a case control study of epileptic school children, assiut

Med. J. Cairo Univ., Vol. 79, No. 2, March: 115-127, 2011

www.medicaljournalofcairouniversity.com

A Case Control Study of Epileptic School Children,

Assiut Governorate, Upper Egypt

ETEMAD A.A. EL-SHEREEF, M.D.*; TAGHREED A. MOHAMED, M.D.*; MOHAMED A. ABDALLAH, M.D.*; MOHAMED A. EL-TORKEY, M.D.** and EMAD EL-DEEN M. HAMMAD, M.D.***

The Departments of Public Health & Community Medicine, Faculty of Medicine, Assiut* and South Valley** Universities and

Neuropediatric Unit, Pediatric University Hospital, Faculty of Medicine, Assiut University***

Abstract Objective: To study the socio-demographic characteristics

of epileptic school children and the risk factors for epilepsy in the study area.

Study Design: Case-Control study.

Setting: Two primary and one preparatory school children,

Assiut Governorate, Upper Egypt.

Subjects: The target population were basic education (primary and preparatory schools) epileptic school children. Matched controls for epileptic children were taken from the

same schools.

Methodology: Structured questionnaire of epileptic chil-dren and their controls included sociodemographic character-istics as age, sex, educational class and questions about the risk factors hypothesized from reviewing the literature and

previous studies such as many perinatal, infantile and childhood illnesses and exposures. Other family factors were included such as history of consanguinity and family history of epilepsy.

The questionnaire was completed through personal interview

with the caregivers of school children either cases or controls.

The part of the questionnaire including questions about the perinatal factors was completed from the mothers of the

children.

Results: The sample included 200 cases and controls each.

53.6% of epileptic cases were females. Rural residents repre-sented 56.0% of cases and controls of the significant risk

factors for developing epilepsy were: Family history of

epilepsy, Low socioeconomic level, birth trauma, head trauma,

history of febrile convulsions, neonatal jaundice, premature rupture of membranes and prematurity.

Conclusion: Raising the socioeconomic level of epileptic persons by finding opportunities for them to education and

employment to break the link between epilepsy and poverty

was recommended. Training of the general practioners, obste-tricians, and pediatricians about proper antenatal, natal and

postnatal care and management to avoid intrauterine infections,

birth trauma and neonatal problems is crucial.

Key Words: Epilepsy – Risk factors – School children.

Correspondence to: Dr. Etemad A.A. El-Shereef, The Department of Public Health & Community Medicine, Faculty of Medicine, Assiut University.

Introduction

EPILEPSY is the most common serious neurolog-ical disorder and is one of the world's most preva-lent non-communicable diseases. It is estimated that the condition affects approximately 50 million

people, around 40 million of them live in develop-ing countries [1] . In Egypt, about 840,000 people have epilepsy. This means that about one million

Egyptian families directly suffer from the various consequences of the condition – physically, socially

and economically [2] .

Many epileptic school children are not known to the education authorities [3] and teachers feel that they have inadequate general knowledge of

epilepsy and had not learnt the specific classroom management of epileptic children or the problems

of pupils with epilepsy [4,5] .

Although antiepileptic drugs are widely avail-able, many patients with active epilepsy are un-treated and the treatment gap is much greater in

developing countries [6] . Moreover, the lack of AED knowledge results in decreased patients com-pliance, which is a serious hindrance to successful treatment and can place the patient at unnecessary

risk [7] .

An increasing awareness of the value of epide-miological studies of epilepsy has been manifested over the past several decades. Epidemiological

studies generate important data about the disease

that cannot be obtained by clinical interviews [8] .

Epidemiological studies of childhood epilepsy are of important to compare incidence and preva-lence rates, age distribution, inheritance, seizure types, epilepsy syndromes and treatment strategies

[9] . In Egypt we still have only very few limited

115

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116 A Case Control Study of Epileptic School Children

data available concerning incidence, prevalence

and demographic characteristics of epileptics [10] .

El-Baz and El-Baz, [11] in their study in Egypt concluded that epilepsy is an existing problem that has many dark areas in its epidemiology and treat-ment compliance, waiting to be further enlightened by further research.

The objectives of the present study was to study the socio-demographic characteristics of epileptic

school children and the risk factors for epilepsy in the study area.

Subjects and Methods

Study design: Case-control study: Comparing epileptic chil-

dren with their matched control for the presence

of risk factors for epilepsy.

Study population: • Basic education school children (primary and

preparatory school children) of both sexes who

are known to have epilepsy and/or receiving antiepileptic drugs and belonging to the study

area in Assiut Governorate. Those children were identified through school records and health

insurance records.

• Control groups for epileptic children were chosen from the same schools compared with epileptic children regarding risk factors for developing epilepsy.

Sampling technique: • A stratification of all the districts in Assiut Gov-

ernorate was done according to their geographical distribution to the east or the west side of the River Nile.

• For convenience, one district from the eastern

group (Al-Fateh District) and two districts from

the western group (Assiut District and Abu-Teeg

District) were selected to represent the governor-ate. Both urban and rural areas were selected

from each district.

• Schools within the chosen districts were stratified

to primary and preparatory schools. The prepara-tory schools were further stratified to male and

female schools.

• Selection of schools within each stratum was

guided by the number of the reported epileptic

cases in the school records, health insurance records and also the personal communication with the educational authorities and the adminis-trators of schools to verify the eligible number

of children within each school. This was done to obtain the highest yield from each school visit.

Sample size: The sample size for cases and controls was

calculated using the EPI info 2000 statistical pack-age. The calculation was done using the expected

frequencies of the different risk factors among

cases and control and/or the calculated odds ratio

from previous studies using 95% confidence inter-val and 80% power of the test, and taking one

control for each case, the largest sample size cal-culated according to the above criteria was 135 cases and control each. The present study included 200 cases and 200 matched controls.

Technical design: I- Preparatory stage:

- Review of literature about epilepsy was carried out through multiple searches in libraries, Medline databases and internet network.

- Preliminary visit and communication with the educational, health insurance and school health authorities were carried out to know about meth-ods of disease reporting and the availability of

the relevant information to trace those children.

- The official approvals of the directors of both

education and health insurance sectors of Assiut

Governorate were obtained.

- Revision of health insurance records and school

records to obtain data about the number, names

and schools of epileptic children.

- Construction of the relevant questionnaires to be

the tools for data collection was carried out:

a- Questionnaire of epileptic children and their controls included sociodemographic characteristics as age, sex, educational class and questions about

the risk factors hypothesized from reviewing the

literature and previous studies such as many peri-natal, infantile and childhood illnesses and expo-sures. Other family factors were included such as

history of consanguinity and family history of epilepsy. Also the questionnaire included questions

about the socioeconomic level of the family ac-cording to family socio-economic status scale prepared by Abdel-Tawab, [12] . The questionnaire was completed through personal interview with

the caregivers of school children either cases or

controls. The part of the questionnaire including questions about the perinatal factors was completed from the mothers of the children.

b- Pilot study was carried out on 20 epileptic cases attending Sedi Galal health insurance clinic

Etemad A.A. El-Shereef, et al. 117

and their caregivers from both rural and urban

school to test the questionnaires, and to identify difficulties that may arise and deal with them accordingly. This step resulted in rephrasing of some question, omitting and adding others and

assessment of the time needed for interview. This step was carried out during October 2004. Cases

of the pilot study were not included in the results

of the thesis.

II- Field work:

The fieldwork of the present study was carried out from November, 2004 to may, 2005. Obtaining the school grade of the cases and controls was carried out later on in the eligible time according

to the school class the child belonged the following

steps were carried out:

III- Statistical analysis:

• Revision of data and coding variables in the three

forms of questionnaire was done to be ready for computer entry.

• Data entry, cleaning and management took place. Statistical analysis and tabulation were done using

Statistical Package for Social Sciences (SPSS for windows, version 9). The SPSS was used in

calculating the socioeconomic score for each case

and control according to the weight of each in-volved variable.

The following statistical tests were used:

• Descriptive statistics: Frequencies, percentages,

means and standard deviations.

• Tests of significance: Chi square test and Student

t-test.

• Odds ratio: Was calculated as a measure of asso-ciation between the different risk factors and

epilepsy at 95% confidence limit. The calculation took place by using the EPI info 2000.

• Logistic regression analysis: Was applied to rank the different risk factors according to their role

in the development of epilepsy.

• Statistically significant differences were consid-ered when p-value was at least less than 0.05%.

Ethical considerations:

• Verbal consents were obtained from all the par-ticipants; school personnel and caregivers of the

epileptic children.

• Privacy and confidentiality of all the information

obtained was observed.

Results

53.5% of epileptic cases and their controls were

males and 46.5% were females. Rural residents represented 56.0% of cases and control while urban residents represented 44.0%. Primary school stu-dents represented 68% of cases and control versus

32.0% for preparatory school students. The mean

age of the cases and control was 11.34 ±2.67 and 11.17±2.55 years respectively without statistical significant difference. There was statistical signif-icant difference between cases and controls as

regard handedness as 12.5% cases were left handed

versus 3.0% of the controls and 1.0% of cases

could use both hands versus none of the controls.

Only 13.5% of epileptic cases were of the high socioeconomic level versus 29.0% of the controls (Table 1).

Table (2) shows that 14.5% of cases had abnor-mal intrauterine position versus 3.5% of the control

with statistical high significant difference and odds ratio (OR) equals 4.7. Mothers of 12.5% of cases

had history of premature rupture of membranes versus 4.0% of controls with statistical high sig-nificant difference (OR = 3.4). On the other hand,

many other antenatal risk factors such as birth

order of the student, history of bleeding during

early or late pregnancy, and maternal age at time

of labor showed no statistically significant differ-ence between cases and controls.

Table (3) shows that some mothers' medical problems during pregnancy such as pre-eclampsia

or eclampsia, hypertention and drug intake during

pregnancy occurred more frequently among cases

than controls with odds ratio equals 2.0, 3.0 and 1.8 respectively but this difference was statistically

insignificant.

In addition, mothers' histories of renal diseases, heart disease, diabetes mellitus and exposure to

radiation during pregnancy showed no statistical

significant difference between cases and controls.

Table (3) also shows that although mothers' past history of miscarriage (abortion and stillbirth)

showed higher occurrence among cases than con-trols, the difference didn't reach the level of statis-tical significance.

Table (4) shows that there was statistically high significant difference between cases and controls as regard prematurity as 7.5% of cases were born

prematurely versus 0.5% of the controls (OR = 16.3) while postmaturity represented 1.5% of cases

versus 0.5% of the controls without statistically

significant difference (p>0.05).


As regards birth attendants, a doctor or a nurse

delivered more cases than controls (41.0% & 14.5% versus 33.0% & 6.0% respectively) while dayas were responsible for delivery of more controls than

cases (48.0% versus 32.0% respectively) with

statistical high significant difference (p=00.3).

As regards type of labor, 2.5% of cases had

been delivered by ventose or forceps versus none of the controls while 7.0% of controls were deliv-ered by cesarean section versus 4.0% of cases with

statistically significant difference (p=0.01).

The same Table (4) shows that 17.0% of cases

had a history of birth trauma versus 1.0% only of

the controls (OR = 20.3) and 13.5% of the cases

had a history of cyanosis after birth versus 0.5% of the controls (OR = 31.1) with statistical high significant difference for both factors. Also the

same table shows that 20.5% of cases had a history of delayed crying after birth versus 9.5% of the controls with statistically significant difference

(OR = 2.5). There was no statistically significant difference between cases and controls as regards the place of labor.

Table (5) shows that 10.0% of cases needed

neonatal incubator versus 1.0% of controls with statistically significant difference (OR = 11). Also

3.0% of cases had a history of neonatal convulsion versus none of the controls. History of neonatal

jaundice showed statistically high significant dif-ference between cases and controls (13.5% versus 1.5% respectively) with odds ratio equals 10.3.

Table (6) shows that there, were statistically

significant difference between cases and controls as regards history of encephalitis, meningitis and

pyrexia of unknown origin as they represented 3.0%, 3.5%, 4.5%, of cases versus 0.5%, 0.5%,

1.0% of controls with odds ratio equals 6.2, 7.2

and 4.7 for the three diseases respectively.

Other infectious diseases as chicken pox, mea-sles, tuberculosis, showed no statistically significant difference between cases and controls. The same

Table (6) shows that 6.5% of cases versus 0.5% of the controls had a history of febrile convulsions

(OR = 13.8) with statistically significant difference.

There was no statistical significant difference

between cases and controls as regard history of

cerebral hemorrhage or brain tumors.

Table (6) also shows that history of head trauma

was positive among 16.5% of cases versus 3.5%

of the controls with statistical high significant

difference and odds ratio equals 5.5.

Fig. (1) shows that there was statistically high

significant difference between cases and controls as regard family history of epilepsy (46.0% versus

21.0% respectively) with odds ratio equals 3.2.

Fig. (2) also shows that there was statistical significant difference between cases and controls as regard family history of mental retardation

(13.5% for cases versus 3.5% for controls) with

odds ratio equals 4.3.

Fig. (3) shows that consanguinity between

parents did not show statistical significant differ-ence between cases and controls ( p=0.09426).

Table (7) shows the risk factors for developing

epilepsy according to the level of significance.

These risk factors in a descending order were:

Family history of epilepsy, low socioeconomic level, birth trauma, head trauma, history of febrile

convulsions, neonatal jaundice, rupture of mem-branes and Prematurity.

Table (1): Background characteristics of epileptic school children and their controls, Assiut Governorate, 2005.

Background characteristic Cases

(No.=200) Controls

(No.=200) Statistical test p-value No. % No. %

Sex: Males 107 53.5 107 53.5 – – Females 93 46.5 93 46.5

Residence: Rural 112 56.0 112 56.0 – – Urban 88 44.0 88 44.0

School: Primary 136 68.0 136 68.0 – – Preparatory 64 32.0 64 32.0

Handedness: Right 173 86.5 194 97.0 X2=14.8 0.0001** Left 25 12.5 6 3.0 Both 2 1.0 – –

Age/years: (Mean±SD) 11.34±2.67 11.17±2.55 t=0.64 0.261 *

Socioeconomic level: Low 32 16.0 29 14.5 X2=14.6 0.0007** Middle 141 70.5 113 56.5 High 27 13.5 58 29.0

*p>0.05 Non Significant. **p<0.05 Significant.


Table (2): Antenatal risk factors among epileptic school children and their controls, Assiut Governorate, 2005.

Cases Controls Antenatal risk factor (No.=200) (No.=200) Statistical test p-value Odds ratio

No. % No. %

Intrauterine position of the baby: Normal 171 85.5 193 96.5 X2=14.8 0.000 4.7 Abnormal 29 14.5 7 3.5

Premature rupture of membranes: Yes 25 12.5 8 4.0 X2=9.6 0.002 3.4 No 175 87.5 192 96.0

Birth order: First baby 41 20.5 41 20.5 X2=00.0 N.S 1.0 Second to fourth 109 54.5 109 54.5 Fifth and higher 50 25.0 50 25.0

History of bleeding during first trimester: Yes 9 4.5 4 2.0 X2=1.9 0.1681 2.3 No 191 95.5 196 98.0

History of bleeding during Last trimester: Yes 7 3.5 2 1.0 X2=2.8 0.0943 3.6 No 193 96.5 198 99.0

Mother age at delivery: Less than 20 years 17 8.5 10 5.0 X2=2.0 0.3679 1.2 20-35 years 163 81.5 169 84.5 Above 35 years 20 10.0 21 10.5

Mother age at delivery by years: (Mean ± SD) 26.77±6.04 27.40±5.90 t=1.0 0.2952 –

*p>0.05 Non Significant. **p<0.05 Significant.

Table (3): Mothers' medical and obstetric history among epileptic school children and their controls, Assiut Governorate, 2005.

Variables Cases

(N=200) Controls (N=200) X2

p-value Odds ratio

No. % No. %

Pre-eclampsia or eclampsia:

Yes 4 2.0 2 1.0 0.7 0.4028* 2.0 No 196 98.0 198 99.0

Hypertension: Yes 6 3.0 2 1.0 2.0 0.1573* 3.0 No 194 97 198 99.0

Drug intake during pregnancy: Yes 24 12.0 14 7.0 2.9 0.0886* 1.8 No 176 88.0 186 93.0

Renal diseases: Yes 4 2.0 4 2.0 0.0 1.0 No 196 98.0 196 98.0

Heart diseases: Yes 2 1.0 2.8 0.0943* – No 198 99.0 200 100

Diabetes mellitus: Yes 3 1.5 3.0 0.0833* – No 197 98.5 200 100

Exposure to radiation: Yes 1 0.5 1 0.5 0.0 N.S* 1.0 No 199 99.5 199 99.5

History of abortion: Yes 84 42. 75 37.5 0.85 0.3566* 1.2 No 11.6 58.0 125 62.5

History of still birth: Yes 12 6.0 7 3.5 1.4 0.2367* 1.8 No 188 94.0 193 96.5

*p>0.05 (Non Significant).


Table (4): Perinatal risk factors among epileptic school children and their controls, Assiut Governorate, 2005.

Perinatal risk factors Cases Controls

X2 p-value Odds ratio

No. % No. %

Time of labor: At time 182 91.0 198 99.0 Before expected 15 7.5 1 0.5 12.9 0.000 16.3 After expected 3 1.5 1 0.5 1.16 0.5599 3.2

Labor attendant: Doctor 82 41.0 66 33.0 Nurse 29 14.5 12 6.0 Daya 64 32.0 96 48.0 Relative/neighbors 24 12.0 24 12.0 15.8 0.003 Alone 1 0.5 2 1.0

Type of labor: Normal 185 92.5 186 93.0 By forceps 2 1.0 0 0.00 11.4 0.01 By ventose 5 2.5 0 0.00 Cesarean section 8 4.0 14 7.0

Birth trauma: Yes 34 17.0 2 1.0 31.3 0.000 20.3 No 166 83.0 198 99.0

Cyanosis after birth: Yes 27 13.5 1 0.5 26.0 0.000 31.1 No 173 86.5 199 99.5

Crying immediately after birth: Yes 159 79.5 181 90.5 9.5 0.002 2.5 No 41 20.5 19 9.5

Place of delivery: At home 123 61.5 136 68.0 3.4 0.1827 – At hospital 69 34.5 61 30.5 Private clinic 8 4.0 3 1.5

Table (5): Neonatal risk factors among epileptic school children and their controls, Assiut Governorate, 2005.

Neonatal risk factor

Cases (No.=200)

Controls (No.=200) Statistical test p-value Odds ratio

No. % No. %

Need for incubator: Yes 20 10.0 2 1.0 X2=15.6 0.000 11.0 No 180 90.0 198 99.0

Neonatal convulsion: Yes 6 3.0 – – X2=6.1 0.01 – No 194 97.0 200 100

Neonatal jaundice: Yes 27 13.5 3 1.5 X2=20.8 0.000 10.3 No 173 86.5 197 98.5

Age at beginning of jaundice by days: Mean ± SD 3.3±2.0 4.0±2.6 t=0.5 N.S

Duration of jaundice by days: Mean ± SD 11.4±8.7 6.7±3.5 t=0.9 N.S


Table (6): History of exposure to some diseases and head trauma among epileptic school children and their controls, Assiut

Governorate, 2005.

Infectious disease

Cases (No.=200)

Controls (No.=200) Statistical test p-value Odds ratio

No. % No. %

Encephalitis:

Yes 6 3.0 1 0.5 4.0 0.04 6.2

No 194 97.0 199 99.5

Meningitis:

Yes 7 3.5 1 0.5 5.2 0.03 7.2

No 193 96.5 199 99.5

Pyrexia of unknown origin:

Yes 9 4.5 2 1.0 4.6 0.03 4.7 No 191 95.5 198 99.0

Chicken pox:

Yes 12 6.0 6 3.0 2.0 N.S 2.0 No 188 94.0 194 97.0

Measles:

Yes 28 14.0 22 11.0 0.8 N.S 1.3 No 172 86.0 178 89.0

Tuberculosis:

Yes 2 1.0 – – 2.5 N.S –

No 198 99.0 200 100

Febrile convulsions:

Yes 13 6.5 1 0.5 10.7 0.001 13.8 No 187 93.5 199 99.5

Cerebral hemorrhage:

Yes 1 0.5 – – 1.0 N.S –

No 199 99.5 200 100

Brain tumors:

Yes 2 1.0 – – 2.0 N.S –

No 198 99.0 200 100

Past history of head trauma:

Yes 33 16.5 7 3.5 X2=18.8 0.000 5.5 No 167 83.5 193 96.5

Table (7): Logistic regression of the risk factors for epilepsy among epileptic school children,

Assiut Governorate, 2005.

Risk factor Regression coefficient p-value

1 Family history of epilepsy 1.5 0.0000

2 Low Socioeconomic Level 0.8 0.0002

3 Birth trauma 2.9 0.0003

4 Head trauma 1.6 0.0006

5 History of febrile convulsions 2.8 0.01

6 Neonatal jaundice 1.8 0.01

7 Premature rupture of membranes 1.3 0.01

8 Prematurity 2.7 0.02

%

40

20

60

0

46%

X2=28.6

p=0.000

Odds ratio=3.2

21%

%

40

20

60

0

p =N.S X2=2.6

46%

38%

Cases

Control

15

10

5

0

13.5 X2=12.9

p=0.000

Odds ratio=4.3

3.5


Cases Control

Fig. (1): Family history of epilepsy.

Cases Control

Fig. (3): Consangunity.

Discussion

The etiology of epilepsy remained unknown in most cases and many studies sought to investi-gate the role of some factors in the etiology of

epilepsy [13] .

The present matched case-control study attempt-ed to identify some possible risk factors for child-hood epilepsy.

As regards risk factors for developing epilepsy. Findings of the present study accepted and sup-ported the following study hypotheses:

• Children who were exposed to head trauma, some

perinatal, infantile and childhood diseases, and those who have a family history of epilepsy are

at higher risk of developing epilepsy than those

who are not.

• Low socioeconomic class children are more affected by epilepsy than other children.

Logistic regression of data in the present study showed that the most important risk factors for developing epilepsy, according to significance,

Cases Control

Fig. (2): Family history of mental retardation.

were family history of epilepsy, low socioeconomic

level, birth trauma, head trauma, history of febrile

convulsions, neonatal jaundice, premature rupture

of membranes and prematurity, (Table 7). So, many

of these factors are preventable or at least modifi-able.

Background characteristics: In the present study 53.5% of epileptic cases

were males and 46.5% were females. Rural resi-dents represented 56.0% of cases while urban residents represented 44.0% (Table 1). In agreement

with the present study, Artemowicz, et al., 2003

[14] reported that 53.4% of epileptic children were

boys and 46.6% were girls while 44.4% of the children lived in cities and 55.6% in small towns or villages. Also El-Baz and El-Baz, [11] in their of epilepsy among female university students in Egypt reported that 72.5% of epileptics were rural residents versus 27.5% were urban residents.

Handedness: The results of the present study revealed that

significantly higher percent of epileptic cases were

left handed compared to controls (12.5% versus

3.0% respectively) and another 1.0% of cases can use both hand versus none of the controls.

Although this factor was not deeply discussed in many of the available previous studies, there are

some studies that may pave the way to the interpre-tation of this observation. For example, Van Strein et al., [15] in their study reported that the left-handed persons were more exposed to birth complications than the right-handed ones (Table 1).

Socioeconomic level:

The present study reported that the development

of epilepsy was significantly associated with low

socioeconomic state and there was statistical sig-nificant difference between cases and controls as


regards the mean socioeconomic score ( p<0.001). This agrees with Heaney et al., [16] and Murphy et al., [17] who confirmed that epilepsy is signifi-cantly higher among persons in the low socioeco-nomic class. This finding is supported to some extent by the observation that the incidence of

epilepsy is higher in developing than developed countries [18] .

According to BBC 2002 [19] , researchers re-ported that poorer people are more likely to develop

epilepsy. This may be due to other risk factors

associated with epilepsy such as birth defects, which are known to be more common among de-prived groups. However, the explanation is not likely to be single cause and it is likely to be multifactorial (Table 1).

The result of the present study is in disagree-ment with El-Baz and El-Baz, [11] .

Antenatal, natal and perinatal risk factors:

Both pre-and perinatal factors may be associated

with later development of epileptic seizures in

children [20] .

While epilepsy can present at any age, this

condition often occurs because of adverse events

occurred early in life. Pathogenetic mechanisms

also cause deleterious consequences to the brain during prenatal life. Maternal, fetal, and placental disease also contribute to either brain malformation

or injuries, depending on events during the first or second half of pregnancy. Sequential stages during

prenatal brain development, from embryonic through

perinatal periods, specify which gray and white matter structures may be adversely altered [21] .

Intrauterine position of the child during pregnancy: Abnormal position of the baby during pregnancy

was detected in this study as a risk factor of sub-sequent epilepsy (Table 2). The abnormal position

during pregnancy may increase the risk of difficult

and prolonged labor especially in our community where neither mothers nor families prefer the early

intervention by cesarean section. This subsequently

can result in birth trauma and/or hypoxia and brain

injury and so increase the risk of subsequent epi-lepsy. In agreement with the present results. Krebs and Langhoff-Roos, [22] concluded that breech presentation was a risk factors for epilepsy (OR:

1.2) and this increased risk is not related to intra-partum events, but to growth restriction during

pregnancy.

Premature rupture of membranes during pregnancy: This factor showed statistical significant differ-

ence between cases and control in the present study

(p<0.01) (Table 2). Premature rupture of mem-branes may be an indicator of early exposure to

infection (intrauterine or perinatal infections).

Artemowicz et al., [14] also revealed that neuroin-fections in the neonatal period is a risk of epilepsy.

Birth order of the child:

The present study revealed that birth order of

the child did not show statistical significant differ-ence between cases and controls (Table 2). This is conforming to the results reported by Murphy et al., [17] who investigated the same factor.

Chapa and Ottman, [23] reported that even if there is an association between birth order and

epilepsy, it couldn’t be explained by any conven-tional genetic model because genetic transmission

is independent from sequential birth of the parents.

Mother’s history of bleeding during pregnancy: The present study revealed no statistical signif-

icant difference between cases and control as regard maternal history of bleeding during pregnancy

(p>0.05) (Table 2). The is conforming to what was

observed by Ogunniyi et al., [24] ; Rocca et al., [25] and Bertolote, [26] that mothers’ history of bleeding

during pregnancy did not constitute a risk for

developing epilepsy among children.

In contrast, Sidenvall et al., [20] reported an association between vaginal bleeding during preg-nancy and subsequent epilepsy.

Age of the mother at delivery:

Results of the present study showed no statis-tically significant difference between cases and

controls as regards mother’s age at delivery

(p>0.05) (Table 2). This is consistent with the results reported by Rocca et al., [25] ; Murphy et al., [17] and Asadi-Pooya & Hojabri, [27] that pa-rental age added no risk of epilepsy. In disagreement with the present study, Monetti et al., [28] and Shawki, [29] reported that maternal age >35 years

is risk in developing epilepsy.

Medical and obstetric problems to the mothers during pregnancy:

In the present study, there was an association

between histories of pre-eclampsia or eclampsia, hypertension and drug intake during pregnancy

and subsequent epilepsy, but this association did

not reach the level of statistical significance ( p> 0.05) (Table 3).

In agreement with our results, Rocca et al., 1987 [25] could not confirm an association between

gestational toxemia or eclampsia and epilepsy.


Bertolote, [26] stated that “it is surprising to see that some factors such as toxaemia during preg-nancy, firmly believed on clinical grounds to cause epilepsy, failed to confirm this impression in the

controlled studies conducted”.

In this study, there was no statistical significant

association between epilepsy and medical problems during pregnancy such as heart diseases, renal

diseases, diabetes mellitus, or exposure to radiation

during pregnancy (p> 0.05) (Table 3). In agreement with the present study, Murphy et al., [17] did not confirm an association between mothers’ histories

of antenatal problems and the development of epilepsy among children.

Pre and postmaturity: This study showed that prematueity was a highly

significant risk factor for epilepsy (OR=16.3)

(Table 4). Prematurity can also be explained by

the need for incubator after birth, which also

showed statistically high significant difference

between cases and controls in our study (Table 6).

In agreement with the results of the present study, Sidenvall et al., [20] ; Murphy et al. [17] and Serdaroglu et al., [30] revealed that preterm delivery may be an important risk factor for epilepsy because

of its strong association with neonatal cerebral

lesions. In addition, Daoud et al., [31] reported that history of admission to the neonatal ICU increased the risk of epilepsy.

As regards postmaturity, the present study showed no statistically significant difference be-tween cases and controls (p>0.05). In consistence with the results of the present study, Rocca et al., [25] did not confirm postmaturity as risk for devel-oping epilepsy.

On the other hand, Sidenvall et al., 2001 [20] and Serdaroglu et al., [20] in their studies reported that post-term delivery increased the risk of devel-oping epilepsy.

Labor attendant: In the present study, it was observed that doctors

and nurses were the birth attendants among higher

percent of cases than control while dayas were the

birth attendants among higher percent of controls

than cases (Table 4).

This finding could be the results of NMMS,

[32] in Egypt that poor diagnosis and management of pregnancy and labor complications were prac-ticed by obstetricians and contributed to 43.0% of the avoidable causes of maternal mortality, another 11.0% were caused by general practitioners while

midwives and dayas contributed to 4.0% and 8.0% respectively. So most complicated labors were done by doctors either obstetricians or general

practitioners while the training programs conducted in Egypt by the MOHP in collaboration with UNICEF and USAID have been relatively success-ful in encouraging dayas to refer promptly women

with complications and to reduce the use of harmful

practices either to the mother or the fetus.

Type of labor and place of delivery:

The present study reported that 2.5% of cases

had been delivered by ventose or forceps (instru-mental delivery) versus none of the control (Table 4). In agreement with the present study, Mahesh-wari, [33] reported that significantly more children

who were delivered by forceps developed seizures.

The present study reported that more controls

were delivered by cesarean section than cases. This

can be interpreted by the avoidance of prolonged, obstructed labor and subsequent birth trauma, so

cesarean section can be considered as a protective

factor if normal labor cannot be attained. In dis-agreement with the present results, Sidenvall et al., [20] considered cesarean section as a risk factor

for developing epilepsy.

The present study revealed no significant dif-ference between cases and control as regards place

of delivery (Table 4). The same finding was also reported by Serdaroglu et al., [30] .

History of birth trauma, cyanosis after birth, crying immediately after birth:

The present study revealed that significantly

higher percent of epileptic cases had a history of

birth trauma and/or cyanosis after birth and also

significantly lower number of cases had a history of crying immediately after birth. In agreement

with the present study, Shawki, [29] and Daoud et al., [31] who confirmed significant association between birth trauma and subsequent epilepsy.

Artemowicz et al., [14] reported that the most common etiology of epilepsy was hypoxic-ischemic damages to the brain in the perinatal period. In

addition, Hackett et al., [34] in their studies con-cluded that histories of perinatal complications either perinatal hypoxia and/or intracranial birth

injury caused by poor obstetric management were

independently associated with active epilepsy.

Al-Rajeh et al., [35] concluded that the high incidence of associated perinatal encephalopathy

reported in their study suggests that perinatal factors

play a major role in the pathogenesis of epilepsy in Saudi Arabia.


Mothers’ history of miscarriage: The present study showed no statistically sig-

nificant difference between cases and control as

regards maternal history of miscarriage and subse-quent epilepsy (Table 3). This is conforming to the

results reported by Rocca et al., [25] .

Neonatal risk factors: Neonatal convulsions:

The present study revealed an association be-tween neonatal convulsions and epilepsy (Table 5). In agreement with the present results, Daoud et al., [31] reported that neonatal seizures were

associated with a high incidence of postnatal epi-lepsy.

In addition, Aziz et al., [36] and Aziz et al., [37] reported positive history of neonatal convulsion among 14.3% of epileptic cases.

Neonatal seizures are considered an acute man-ifestation of disturbance of the neonatal brain.

Some of them could be considered as neonatal epilepsy [38] .

Neonatal jaundice:

In the present study, neonatal jaundice was

reported to be significantly increases the risk of

epilepsy (OR=10.3) (Table 5). This is consistent with the results reported by Aziz et al., [36] and Aziz et al., 1997b [37] reported of neonatal jaundice among 7.5% of epileptic cases. The present study

disagrees with the findings reported by Asadi-Pooya and Hojabri, [27] that neonatal jaundice added no risk for developing epilepsy.

History of exposure to disease (Table 6): This study revealed significant association

between epilepsy and history of meningitis (OR= 7.2), encephalitis (OR=6.2) and pyrexia of unknown

origin (OR=4.7). Pyrexia of unknown origin may be an indicator of undetectable CNS infection, which may be viral infection that cannot be diag-nosed by the available methods (Table 6).

In agreement with the results of the present study Daoud et al., [31] reported that patients with history of CNS infection were more than controls

but this difference did not reach the level of sig-nificance.

Febrile convulsions: The present study revealed an association be-

tween past history of febrile convulsions and epi-lepsy (OR=13.8) (Table 6). This is consistent with

the results reported by Bertolote, [26] who reported

an odds ratio of febrile convulsion as a risk for

epilepsy between 3.0-14.2.

In other studies, febrile seizures were reported

to be associated with five to six folds increased

risk of subsequent epilepsy [31] .

Brain tumors and cerebral hemorrhage:

The present results could not confirm an asso-ciation between neither cerebral space occupying

lesions nor cerebral hemorrhage and epilepsy (Table

6). This may be due to the small number of positive cases. These results disagree with the results re-ported by Danesi, [38] .

In the present study, history of brain tumors

was positive among 1.0% of epileptic cases. Al-Rajeh et al., [35] reported brain tumor among 0.5% of cases.

History of head trauma: In the present study, an association was reported

between history of head trauma and epilepsy with OR=5.5 (Table 6). This is consistent with the results

reported by Bertolote, [26] who calculated OR between 1.4-12.7.

The present study showed that the percentage

of head trauma among cases and control were

16.5% and 3.5% respectively. In agreement with

the results of the present study, Shawki, [29] in Assiut, Egypt reported the percentage of head

trauma among cases and controls to be 18.8% &

1.6 respectively.

In Saudi Arabia, Al-Rajeh et al., [35] reported cerebral trauma among 11.0% of cases. Daoud et

al., [31] had also confirmed head trauma as a risk

factor of epilepsy.

Family history of epilepsy:

The present study revealed that family history

of epilepsy was significantly higher among cases

than controls (Fig. 1).

Positive family history of epilepsy was also reported to be significantly higher among epileptic persons than non epileptics by Aimaan, 1996 [10] ; Shawki, [29] ; El-Baz and El-Baz, [11] ; and Murphy et al., [17] .

In the present study, positive family history of

epilepsy represented 46.0% and 21.0% among

cases and control s respectively. These results are

much higher than those observed by Shawki, [29] (22.0% and 7.2% for epileptics and non epileptics

respectively) and El-Baz and El-Baz, [11] who reported 17.5% and 0.6% for cases and controls respectively.


Family history of mental retardation: The present study revealed that family history

of mental retardation was significantly higher among epileptics than controls (13.5% versus 3.5%

respectively) (Fig. 2).

The present results is higher than what was

reported in Egypt by Shawki, [29] that family history of mental retardation among epileptic cases repre-sented 4.2% and 3.9% respectively.

Parental consanguinity:

The present study reported that consanguinity was more common among the parents of epileptic

students than controls (46.0% versus 38.0%) with-out statistically significant difference ( p=0.09426) (Fig. 3).

In agreement with the present study, Daoud et

al., [31] confirmed that although consanguinity is

widely practiced in many developing countries, it

does not increase the risk of epilepsy as the majority

of genetically influenced epilepsy is multifactorial

where the positive family history reflects familial

aggregation.

In disagreement with the present study, Aimaan, [10] ; Shawki, [29] and El-Baz and El-Baz, [11] re-ported statistically insignificant difference between cases and controls as regards parental consanguin-ity.

Al-Rajeh et al., [35] confirmed that although consanguinity of the parents appeared not to be a

major factor in the genetics of convulsive disorders,

it might potentiate the tendency of familial aggre-gation of convulsive disorders in the community. Consanguinity may be an important factor in the

production of some of these disorders but its precise role has not been determined.

Recommendations: Raising the socioeconomic level of epileptic

persons by finding opportunities for them to edu-cation and employment to break the link between

epilepsy and poverty was recommended. Training

of the general practioners, obstetricians, and pedi-atricians about proper antenatal, natal and postnatal

care and management to avoid intrauterine infec-tions, birth trauma and neonatal problems is crucial.

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a case control study of epileptic school children, assiut

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