Survey on the management of childhood epilepsy among general practitioners in the area of Marrakech

Epilepsy is the most common chronic neurological pathology in children. It affects 0.5 to 1% of children worldwide, and one in 150 children has epilepsy during the first 10 years of life [4]. The incidence is highest in low to middle income countries [5]. Indeed, nearly 80% of people with epilepsy live in these countries [2]. In children, the incidence of epilepsy is highest in the first year of life and decreases in adulthood from the age of 10 years [5]. World Health Organization (WHO) also draws attention to the fact that treatment for epilepsy is very rarely available in low-income countries. For Morocco, we have little information on this subject because very few studies have been published on this subject [6]. A study carried out in Marrakech in 2010 estimated that cases of childhood epilepsy represented 8.5% of pediatric service consultants [7]. In Australia, a similar survey found that GPs see a median of six patients with epilepsy, mostly adults [8]. In another Australian study, childhood epilepsy (0–14 years) accounted for 6.6% of all epilepsy treated with MG [9]. While the International Bureau of Epilepsy carrying out a survey in 16 different countries (Europe, Canada, USA and Asia) showed that 27% of the doctors questioned encountered at least 4 cases of childhood epilepsy per day, and almost half of the doctors saw an average of 1 case per day [10]. These consultation rates remain high compared to our survey where the majority of the interviewed doctors (80%) encountered less than 5 cases of childhood epilepsy per month in their workplaces. According to statistics from the WHO, Africa has the lowest rates of health personnel per capita resulting in reduced access to basic and quality health care [2]. In Morocco, GPs are at the forefront of the care of patients followed for epilepsy given the lack of pediatricians and neuro-pediatricians. According to a Swedish study, more than a third of children (36.6%) did not have access to the neuropediatrician [11]. In our survey, two-thirds of GPs surveyed (67.8%) had never benefited from continued education sessions about childhood epilepsy. This explains the lack of knowledge of the latest classification of the ILAE (3.9%) and the large number of transfers to specialists (84.5%) in our survey. These data once again emphasize the value of involving and training GPs for better management of childhood epilepsy. A study conducted in Brazil showed that the majority of general practitioners and pediatricians (72.2%) were unsatisfied with their further education on childhood epilepsy [12]. While in Australia, only 42% considered their knowledge of epilepsy adequate for their practice [13]. Another study carried out in Laos found that only a minority of GPs (3.5%) remembered having received training on epilepsy and concluded that improving their knowledge will go a long way towards better management of epilepsy [14]. In Latin America, an initiative to address the shortage of neurologists through e-learning for the benefit of GPs was concluded with satisfactory results in terms of adherence to courses with considerable improvement in their knowledge for better management of childhood epilepsy [15]. Likewise, a survey carried out in Zambia had shown that through a pilot project, a targeted training program can improve the knowledge and confidence of health workers towards better management of childhood epilepsy [16].

The etiologies of epilepsies are multiple and varied resulting from the conjunction of genetic and acquired factors. Idiopathic epilepsies are strongly correlated with a genetic predisposition. The etiology is significantly correlated with the age of onset. About half have a documented etiology of which about 22% are presumed to be of genetic origin [5]. Two thirds of GPs (66.5%) cited genetic etiologies as the main causes of childhood epilepsies. In developed countries, the vast majority of cases are currently not preventable. In contrast, in developing countries, perinatal causes, central nervous system infections and head trauma are predominant [5, 17, 18]. According to an African study, perinatal accidents are the main causes in children (10.8%) [19]. Harimanana’s study found that 56.3% of GPs did not know any cause for the epilepsy [14]. Locally, the study carried out in the Marrakech region in 2010 found that the etiologies were dominated by perinatal complications (31.6%) [7]. During our investigation, the lesional etiologies were mentioned by 29% of physicians surveyed. Misdiagnosis of epilepsy is common, especially in pediatrics. Thus, the attending physician should take the necessary precautions to avoid overdiagnosis sparing the child and his family unnecessary treatment and lifestyle restrictions. A Danish study found that over a third of referred children (39%) did not suffer from epilepsy [20]. Another Norwegian study showed that 32% of diagnostic errors were due to a false judgment of treating physicians [4]. In Laos, only 50.7% of GPs mentioned differential diagnoses [14]. In our survey, this rate was 71.6%. However, it turned out that the vast majority (96%) of GPs referred to differential diagnoses other than those reported in the literature. While EEG video is currently the gold standard that should be used in questionable cases, the use of smartphones in these situations should be encouraged in low-income countries, allowing better description and classification of types of crises [21, 22]. A large majority of our GPs (85.2%) said they rely on performing a systematic EEG to support the diagnosis and none mentioned the usefulness of smartphones. Regarding therapeutic management, two-thirds of our GPs (65.8%) adopted monotherapy, which complies with the ILAE recommendations. Sodium Valproate also remains the antiepileptic of choice in our survey (68.4%). This can be explained by lack of continued education sessions about childhood epilepsy, absence of actualisation of GPs’ knowledge about the new antiepileptics leaving their prescriptions classical. So, for most GPs, VPA is the drug of choice for many pediatric epileptic syndromes. Nevertheless, phenobarbital was described by 16.8% of GPs in our series against 33% by Harimanana and al. [14]. Generally, newly diagnosed patients with epilepsy are initially treated with monotherapy. Polytherapy should be considered only after the failure of at least two or three monotherapies in case of pharmacoresistant epilepsy [23]. Most of our GPs (65.8%) opted for the monotherapy. Concerning the side effects of treatment, most GPs in our series were warned about this problem (75%). This was not the case in other surveys like Gomes's study [12] in which most practitioners (93.3%) are not sensitized on this problem. A very recent study among pediatric patients aged 6–18 years showed that 37% of them described different adverse drug events dominated by neurologic or psychiatric symptoms [24]. Most of the studies emphasize the importance of normal schooling for better integration of children treated for epilepsy. Active communication between medical institutions and the school with clearly provided information is necessary for better safety of pupils being monitored for epilepsy at school [25]. School performance difficulties (SPD) in children with seizures are probably related to the neurobiological, cognitive, psychological, and social consequences of seizure recurrence [5]. Thus, children with recurrent seizures or epilepsy had a higher rate of SPD than children without seizures [26]. None of the physicians interviewed in our series assessed the educational impact of epilepsy. A very recent study showed that children with epilepsy may exhibit visuospatial memory impairment compared to their peer. These disorders may be correlated to some features of the epilepsy itself and to the impairment of executive functions. Different antiseizure medications can affect visuospatial memory differently, so it is important monitoring this aspect in pediatric patients [27]. The development of cognitive and behavioral side effects had been also reported with the new antiepileptic drugs in pediatric epilepsy [28]. Moreover, Perampanel in association with 1 or 2 concomitant antiseizure medications demonstrated a good effectiveness in pediatric patients, without having to use a high dose of the drug [29]. The psychological and social care of the child with epilepsy and his parents is also an essential part of the treatment. Indeed, epilepsy is a major source of anxiety and depression for children and their parents [21, 30]. These comorbidities potentially affect seizure control with repercussions on the prognosis and quality of life of children [21]. In a cross-sectional observational study, Operto et al. [31] found in the epilepsy pediatric group a higher levels of parental stress and higher presence of emotional and behavioral symptoms compared to controls, mainly represented by internalizing problems (anxiety and depression symptoms). Therefore, parents of children with epilepsy should be offered psychological support to cope with stress and to improve the relationship with their children [31]. Only 39.4% of GPs in our survey considered this psychotherapy to be always necessary. Therapeutic education of the family and the child followed for epilepsy is an essential part of management. This participatory role of parents will contribute to good adherence to treatment, better monitoring of the social life of their children thus avoiding excessive restrictions negatively impacting the psychosocial development of children. It was only performed in only half of our GPs (48.4%) compared to 72.2% in Harimanana’s study [14].