Child neurology services in Africa

Access to Pediatric Neurology Training and Services Worldwide: A Survey by the International Child Neurology Association

Pediatric neurology is the medical subspecialty responsible for diagnosing and managing diseases and disorders of the nervous system in childhood and adolescence. In many, but not all, regions of the world, the discipline of pediatric neurology is recognized as a specialty or subspecialty of either neurology or pediatrics. Significant knowledge and competencies in this area are necessary to be effective in clinical practice. The need for this is driven by the high burden of disease from neurologic conditions in children and the effect on their families. As the first part of a multistaged project under the auspices of the International Child Neurology Association, in collaboration with key stakeholders, a survey was undertaken to establish which countries have practicing child neurologists. For those countries that have child neurologists, the survey established the number of practitioners and which countries have access to in-country child neurology training. Responses were obtained from 177 countries. Worldwide, there is a median of 0.07 and mean of 0.39 child neurologists per 100,000 population. The greatest deficits in child neurology specialists and access to training were evident in countries which fell under the World Bank rating of low-income country status (range of 0-0.008 child neurologists per 100,000 population). Seventy-three percent of low-income countries lack access to child neurologists: The majority are in the African and South-East Asia regions. For the population of 1.37 billion in the continent of Africa, there were 324 child neurologists, equating to a median of 0.01 per 100,000 population in comparison with a median of 0.59 child neurologists per 100,000 across high-income countries. Ninety-four countries had capacity to support in-country pediatric neurology training. Worldwide, there are inadequate numbers of child neurologists and a great need for increased training capacity.

Family Needs Assessment of Patients with Cerebral Palsy Attending Two Hospitals in Accra, Ghana

BACKGROUND

The family represents the most essential and supportive environment for children with cerebral palsy (CP). To improve children's outcomes, it is crucial to consider the needs of families in order to offer family-centered care, which tailors services to these needs.

OBJECTIVE

We conducted a needs assessment to identify the family needs of patients with CP attending two hospitals in Accra.

METHODS

The study was a cross-sectional study involving primary caregivers of children with CP attending neurodevelopmental clinics. Structured questionnaires were used to collect data spanning an 8-month period. The data were summarized, and statistical inference was made.

RESULTS

Service needs identified were childcare, counseling, support groups, financial assistance, and recreational facilities. Information needs included adult education, job training/employment opportunities, education, health and social programs, knowledge about child development, and management of behavioral and feeding/nutrition problems. Reducing extensive travel time was desirable to improve access to healthcare. With the increasing severity of symptoms came the need for improved accessibility in the home to reduce the child's hardship, as well as assistive devices, recreational facilities, and respite for the caregiver(s).

CONCLUSION

Families of children with CP have information, service, and access needs related to their disease severity and family context.

Management of Pediatric Stroke - Challenges and Perspectives from Resource-limited Settings

Childhood stroke is not as common as adult stroke, but it is underrecognized the world over. Diagnosis is often delayed due to lack of awareness not only by the lay public but also by emergency and front-line health care workers. Despite the relative rarity of childhood stroke, the impact on morbidity, mortality and the economic burden for families and society is high, especially in poorly resourced settings. The risk factors for stroke in children differ from the adult population where lifestyle factors play a more important role. The developmental aspects of the pediatric cerebral vasculature and hematological maturational biology affects the clinical presentation, investigation, management and outcomes of childhood stroke in a different way compared to adults. The management of childhood stroke is currently based on expert guidelines and evidence extrapolated from adult studies. Hyperacute therapies that have revolutionized the treatment of stroke in adults cannot be easily applied to children at this stage due to the diagnostic delays, diverse risk factors and developmental considerations mentioned above. Much has been achieved in the understanding of genetic, acquired, preventable and recurrent stroke risk factors in the past decade through international collaborative efforts like the International Pediatric Stroke Study. Evidence for the prevention and treatment of childhood stroke remains elusive. Even more elusive are relevant and achievable management guidelines for pediatric stroke in resource-limited settings. This narrative review focusses on the current management practices globally, emphasizing the challenges, and gaps in knowledge of pediatric stroke in low- and middle-income countries and other areas with limited resources. Priorities and some potential solutions at national and local level are suggested for these settings.

A world away and here at home: a prioritisation framework for US international patient programmes

Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients' home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children's hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.

Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective

The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases. The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden. Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically "tropical" conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.

Functional development in children with cerebral palsy in Uganda: population-based longitudinal cohort study

AIM

To follow the functional development of a population-based cohort of children with cerebral palsy (CP) in rural Uganda and compare their development with the developmental trajectories of children from high-income countries (HIC).

METHOD

Eighty-one children (33 females, 48 males) aged 2 to 17 years (mean 8y 6mo, SD 4y 6mo) with CP were initially assessed in 2015 and then 4 years later using the 66-item Gross Motor Function Measure (GMFM-66), Pediatric Evaluation of Disability Inventory, Ugandan version (PEDI-UG), and functional classification systems. We calculated actual and reference scores (level of deviation from the developmental trajectories in HIC). A Wilcoxon signed-rank test was used for statistical analyses.

RESULTS

Children and young people with CP in Uganda exhibited no differences in scores between the first and second assessments for the GMFM-66 and PEDI-UG mobility skills, whereas they exhibited increased PEDI-UG social function (p<0.001) and self-care skills scores (p<0.001). Reference scores were more negative at the second assessment than at the first for the GMFM-66 (p=0.002) and PEDI-UG mobility (p=0.036) but not for PEDI-UG self-care. The increased difference in reference scores over the 4 years was primarily driven by younger children (2-5y) and children with milder impairments.

INTERPRETATION

The increased difference in reference scores between assessments suggests that children with CP in Uganda develop motor skills at a slower rate than peers in HIC. Limited access to health care and rehabilitation likely contributed to the lower scores and slower rate of development.

A comparative study of perceived burden in parent caregivers of adolescents with epilepsy in a resource-restricted setting: Investigating the explanatory factors of perceived burden

OBJECTIVE

Parent caregivers often play vital roles in the care of adolescents with epilepsy (AWE) in resource-restricted settings; however, little is known about the burden borne by these parents. This study investigated the burden perceived by parents of AWE and described the explanatory factors.

METHODS

An equal number (n = 121) of age- and gender-matched parent caregivers of AWE (cases) and parents of adolescents with sickle cell disease (comparison group) were interviewed with the Parent Illness Intrusiveness Rating Scale to assess disruptions in their relationships and lifestyle. Parents of AWE were assessed for psychological distress with the 12-item General Health Questionnaire, and AWE were interviewed with the Hospital Depression-Anxiety Scale.

RESULTS

The majority of the cases and the comparison group were mothers (76%), with mean (SD) ages of 44.11 (SD = 6.92) versus 43.59 (SD = 6.39) years, respectively. The prevalence rate of psychological distress in cases was 38%, and depressive-anxiety symptom was prevalent in 39.7% of AWE. The level of perceived burden was significant in all parent caregivers, albeit higher in cases relative to the comparison group across multiple domains, including relationship/personal development, intimacy, instrumental and global. A high level of burden in parents of AWE was predicted by a poor family financial and material support to the adolescents, increased contact hours with adolescents, psychological distress in the parent caregivers, and anxiety-depressive symptoms in AWE after controlling for cofounders.

CONCLUSION

The study findings underscore the need for psychosocial support to bolster resilience and adaptive coping styles in parents of AWE, particularly in resource-restricted settings. A culturally sensitive interdisciplinary blueprint of locally viable actions model for psychosocial support for parent caregivers of AWE is strongly suggested. Future studies are indicated to shed more light on the modifiable risks of perceived burden, and the effectiveness of psychosocial interventions in parents of AWE.

Akwenda intervention programme for children and youth with cerebral palsy in a low-resource setting in sub-Saharan Africa: protocol for a quasi-randomised controlled study

INTRODUCTION

Cerebral palsy (CP) is the most common childhood-onset motor disorder accompanied by associated impairments, placing a heavy burden on families and health systems. Most children with CP live in low/middle-income countries with little access to rehabilitation services. This study will evaluate the Akwenda CP programme, a multidimensional intervention designed for low-resource settings and aiming at improving: (1) participation, motor function and daily activities for children with CP; (2) quality of life, stress and knowledge for caregivers; and (3) knowledge and attitudes towards children with CP in the communities.

METHODS

This quasi-randomised controlled clinical study will recruit children and youth with CP aged 2-23 years in a rural area of Uganda. Children will be allocated to one of two groups with at least 44 children in each group. Groups will be matched for age, sex and motor impairment. The intervention arm will receive a comprehensive, multidimensional programme over a period of 11 months comprising (1) caregiver-led training workshops, (2) therapist-led practical group sessions, (3) provision of technical assistive devices, (4) goal-directed training and (5) community communication and advocacy. The other group will receive usual care. The outcome of the intervention will be assessed before and after the intervention and will be measured at three levels: (1) child, (2) caregiver and (3) community. Standard analysis methods for randomised controlled trial will be used to compare groups. Retention of effects will be examined at 12-month follow-up.

ETHICS AND DISSEMINATION

The study has been approved by the Uganda National Council for Science and Technology (SS 5173) and registered in accordance with WHO and ICMJE standards. Written informed consent will be obtained from caregivers. Results will be disseminated among participants and stakeholders through public engagement events, scientific reports and conference presentations.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trials Registry (PACTR202011738099314) Pre-results.

[Clinical and paramedical features of epilepsy in children at the Ziguinchor Peace Hospital: a documentation review]

Epilepsy poses a public health problem in Senegal. The purpose of the study was to describe the clinical and paramedical features of epilepsy in children at the Ziguinchor Peace Hospital (ZPH). We conducted a literature review of the medical records of children with epilepsy, from January 1, 2015 to December 31, 2018. Patients aged < 15 years followed up for epilepsy at the ZPH were included. Incomplete medical records were excluded. Data from fifty-five (37 boys and 18 girls) children were collected; 70.9% of them were ≤5 years of age. Mean age of patients was 4.3 years. Patients were from rural (60%) and disadvantaged families (67.3%). Seizures were generalized (72.7%) and focal (27.3%). Eighteen patients had idiopathic epilepsy, 17 had non-idiopathic epilepsy. Etiological factors were dominated by abnormalities associated with pregnancy and childbirth (29.1%). Epilepsy is common at the ZPH. It is most common in rural areas among boys under the age of 5 years from disadvantaged families. Generalized tonic-clonic and focal seizures are the most frequent clinical state and abnormalities associated with pregnancy and childbirth are the most commonly found etiologies.

Impairments, functional limitations, and access to services and education for children with cerebral palsy in Uganda: a population-based study

AIM

To describe the functional limitations and associated impairments of children with cerebral palsy (CP) in rural Uganda, and care-seeking behaviour and access to assistive devices and education.

METHOD

Ninety-seven children with CP (42 females, 55 males; age range 2-17y) were identified in a three-stage population-based screening with subsequent medical examinations and functional assessments. Information on school and access to care was collected using questionnaires. The data were compared with Swedish and Australian cohorts of children with CP. We used the χ² test and linear regression models to analyse differences between groups.

RESULTS

Younger children were more severely impaired than older children. Two-fifths of the children had severe impairments in communication, about half had intellectual disability, and one third had seizures. Of 37 non-walking children, three had wheelchairs and none had walkers. No children had assistive devices for hearing, seeing, or communication. Care-seeking was low relating to lack of knowledge, insufficient finances, and 'lost hope'. One-third of the children attended school. Ugandan children exhibited lower developmental trajectories of mobility and self-care than a Swedish cohort.

INTERPRETATION

The needs for children with CP in rural Uganda are not met, illustrated by low care-seeking, low access to assistive devices, and low school attendance. A lack of rehabilitation and stimulation probably contribute to the poor development of mobility and self-care skills. There is a need to develop and enhance locally available and affordable interventions for children with CP in Uganda.

WHAT THIS PAPER ADDS

Development of mobility and self-care skills is lower in Ugandan than Swedish children with cerebral palsy (CP). Older children in Uganda with CP are less impaired than younger children. Untreated seizures and impairments of communication and intellect are common. Access to health services, assistive devices, and education is low. Caregivers lack knowledge and finances to seek care and often lose hope of their child improving.

Therapeutic itinerary of children living with epilepsy in Kinshasa: Features, determinants, and relationships with behavioral problems and cognitive impairment

BACKGROUND

Epilepsy mostly affects children in sub-Saharan Africa. However, little is known about the therapeutic itinerary of these children living with epilepsy (CWE). This study aimed to describe the therapeutic itinerary of CWE in Kinshasa and to analyze its relationships with clinical features, behavioral problems, and cognitive impairment.

METHODS

This hospital-based study has included 104 CWE aged 6 to 17  years. The features of their therapeutic itinerary and their relationship with clinical features, behavioral problems, and cognitive impairment were analyzed.

RESULTS

The vast majority of CWE (87%) has started their therapeutic itinerary by the Western medicine. The first source of information about epilepsy as well as the type of antiepileptic treatment varied with the socioeconomic status of families of CWE. The total duration of the therapeutic itinerary was shorter for the CWE who were living with both their parents (P = .038), who had generalized seizures (P = .0073) or who had no family history of epileptic seizures (P = .019). The CWE who had total behavioral problem, compared with the others, were putting more time (P = .021) to reach the Centre de Santé Mentale Telema (CSMT) after the suspicion or the diagnostic of epilepsy. The total duration of CWE who had cognitive impairment (P = .021) was longer than that of CWE who had not cognitive impairment.

CONCLUSION

The therapeutic itinerary of CWE in Kinshasa began with Western medicine. The remainder of this therapeutic itinerary looks like what is described in sub-Saharan literature with the majority of CWE seeking the healing based on beliefs. This study also shows that the therapeutic itinerary of CWE was associated with socioeconomic conditions, clinical features, behavioral problems, and cognitive impairment.

Risk Factors and Pathogenesis of HIV-Associated Neurocognitive Disorder: The Role of Host Genetics

Neurocognitive impairments associated with human immunodeficiency virus (HIV) infection remain a considerable health issue for almost half the people living with HIV, despite progress in HIV treatment through combination antiretroviral therapy (cART). The pathogenesis and risk factors of HIV-associated neurocognitive disorder (HAND) are still incompletely understood. This is partly due to the complexity of HAND diagnostics, as phenotypes present with high variability and change over time. Our current understanding is that HIV enters the central nervous system (CNS) during infection, persisting and replicating in resident immune and supporting cells, with the subsequent host immune response and inflammation likely adding to the development of HAND. Differences in host (human) genetics determine, in part, the effectiveness of the immune response and other factors that increase the vulnerability to HAND. This review describes findings from studies investigating the role of human host genetics in the pathogenesis of HAND, including potential risk factors for developing HAND. The similarities and differences between HAND and Alzheimer's disease are also discussed. While some specific variations in host genes regulating immune responses and neurotransmission have been associated with protection or risk of HAND development, the effects are generally small and findings poorly replicated. Nevertheless, a few specific gene variants appear to affect the risk for developing HAND and aid our understanding of HAND pathogenesis.

Advocacy for children with epilepsy: Leveraging the WHA resolution. Advocacy Task Force, Commission of Pediatrics, International League Against Epilepsy

In May 2015 the World Health Assembly (WHA) approved the Resolution on the Global Burden of Epilepsy. This report addresses how the Resolution can be leveraged to improve the care of children with epilepsy worldwide. Children with epilepsy have unique needs and face unique challenges from stigma at all levels of society. Children lack a voice to lobby for their own needs, including their right to have access to education. Effective leadership and governance should be enhanced through the support of stakeholders empowered to counsel, advise, and lobby for appropriate care. National health care plans should integrate primary and specialist care, and they need to be adapted to local specificities. Antiepileptic medicines should be widely accessible in appropriate, sustained, and affordable ways. Public awareness initiatives are needed to improve the inclusion of affected children in society and to reduce stigma. Cost-effective interventions are also needed to address preventable causes of epilepsy. Without greater investment in research, evidence-based interventions cannot be implemented. Through all of this, civil society must be engaged to ensure that the multivariate dimensions from the clinic to the community are addressed to fulfil the needs of children with epilepsy.

Malnutrition frequency among cerebral palsy children: Differences in onset of nutritional intervention before or after the age of five years

ABSTRACT Objective To evaluate the frequency of malnutrition and food consumption of children with cerebral palsy according to the age at the beginning of speech and hearing rehabilitation treatment. Methods Two to eleven-year-old children diagnosed with cerebral palsy who had up to three months of speech-language and nutritional rehabilitation were included in two reference centers in Recife, Pernambuco, Brazil. The following measurement of the children were taken: weight, knee height, arm circumference and triceps skinfold. Weight, estimated height and body mass index were classified into Z-scores according to the World Health Organization curves. Brachial circumference, triceps skinfold and arm circumference were classified according to Frisancho. The 24-hour recall was used to calculate intake of calories, proteins, calcium, iron, vitamin A, and zinc using the NutriWin software. Results A total of 68 patients were evaluated. Children older than five had a higher frequency of malnutrition when weight (.=0.02) and arm circumference (.<0.001) were considered, although there was less triceps malnutrition (.=0.002). These also had lower calorie consumption per kg/day, protein/kg/day and calcium than the younger children. Conclusion The greatest nutritional impairment after the age of five suggests that nutritional and speech therapy interventions could have a greater effect if they were performed before that age.

A pediatric epilepsy diagnostic tool for use in resource-limited settings: A pilot study

OBJECTIVE

It is estimated that nearly 80% of the 50 million people affected with epilepsy globally live in regions where specialist care and diagnostic tests are scarce and care is often delivered through a primary health provider with limited training. To improve diagnostic accuracy of the history and physical examination, we developed and piloted a questionnaire to discriminate between focal versus generalized epilepsy, with the future goal to guide medication choices.

METHODS

Through literature review and retrospective chart review of 75 children with epilepsy at Boston Children's Hospital, a 15-item questionnaire was developed. Simple motor seizures were excluded for the purposes of this questionnaire. The questionnaire was then translated in local dialects and prospectively validated at Muhimbili National Hospital in Dar Es Salaam, Tanzania, and University Teaching Hospital in Lusaka, Zambia. Children 6months-18years of age with suspected or active epilepsy were identified, and a nonphysician administered the questionnaire to the patient's caregiver. Next, each patient was evaluated by a pediatric neurologist blinded to the questionnaire results, and together with locally obtained but remotely interpreted EEG, an electroclinical diagnosis was made. The questionnaire data were compared with this clinical gold standard.

RESULTS

A total of 59 children participated: 28 from Tanzania and 31 from Zambia. Sixteen patients were excluded: 5 were excluded because of incomplete data, and 11 did not meet criteria for epilepsy based on initial screening questions. Of the remaining 43 patients, 28 had focal or multifocal epilepsy (65%), and 15 (35%) had generalized epilepsy. The questionnaire had a sensitivity of 78% and positive predictive value of 81.5%. Data were analyzed using a Rasch model, testing the questionnaire's internal consistency, reliability, and its discriminative validity in classifying focal versus generalized epilepsy against an electroclinical diagnosis. The mean epilepsy score for focal epilepsy was 0.084 logits compared with -1.147 logits for generalized epilepsy, demonstrating a large effect size [F (1, 41)=13.490, p<0.001].

CONCLUSIONS

Our questionnaire provides a straightforward method to improve diagnostic accuracy, and could assist in bridging the diagnostic gap in pediatric epilepsy in resource-limited settings. This tool was specifically designed to be easily implemented by any healthcare provider. This pilot study prompts broader prospective validation in additional settings for further refinement, and for performance assessment of impact on provider's practice, ability to guide medication choices, and ultimately improve treatment outcomes in resource-limited regions.

Neurology training in sub-Saharan Africa: A survey of people in training from 19 countries

OBJECTIVE

To provide a comprehensive understanding of neurology training from the sub-Saharan African perspective.

METHODS

A 40-question survey was distributed to attendees of the 7th annual sub-Saharan African neurology teaching course in Khartoum, Sudan (2015). Themes included the student body, faculty, curriculum, assessment and examinations, technology, and work hours and compensation.

RESULTS

Of 19 responding countries, 10 had no formal neurology training programs; Burkina Faso, Cameroon, Republic of the Congo, and Mozambique had an adult neurology program; Ethiopia, Madagascar, Nigeria, Senegal, and South Africa had adult and pediatric neurology programs (training duration range = 3-6 years). There was a median of 2.5 full-time neurologists on the teaching faculty at the respondents' training institutions (neurologists on-faculty:in-country ratio = 0.48), with the lowest ratios in Sudan and Nigeria. Neurology was perceived to be a competitive specialty for entrance in 57% of countries, with 78% of respondents reporting a requisite entrance examination. Ninety-five percent had access to a personal smartphone, 62% used the Internet more than occasionally, and 60% had access to online neurology journals. The average number of weekly work hours was 51 (range = 40-75), and average monthly salary among those earning income was 1,191 USD (range = 285-3,560). Twenty percent of respondents reported paying for training. The most common barriers to neurology postgraduate education were few training programs and lack of training in neurodiagnostic tests. Among 17 reporting countries, there is an estimated average of 0.6 neurologists per million people.

INTERPRETATION

Neurology training programs in sub-Saharan Africa are relatively limited in number and have several unmet needs including a small cadre of faculty and an opportunity to standardize curricula and financing of programs. Ann Neurol 2016;79:871-881.

[Epilepsy and acute seizures in childhood in sub-Saharan Africa: challenges and hopes]

Epilepsy is a neurological disease common among children in sub-Saharan Africa (SSA). Although its exact prevalence in this population is unknown, it is probably similar to that found in the general population because of its early onset (60% starts before the age of 20 years) and the absence of bimodal distribution found in western countries. This review acknowledges the reality that current management of pediatric epilepsy in SSA is imperfect. To reverse this trend, the challenges are three fold: better education, improved therapeutics and more research. Doctors need to be trained in the practice of pediatric neurology and provided with working conditions that limit the brain drain. The resources necessary for the proper management of children with epilepsy in SSA need to be identified and provided (better availability of antiepileptic drugs, clear national guidelines, proper registration of traditional healers etc…). Finally, it is imperative that research be conducted to establish accurate incidence and prevalence figures for pediatric epilepsy, so that targeted control measures can be implemented.

Clinical Profile of Pediatric Neurological Disorders: Outpatient Department, Khartoum, Sudan

BACKGROUND

There is no available data from Sudan reflecting the magnitude of the neurological disorders and disabilities in the pediatric age-group. This study aims to evaluate the pattern of neurological disorders among Sudanese children.

PATIENTS AND METHODS

This is a retrospective survey of children with epilepsy and other neurodisability disorders seen at pediatric neurology outpatient clinic, during the period from January 2007 to August 2013. The data of 9600 patients were analyzed.

RESULTS

A total of 6019 patients were included in the study. The majority of the patients had epilepsy that amounted to 52.8%, followed by cerebral palsy (19.1%), congenital anomalies of the central nervous system (6.2%), neuromuscular disorders (3.2%), stroke (2.4%), ataxia and movement disorders (1.9%), assumed genetic syndromes (1.2%), and others.

CONCLUSION

Neurological disorders constitute a major cause of chronic morbidity in pediatric age-group.

Electroencephalographic features of convulsive epilepsy in Africa: A multicentre study of prevalence, pattern and associated factors

•

Electroencephalographic abnormalities are common in Africans with epilepsy, with an adjusted prevalence of 2.7 (95% confidence interval, 2.5–2.9) per 1000 population.

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Electroencephalographic abnormalities are associated with preventable factors such as adverse perinatal events and frequent seizures.

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Electroencephalography is helpful in identifying focal epilepsy in Africa, where timing of focal aetiologies is problematic and there is a lack of neuroimaging services.

Objective

We investigated the prevalence and pattern of electroencephalographic (EEG) features of epilepsy and the associated factors in Africans with active convulsive epilepsy (ACE).

Methods

We characterized electroencephalographic features and determined associated factors in a sample of people with ACE in five African sites. Mixed-effects modified Poisson regression model was used to determine factors associated with abnormal EEGs.

Results

Recordings were performed on 1426 people of whom 751 (53%) had abnormal EEGs, being an adjusted prevalence of 2.7 (95% confidence interval (95% CI), 2.5–2.9) per 1000. 52% of the abnormal EEG had focal features (75% with temporal lobe involvement). The frequency and pattern of changes differed with site. Abnormal EEGs were associated with adverse perinatal events (risk ratio (RR) = 1.19 (95% CI, 1.07–1.33)), cognitive impairments (RR = 1.50 (95% CI, 1.30–1.73)), use of anti-epileptic drugs (RR = 1.25 (95% CI, 1.05–1.49)), focal seizures (RR = 1.09 (95% CI, 1.00–1.19)) and seizure frequency (RR = 1.18 (95% CI, 1.10–1.26) for daily seizures; RR = 1.22 (95% CI, 1.10–1.35) for weekly seizures and RR = 1.15 (95% CI, 1.03–1.28) for monthly seizures)).

Conclusions

EEG abnormalities are common in Africans with epilepsy and are associated with preventable risk factors.

Significance

EEG is helpful in identifying focal epilepsy in Africa, where timing of focal aetiologies is problematic and there is a lack of neuroimaging services.

Electroencephalography as a tool for evidence-based diagnosis and improved outcomes in children with epilepsy in a resource-poor setting

Introduction

Electroencephalography (EEG) remains the most important investigative modality in the diagnostic evaluation of individuals with epilepsy. Children living with epilepsy in the developing world are faced with challenges of lack of access to appropriate diagnostic evaluation and a high risk of misdiagnosis and inappropriate therapy. We appraised EEG studies in a cohort of Nigerian children with epilepsy seen in a tertiary center in order to evaluate access to and the impact of EEG in the diagnostic evaluation of the cases.

Methods

Inter-ictal EEG was requested in all cases of pediatric epilepsy seen at the pediatric neurology clinic of the University College Hospital, Ibadan, Nigeria over a period of 18 months. Clinical diagnosis without EEG evaluation was compared with the final diagnosis post- EEG evaluation.

Results

A total of 329 EEGs were recorded in 329 children, aged 3months to 16 years, median 61.0 months. Clinical evaluation pre-EEG classified 69.3% of the epilepsies as generalized. The a posteriori EEG evaluations showed a considerably higher proportion of localization-related epilepsies (33.6%). The final evaluation post EEG showed a 21% reduction in the proportion of cases labeled as generalized epilepsy and a 55% increase in cases of localization-related epilepsy(p<0.001).

Conclusion

Here we show that there is a high risk of misdiagnosis and therefore the use of inappropriate therapies in children with epilepsy in the absence of EEG evaluation. The implications of our findings in the resource-poor country scenario are key for reducing the burden of care and cost of epilepsy treatment on both the caregivers and the already overloaded tertiary care services.

Global medical education partnerships to expand specialty expertise: a case report on building neurology clinical and research capacity

BACKGROUND

Neurological disorders are a common cause of morbidity and mortality in sub-Saharan African, but resources for their management are scarce. Collaborations between training institutions in developed and resource-limited countries can be a successful model for supporting specialty medical education and increasing clinical and research capacity.

CASE REPORT

This report describes a US National Institutes of Health (NIH) funded Medical Education Partnership Initiative (MEPI) to enhance expertise in neurology, developed between Makerere University College of Health Sciences in Kampala, Uganda, and Case Western Reserve University School of Medicine in Cleveland, OH, USA. This collaborative model is based on a successful medical education and research model that has been developed over the past two decades. The Ugandan and US teams have accumulated knowledge and 'lessons learned' that facilitate specialty expertise in neurological conditions, which are widespread and associated with substantial disability in resource-limited countries. Strengths of the model include a focus on community health care settings and a strong research component. Key elements include strong local leadership; use of remote technology, templates to standardize performance; shared exchanges; mechanisms to optimize sustainability and of dissemination activities that expand impact of the original initiative. Efficient collaborations are further enhanced by external and institutional support, and can be sequentially refined.

CONCLUSION

Models such as the Makerere University College of Health Sciences - Case Western Reserve University partnership may help other groups initiate collaborative education programmes and establish successful partnerships that may provide the opportunity to expand to other chronic diseases. A benefit of collaboration is that learning is two-directional, and interaction with other international medical education collaborators is likely to be of benefit to the larger global health community.

Efficacy of sublingual lorazepam versus intrarectal diazepam for prolonged convulsions in Sub-Saharan Africa

In Sub-Saharan Africa, intrarectal diazepam is the first-line anticonvulsant mostly used in children. We aimed to assess this standard care against sublingual lorazepam, a medication potentially as effective and safe, but easier to administer. A randomized controlled trial was conducted in the pediatric emergency departments of 9 hospitals. A total of 436 children aged 5 months to 10 years with convulsions persisting for more than 5 minutes were assigned to receive intrarectal diazepam (0.5 mg/kg, n = 202) or sublingual lorazepam (0.1 mg/kg, n = 234). Sublingual lorazepam stopped seizures within 10 minutes of administration in 56% of children compared with intrarectal diazepam in 79% (P < .001). The probability of treatment failure is higher in case of sublingual lorazepam use (OR = 2.95, 95% CI = 1.91-4.55). Sublingual lorazepam is less efficacious in stopping pediatric seizures than intrarectal diazepam, and intrarectal diazepam should thus be preferred as a first-line medication in this setting.

The challenges and innovations for therapy in children with epilepsy

Major advances have been made in the diagnosis, evaluation and management of children with epilepsy over the past 15 years. There has been a marked increase in genetic diagnoses of a number of key childhood-onset epilepsy syndromes, such as Dravet syndrome, which has been linked to mutations in the SCN1A gene. The reorganization and reclassification of epilepsies, devised by the International League Against Epilepsy, has stimulated specialists to reassess their diagnostic practices; however, many studies have not addressed the global issues in treating children with epilepsy-specifically, the challenges of diagnosis through to optimal, and appropriate, therapeutic management. Also, Class I evidence-based data that are needed as a foundation for the development of treatment guidelines worldwide are lacking. Epilepsy is common, and the impact of this disease crosses age ranges and should be managed at all levels of care from community to quaternary care. In this Review, existing data and new therapeutic management approaches are discussed with the aim of highlighting the incidence of standard practices that may not be based on clinical evidence.

The challenges of managing children with epilepsy in Africa

Children with epilepsy who reside in the African continent are faced with some of the greatest challenges of receiving adequate care. The burden of disease is exacerbated by the high incidence of acquired causes and the large treatment gap. Skilled teams to identify and care for children with epilepsy are lacking. Many patients are managed through psychiatric services, thus potentially compounding the stigma associated with the condition. Little data exist to assess the true proportion of comorbidities suffered by children with epilepsy, the assumption is that this is high, further aggravated by delayed interventions and adverse responses to some of the more commonly used antiepileptic drugs.

Status epilepticus in sub-Saharan Africa: New findings

Status epilepticus (SE) is common in sub-Saharan Africa, particularly in children. Most cases in children are caused by infections, particularly malaria in endemic areas. The outcome is worse than in the West, probably because of delays in initiating treatment, and lack of skills and facilities for the management of SE. However some of the causes, for example, falciparum malaria, offer challenges in the diagnosis and the treatment of SE. Exposure to falciparum malaria increases the risk of SE. Much of the SE in Africa could be prevented by reducing the incidence of infections. The outcome could be improved through education, development of locally appropriate guidelines, and provision of appropriate facilities.

Children with epilepsy in Africa: recommendations from the International Child Neurology Association/African Child Neurology Association Workshop

This article presents key findings from the International Child Neurology Association/African Child Neurology Association Workshop. The viability of international guidelines for the management of children with epilepsy should be reviewed within each African country, and adapted to comply with the regional capacity. Such recommendations can be used to lobby for resources. More training centers should be developed in Africa, so that specialists can be trained within Africa, in skills relevant to the continent, in collaboration with "out of Africa" visiting-specialists to develop the concept of "train the trainers." At least 1 child neurology specialist per 100,000 of the population is required. Specific to Africa are the challenges from stigma, prejudice, and misconceptions. "Epilepsy teams," inclusive of the traditional healers, would enable management of increased numbers of children, and challenge policy such that it is the right of the child with epilepsy to have reliable access to appropriate antiepileptic drugs, support, and health care equity between the rural and urban settings.

Diagnosis and management of pediatric peripheral neuropathies in resource-poor settings

The diagnosis of a peripheral neuropathy in a child who resides in the majority of resource-poor settings is based on the history taken and the clinical examination. The majority of children, unless they demonstrate additional clinical markers, will lack a more definitive diagnosis beyond the label ‘peripheral neuropathy’. The treatable, typically acquired conditions, which are prevalent in these settings, are the priority to identify. This would include neuroinfections, neuroinflammation, toxins and vitamin deficiencies. The management of children with peripheral neuropathies in resource-poor settings must be approached in a different manner to that of more ‘resource-equipped’ settings. Secondary or tertiary centers are scarce, often significant distances away from the patient, and this leads to long delays before access is possible. Most children present to primary healthcare settings and are seen by practitioners with little training in the features suggestive of a peripheral neuropathy. As such, basic aids to assist the healthcare worker in the early recognition and interventions of a child with a peripheral neuropathy are important. In addition, there must be recognition of the child with a rapidly progressive neuropathy where a life-threatening condition is present, and urgent referral to a tertiary setting made wherever possible.