Nutritional status of children with epilepsy, attending the Pediatric Neurology Clinic of University of Nigeria Teaching Hospital, Enugu

Ann E Aronu; Ndubuisi A Uwaezuoke; Adaobi Bisi-Onyemaechi; Agozie C Ubesie; Ngozi C Ojinnaka

doi:10.4103/ijmh.IJMH_22_20

ORIGINAL ARTICLE

Year : 2022 | Volume : 27 | Issue : 1 | Page : 63-67

Nutritional status of children with epilepsy, attending the Pediatric Neurology Clinic of University of Nigeria Teaching Hospital, Enugu

Ann E Aronu, Ndubuisi A Uwaezuoke, Adaobi Bisi-Onyemaechi, Agozie C Ubesie, Ngozi C Ojinnaka
Department of Paediatrics, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria

Date of Submission	01-May-2020
Date of Decision	03-Jul-2020
Date of Acceptance	27-Mar-2021
Date of Web Publication	3-Dec-2021

Correspondence Address:
Ndubuisi A Uwaezuoke
Department of Paediatrics, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu.
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_22_20

Abstract

Background: Malnutrition is a direct or underlying cause of 45% of all deaths of under-five children in Nigeria. Nigeria has one of the highest burden of malnourished children in the world. Certain vulnerable groups such as children with chronic diseases are often neglected in nutritional studies. Objective: This study sought to determine the prevalence of malnutrition among children with epilepsy, attending the Neurology Clinic of the University of Nigeria Teaching Hospital. Materials and Methods: This was a descriptive cross-sectional study. Study participants were epileptic children aged 6 months to 18 years. Socio-economic status was determined using the Oyedeji classification. Weight and height were measured using standard protocols. The weight for height, body mass index for age, and height for age z-scores were calculated using the WHO Anthro and Anthro Plus software. Data were analyzed using SPSS version 20.0, and significant p-values were set at less than 0.05. Results: One hundred and twenty children with epilepsy aged 6 months to 18 years who met the inclusion criteria were included in the study. Seventy-eight (65%) were males; (male: female ratio = 1: 0.5). The overall prevalence of wasting, stunting, overweight, and obesity were 5.8%, 9.2%, 10.8%, and 5.8%, respectively. There were no statistically significant differences between various forms of malnutrition and the gender, age group, and socio-economic status of study participants (p > 0.05). Conclusion: Overweight was the most common form of malnutrition, followed by stunting among the epileptic children. There is need for regular anthropometric monitoring of children with drug-naive epilepsy with targeted interventions to correct malnutrition in them during the course of epilepsy management.

Keywords: Epilepsy, malnutrition, Nigeria, prevalence

How to cite this article:
Aronu AE, Uwaezuoke NA, Bisi-Onyemaechi A, Ubesie AC, Ojinnaka NC. Nutritional status of children with epilepsy, attending the Pediatric Neurology Clinic of University of Nigeria Teaching Hospital, Enugu. Int J Med Health Dev 2022;27:63-7

How to cite this URL:
Aronu AE, Uwaezuoke NA, Bisi-Onyemaechi A, Ubesie AC, Ojinnaka NC. Nutritional status of children with epilepsy, attending the Pediatric Neurology Clinic of University of Nigeria Teaching Hospital, Enugu. Int J Med Health Dev [serial online] 2022 [cited 2023 Mar 30];27:63-7. Available from: https://www.ijmhdev.com/text.asp?2022/27/1/63/331724

Introduction

Epilepsy is the most common chronic neurologic disorder in children with variable clinical manifestations. Children with epilepsy have an enduring propensity to generate epileptic seizures.^[1] According to the International League Against Epilepsy (ILAE), epilepsy is defined as having at least two unprovoked or reflex seizures occurring >24 h apart.^[1] About 10.5 million children worldwide are affected by epilepsy.^[2],[3],[4] Prevalence increases with age and peaks at 5–9 years of age in children. Eighty percent of children with epilepsy live in the developing world.^[2],[3],[4] Epilepsy, therefore, appears to have a root in poverty. About 80–90% of epileptics receive no treatment in the developing nations.^[2],[3],[4] Various hospital-based studies in Nigeria have reported prevalence rates for malnutrition ranging from 45% to 75%, with majority of the children belonging to low socio-economic class.^{[5],[6],[7],[8],[9]}

Although malnutrition abounds around the world, undernutrition is the most prevalent in Southeast Asia and sub-Saharan Africa. Sadly, Nigeria has a high burden of both malnutrition and epilepsy.^{[5],[6],[7],[8],[9],[10]} The relationship between epilepsy and malnutrition is speculated to be two ways: malnutrition predisposing to epilepsy or epilepsy predisposing to malnutrition.^[11] Undernutrition could affect seizure onset through effect on protein energy, electrolytes, vitamin or trace elements deficiency, as well as imbalance in neurotransmitters.^[12] A known mechanism involved in the pathogenesis of seizure related to nutritional status is the imbalance between free radicals and antioxidant agents.^[13] Conversely, certain characteristics and associated features of epilepsy such as cognitive decline, motor problems, behavior disorders, food taboos/feeding problems, social exclusion, and adverse effects of anti-epileptic treatments could lead to undernutrition.^[11] Nutritional status in epileptic children with severe neurological disorders could be adversely affected. Aydin et al.^[14] in Turkey reported high prevalence of epilepsy and malnutrition among children with spastic quadriplegic form of cerebral palsy. The use of anti-epileptic drugs (AEDs) as well as steroids in the treatment of epilepsy has also been reported to affect the nutritional status.^{[15],[16],[17]} While some of these medications (carbamazepine and valproate) increase appetite and food intake, thereby increasing body weight, others like topiramate cause anorexia, cognitive decline, and gastrointestinal and metabolic disturbances, leading to reduced nutrient absorption and growth.^[18] Liver enzyme inducing anti-epileptic drugs such as phenytoin, phenobarbital, and carbamazepine causes catabolism of some nutrients and attendant malnutrition.^[13] Although there are data on malnutrition and epilepsy in developed countries, significant gaps exist in literature regarding relationship between malnutrition and epilepsy in developing countries in which burden of malnutrition is high. Knowledge of this relationship will provide baseline data for further research on improving nutritional outcomes for children with epilepsy. This study, therefore, aims to describe the nutritional status of children with epilepsy at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.

Materials and Methods

Study location

The study was carried out at the pediatric neurology clinic of the University of Nigeria Teaching Hospital Ituku Ozalla, Enugu, Nigeria. The clinic provides services for neurological and neurodevelopmental pediatric patients and serves as a referral center for the entire Southeast Nigeria. The clinic holds once a week and patients, old and new cases, are seen on scheduled appointment every 1–3 months according to need. The clinic has more than 40 epilepsy patients in attendance weekly, from a patient pool of more than 600 epileptic patients.

Study design

This was a hospital-based cross-sectional study.

Study participants

Participants were children and adolescents who attended the pediatric neurology clinic on appointment within the study period. They were aged 6 months to 18 years.

Inclusion/exclusion criteria

Children with diagnosis of epilepsy confirmed by electroencephalogram (EEG) who were only on anti-epileptic medications at the time of the study, irrespective of type and duration of treatment, were consecutively enrolled. Excluded from the study were those with other comorbidities which impact on nutritional status such as cerebral palsy, feeding difficulties, chronic infections, thyrotoxicosis, and diabetes mellitus due to its catabolic nature, cancers, and sickle cell stroke.

Ethical considerations

The study protocol was approved by the Health Research and Ethics Committee (HREC) of UNTH. Informed written consent was obtained from the parents or guardians, and oral assent was obtained from the children.

Data collection

A proforma was used to obtain information on participants’ demographic characteristics and other relevant information from patients’ medical records. Height and weight were measured and recorded for each child following standard techniques.^[19] Height was measured on a manual stadiometer (Marsdens London W9- 01-289-1066 machine number 933). Height was measured when the participant stood on the stadiometer without a head gear or footwear; he/she stood with the trunk straightened and the knee locked in the erect position with the feet placed flat on the floor of the stadiometer. The eye was fixed in horizontal gaze and both hands by the side. The bar of the stadiometer read off the measurement at the vertex of the head. Height was measured in meters. The Marsden stadiometer could give an error of 0.2 cm. Those who were younger than 2 years had both length and weight read off from an infantometer. The manual scaled infantometer (SECA) has a pointer which points to the corresponding weight (kg) of the naked infant lying in the scale.

Weight was measured with an Omron N 286 ultrathin automatic digital weighing scale, with minimal clothing and without foot wear or head gear. The weight was measured when the participant mounts the Omron weighing scale, the value obtained for weight was read of when standing erect, and the reading on the electronic scale stabilized. The entire foot was to be on the scale, and no part was to be outside the surface. Weight was measured in kilogram (kg), and reading was to one decimal place.

The precision from the digital scale was 0.1 kg. All measurements were made by a trained research assistant, who was a registrar trained for two sessions by two unit consultants (researchers) and supervised.

Standardization of techniques and measurements

The digital weighing scale starts at zero before weighing. Standard weight of 1 kg was placed on the scale to access reliability and accuracy of the scale after every 10 measurements. A spare button alkaline battery was made available for the electronic weighing scale. Weight and height were measured twice and mean value used for analysis. The quality accuracy of the measurements was assessed by randomly re-measuring the weights and heights of children that had been previously measured. An acceptable tolerance limit for variation in measurement was 1 cm for height and 0.1 kg for weight.

Data management and analysis

The weight for height, body mass index (BMI) for age, and height for age z-scores were calculated using the WHO Anthro and Anthro Plus software (1.0.4 of 2018). Obesity was defined as BMI-for-age > + 2 SD. Normal weight was > −2 SD to +1 SD.^[19] Overweight (weight above what is considered healthy, often measured using BMI) was defined as BMI-for-age > +1 SD but less than +2 SD. Stunting was defined as height-for-age < −2 SD, whereas wasting was defined as weight-for-height < −2 SD. Data were presented in tables, charts, figures, and prose. Data were analyzed using SPSS version 20.0. Frequencies and percentages were used to summarize categorical variables. χ² was used to test association between categorical variables. Z-test was used to compare two proportions. Significant p-values was set at less than 0.05. All reported p-values were two-sided.

Results

One hundred and twenty children aged 6 months to 18 years who met the inclusion criteria were studied. Seventy-eight (65%) were males (male: female ratio = 1: 0.5). The age group, 6 months to 5 years, accounted for 40% of the study participants, as shown in [Table 1].

Table 1: Distribution of study participants according to age and sex

Click here to view

The overall prevalence of malnutrition was 22.5%. Wasting, stunting, overweight, and obesity accounted for 5.8%, 9.2%, 10.8%, and 5.8% of malnutrition rates, respectively, as depicted in [Figure 1]. Some participants had more than one form of malnutrition.

Figure 1: Barchart showing nutritional status of study participants. Prevalence of malnutrition among study participants

Click here to view

About 77.5% (93 participants) had normal nutritional status, while 9.2% (11 participants) were stunted, 5.8% (seven participants) were wasted, 10.8% (13 participants) were overweight, and 5.8% (seven participants) were obese.

Two of 78 males (2.6%) compared to five of 42 females (11.9%) were wasted (p = 0.04). There were no statistically significant differences between various forms of malnutrition and age grouping (pre-adolescents versus adolescents) of study participants, as shown in [Table 2]. There was no statistically significant difference between nutritional status and social status of study participants [Table 3].

Table 2: Distribution of malnutrition according to age and sex of study participants

Click here to view

Table 3: Distribution of malnutrition according to the social class of study participants

Click here to view

Discussion

Very few studies have been conducted on nutritional status of children with epilepsy globally. Our study showed that the prevalence of malnutrition among children with epilepsy was 22.5%. This prevalence is lower than 40% reported by Bertoli et al.^[18] in Italy among 17 children with refractory epilepsy. Bertoli et al. used the WHO anthropometric cutoffs used in this study. Their study had 24% wasted participants, whereas this study had 5.8% wasted participants. The Italian study, although limited by small sample size, involved children with refractory epilepsy and thus more severe diseases with attendant effects on nutrition. Conversely, our study included all children with epilepsy attending our Paediatric Neurology Clinic, irrespective of their disease severity. We however excluded children with co-morbid conditions such as cerebral palsy. Such children are prone to both epilepsy and malnutrition due to associated severe neurological damage.^[14] In a rural area of Benin Republic, Crepin et al.^[16] reported a 13.6% prevalence of malnutrition among children with epilepsy, which is lower than our study. Whereas our study was hospital-based, Crepin et al.^[16] used community-based survey to select their study participants. Thus children without EEG confirmed epilepsy and exposure to anti-epileptic medications was enrolled into the study by Crepin et al. Some anti-epileptic medications have been implicated in the etiopathogenesis of malnutrition among children with epilepsy.^[16],[17]

Overweight was the most common form of malnutrition, followed by stunting among the study participants. These findings are not surprising. The documented rates were below national estimates, being 32% for stunting and 20% for underweight.^[4]

These lower rates of malnutrition in the subjects may be due to drug interference (non-AEDs) or special care being deployed to them as challenged children. Social class did not contribute statistically to the development of malnutrition [Table 3]. Despite our finding, some authors have published articles that suggest that malnutrition and epilepsy have a two-way relationship just like the hen and the egg. They argue that epilepsy is most likely caused by protein energy malnutrition, micronutrient deficiency, and high worm infestation; no wonder 80% of the epileptics are found in the poor nations of the world. They also think that epilepsy goes with poor food intake, resulting in stunted growth and delayed puberty. This hypothesis, of higher malnutrition rates among epileptics, should be more obvious in drug-naive epilepsy patients who in our study had less malnutrition than the national estimate.^[19]

Limitation of the study

This study did not explore relationship between anti-epileptic drugs and nutritional status. It did not also assess the effect of the epilepsy itself on the nutritional status of these children when compared with normal children. The researchers should have compared anthropometric measurement at enrollment, prior to commencement of AEDs, with their current measurement.

Conclusions

Overweight was the most common form of malnutrition, followed by stunting among the epileptic children. There is need for regular anthropometric monitoring of children with epilepsy. Such anthropological measurements should commence at the time of starting patients on anti-epileptic drugs or earlier to remove the confounder caused by some anti-epileptic drugs. This will help the managing physician to also manage the underlying malnutrition and investigate and explore the underlying cause.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	WHO, IBE, ILAE Global Campaign Against Epilepsy. Available from: https://www.who.int.epilepsies. (accessed Mar 1, 2020).
2.	Preux PM, Druet-Cabanac M. Epidemiology and aetiology of epilepsy in sub-Saharan Africa. Lancet Neurol 2005;4:21-31.
3.	Global, regional, and national burden of epilepsy, 1990–2016: A systematic analysis for Global Burden of Disease Study 2016. Lancet Neurol 2019;18:357-75. doi: https://doi.org/10.1016/s1474-4422(18)30454-X
4.	Stafstrom CE. Dietary approaches to epilepsy treatment: old and new options on the menu. Epilepsy Curr 2004;4: 215-22.
5.	Ogunlesi T, Ogundeyi M, Olowu A. Pattern of childhood epilepsies in Sagumu, Nigeria. Indian J Pediatr 2009;76:385-9.
6.	Izuora GI, Iloeje SO. A review of neurological disorders seen at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu. Ann Trop Paediatr 1989;9:185-90.
7.	Iloeje SO, Paed FM. The pattern of childhood epilepsy with mental retardation in Nigeria. J Trop Pediatr 1989;35: 163-8.
8.	Langunju IL, Fatunde OJ, Takon I. Profile of childhood epilepsy in Nigeria. J Ped Neurol 2009;7:135-40.
9.	Igwe WC. Challenges in the management of pediatric epilepsy in Nigeria. Trop J Med Res 2016;19:1-4. [Full text]
10.	UNICEF Nigeria: Nutrition. Available from: https://www.unicef.org/nigeria/nutrition (accessed July 8, 2020).
11.	Daniels ZS, Nick TG, Liu C, Cassedy A, Glauser TA. Obesity is a common comorbidity for pediatric patients with untreated, newly diagnosed epilepsy. Neurology 2009;73:658-64.
12.	Crepin S, Godet B, Chassain B, Preux PM, Desport JC. Malnutrition and epilepsy: A two-way relationship. Clin Nutr 2009;28:219-25.
13.	Soltani D, Ghaffar Pour M, Tafakhori A, Sarraf P, Bitarafan S. Nutritional aspects of treatment in epileptic patients. Iran J Child Neurol 2016;10:1-12.
14.	Aydın K, Kartal A, Keleş Alp E. High rates of malnutrition and epilepsy: Two common comorbidities in children with cerebral palsy. Turk J Med Sci 2019;49:33-7.
15.	Ben-Menachem E. Weight issues for people with epilepsy—A review. Epilepsia 2007;48(Suppl 9):42-5.
16.	Crepin S, Houinato D, Nawana B, Avode GD, Preux PM, Desport JC. Link between epilepsy and malnutrition in a rural area of Benin. Epilepsia 2007;48:1926-33.
17.	Lee HS, Wang SY, Salter DM, Wang CC, Chen SJ, Fan HC. The impact of the use of antiepileptic drugs on the growth of children. BMC Pediatr 2013;13:211.
18.	Bertoli S, Cardinali S, Veggiotti P, Trentani C, Testolin G, Tagliabue A. Evaluation of nutritional status in children with refractory epilepsy. Nutr J 2006;5:14.
19.	World Health Organization. WHO Child Growth Standards: Training Course on Child Growth Assessment-Interpreting Growth Indicators. Geneva: Department of Nutrition for Health and Development; 2018.