer some abnormalities, that coordinated transfer of information can become distorted. So, that produces the convulsion. For example, the brain needs to tell the leg to move, so when there is a break in that transmission somehow, when the brain tells the legs to move, instead of moving just once, they move 10 times. So, what is seen manifesting as convulsion is uncontrolled motor activities which may not be purposeful.
Simply put, convulsion is an abnormal motor, psychic or sensory activity that is due to asynchronous electrical impulses from the brain because sometimes the seizures are not just motor activities. Sometimes, they can be sensory. Someone can perceive what is not. Motor is usually the most common which usually has to do with limbs and all that. We can see it as abnormal motor activities of the limb.
You used the word, seizure, in most of the description. Is it another form of describing convulsion?
Convulsions are also called seizures.
Are there types?
Yes.
What are they?
The different types of seizures are motor, sensory and psychic seizures. Under the motor seizures, which is the most common, there are two types. There is a generalised convulsion where the whole body is involved or a focal convulsion where it involves just one limb. Here, the hand twitches uncontrollably but the other parts of the body are fine.
What triggers convulsion in children?
There are many things that can cause convulsion in children. One of the commonest causes in our environment is infection of the brain or infection of the central nervous system which includes the brain and the spinal cords. One of the most popular illnesses in children that might cause seizures is malaria. When children have severe malaria, they could go on multiple convulsions. When we say multiple convulsions, it means that the child faints more than once and it might cause the child to become unconscious the next day because the brain has gone through a lot of stress during convulsion which came as a result of ‘just malaria’.
Another cause, which is a popular one, is meningitis. Meningitis is a bacterial infection of the brain and can be very severe both in children and adults. It will cause seizures. Tuberculosis can also infect the brain and cause seizures. Brain tumors, which are also one of the dreaded diseases like cancers, can cause that too. Also, in children who are less than five years old, we have found out that in some, high body temperature (fever) can trigger convulsion.
Why is that so?
What scientists believe is that a child’s brain is not really mature until that child reaches the age of five because a lot of those connections are still maturing, getting fine tuned and getting specialised and a lot of learning happens then. That’s when the child learns to talk, walk and so on. The brain is not fully matured, hence, when the temperature gets high, it appears that some electrical impulses over shoot. That is called a seizure threshold. Beyond this level of impulse, a seizure will occur. This type of seizure triggered by temperature could just have one episode in 24 hours and that’s it and when the temperature falls back to normal, there’ll be no problem. Sometimes, it might just be something as common as immunisation that triggers the temperature.
Because we sometimes don’t know if the cause is malaria, meningitis or whatever caused the seizures, we usually advise that the child should be brought to the hospital, then, the doctor can ascertain if it was caused by just a fever or there’s a more serious infection of the brain that caused it. If it’s just fever, the doctor advises the parent on how to best manage the fever next time. That is what is called febrile seizures. Some children just have that disposition and interestingly it runs in families. If a child has that genetic disposition, whenever the temperature runs up, the child may have seizures. It’s quite common in children.
How common is it in children?
From literature globally, about two per cent of children will have a febrile seizure in their lifetime. That’s like two out of a hundred. However, once a child has had it before, the likelihood becomes much higher that the child can have it again. So, the thing now is that once it happens, one wants to make sure that the child is taken to the hospital to investigate and see if it’s just a febrile seizure or there is more to it. Once that happens and it’s confirmed that it’s a febrile seizure, the parents will be advised on what to do because the chances that it will happen again is higher. In fact, one out of every two children who have had it will have it again. So, for such a child, the parents have to be proactive with fever to make sure that it doesn’t get higher and doesn’t result in another seizure because nobody wants that. It’s very distressing to see a child convulsing.
There is also a tiny risk that it can progress to epilepsy and epilepsy now means that even with nothing happening, the child continues to have seizures. You wouldn’t want a child who has had seizures to keep going with that anyhow because there’s always that chance of less than one per cent. Epilepsy means that the child is having at least two or more seizures that are unprovoked. In that case, there’s no fever, no meningitis, nothing going on in the brain, the child just continues to have seizures in the brain at regular intervals. It’s a chronic disease actually and if someone has such an ailment, such a person can’t operate machines and can’t drive. He could be driving and have a seizure which will lead to an accident. These are not things you want a child to develop and suffer in later life.
It has been observed that when a child starts convulsing, some people put a spoon or an object in the mouth, between the teeth, some even put a piece cloth. Is that the first thing to do when a child starts convulsing?
That’s a really good question and I’m grateful that you brought it up. It can happen anywhere and people really do all kinds of things because of lack of knowledge. People think it’s a spiritual problem or it’s a demonic thing or something that needs a higher power. Yes, all sicknesses are bad and need the intervention of God but we need to know that seizure comes from the brain. Putting anything in the mouth is really not going to make any difference because it’s not the mouth the problem is coming from, it’s from the brain, hence, that understanding is key in changing people’s perception. A lot of people have terrible perceptions about it and that’s why I’m happy that you are talking about it.
If a child or a person has seizures, the first thing you want to do is to put the child on the ground. The meaning is that the person is usually not conscious of the environment, so, the likelihood of a fall is very high. The person should be placed on the ground, not on the table, not on a chair because in the process of thrashing around, they can fall and do themselves even greater harm. When putting them on the floor, they should be put on their side because of the foam coming out from the mouth. If you put the person to their back, they may choke. They should be put on their left side but any side is fine, so long as the saliva is able to find its way out and not go back into the mouth and cause choking. After that, something should be used to cushion the head because the person will jerk and because the person is on the floor, they may hit their head on the floor. You also would like to remove all the restrictive jewelries around the neck.
Are there other things?
Anything that can restrict breathing generally should be removed and the reason is that when the brain is going through seizures, it usually needs oxygen more than usual and if the brain doesn’t get enough, it gets injured. So, it’s more like a destructive process. The brain keeps releasing charges, and before the brain can rest and relax, another impulse could come. So, what you want to do is to try to get that person as much air as possible. Also, clear things around that can possibly injure the person – tables, sharp objects and so on, so that there’s enough space and enough air, then, after all these, one should call for help as quickly as possible. There are emergency numbers to call abroad but we don’t have that luxury in this part of the world. So, just call for help or rush the person to the hospital as quickly as possible.
There are things that must not be done during a seizure and the first one is to avoid putting anything in the mouth of the person. I saw a mother who put her own finger in the child’s mouth and of course, because the child does not know anything, the child bit the mum’s finger really badly. Don’t put anything in their mouth. Some people fear that the child may bite the tongue but at the same time, the child may not and even if they do, the doctors can sort that out after the event but in putting something in the mouth, the child will clinch on whatever hard object that is put there and the saliva released might go back in and choke that person to death. So, as much as possible, just leave that person alone because the biggest fear is that of choking to death. The child might choke with that secretion.
Another thing that should not be done is that one should not try to make the person come around. Some people start slapping the person, pouring water and beating them to come to. All these are not going to help because it’s coming from the brain. When it ends, it ends. It’s not a case of the person sleeping and you are trying to wake them up. It’s the situation in which the brain is just not functioning well. It’s not in the pouring of water and the like that the seizure stops.
What are the complications that result from convulsion?
Convulsion in children caused by severe malaria can lead to neurological sequelae. For some children, after having a bout of meningitis like that, when they get better and the infection has cleared, there will still be some complications left behind. The brain can be very unforgiven when it has suffered an injury. So, sometimes, when the child has had the malaria and the seizures stopped and the main illness is over, the child may be left with some deficit. You’ll discover that in some children who have started walking already, they will just stop walking and start sitting. If the parents are lucky, the child might regain it and sometimes they don’t. So, that can lead to a disability in children.
Sometimes, some children go blind. Sometimes, it leads to deafness and some children go on to develop epilepsy and then continue to have convulsions that are unprovoked without malaria and fever. In that case, epilepsy has resulted. Each time a child has seizures, some level of damage is done to the brain. Over time, one of the major things we have seen is that some of them start having a decline or poor academic performance. If the child was doing well but started having several episodes of convulsion and no one brought the child to the hospital or control was not done early enough, the child could have problems as intelligence could begin to decline. The cognitive functions begin to decline generally.
How is it managed?
What we do as physicians is to see and investigate the matter to know the root cause, whether it was caused by meningitis, malaria or epilepsy. Treatment is usually medical. We give drugs. The earlier drugs used to have side effects but researches are ongoing and newer ones are being produced. In some cases, when it is very difficult to treat, we do surgery. In some cases, we use keto diets for treatments of epilepsy. That’s the origin of keto diets.
Can it be avoided or prevented?
One of the common causes of epilepsy in our environment happens around the time of birth. We have what we call birth asphyxia which is synonymous to drowning. The foetus (unborn child) usually breathes in fluid in the womb but by the time the child is born, he needs to switch from breathing in water to breathing in air, so, the first cry of a child is very important. Unfortunately, a lot of people give birth in many places such that when the child is unable to take that first breath within the first five minutes of life, he doesn’t get the right assistance to breath and when that happens, the brain begins to suffer injury because the brain is starved oxygen for more than four minutes. It’s like the child is drowning. It has been born but is not breathing. The brain suffers that injury very early and the parents may feel that there is no problem.
That problem at birth leads to seizures especially when the woman is not properly handled or her birth was taken by quacks. It could also be as a result of jaundice. In cases of some accidents too where the child suffered a head injury, the person may have seizures or epilepsy a few years down the line. One of the things to do to prevent seizures in our environment is to make sure that people deliver in hospitals with trained medical practitioners, not just anybody and not just any hospital. Also, the use of mosquito nets and the likes is important to avoid malaria and fever.
