Most preschool teachers are well aware of seizures in children but have poor attitudes: Local study

• Less than half have knowledge regarding first aid care

BY Ruwan Laknath Jayakody

Even though 82% of preschool teachers had a good level of knowledge regarding seizures and 66% of preschool teachers had a good level of awareness about seizures, 61% of preschool teachers had poor attitudes towards children with seizures while only 49% had knowledge regarding first aid care concerning the same, a local study found. The same study found that a higher level of education and prior training on seizure management significantly correlated with having knowledge on seizures.

These findings were made in an original article on the “Knowledge on seizures and their immediate management among preschool teachers in the Colombo District” which was authored by L.S. Peiris (attached to the University of Sri Jayewardenepura and the National Hospital in Colombo), and D.S. Wijesekara, M. Gamage, H. Siriwardana, I. Niwanthika, H.N. Kumarasiri, and C.A. Wettasinghe (attached to the same University) and published in the Sri Lanka Journal of Child Health 50 (4) in December 2021.

Seizure disorders, per R.M. Kliegman, B.F. Stanton, J.W.S. Geme, N.F. Schor, R.E. Behrman, and W.E. Nelson’s Textbook of Paediatrics (19th edition) “Chapter 586 – Seizures in childhood”, include epilepsy, febrile seizures (these convulsions exist only in association with an elevated temperature when a young child is feverish, and represent the most common childhood seizure disorder) and seizures secondary to metabolic, infectious, or other causes. Epilepsy has a cumulative lifetime incidence of 3% (per a Pakistani study) and a prevalence of 4.5-5 per 1,000 (per a systematic review in Europe). Around 4-10% of children experience at least one seizure in the first 16 years of life (per an Iranian study). Epilepsy, according to R.J. Baumann and A. Kao’s “Paediatric febrile seizures” and the National Institute of Neurological Disorders and Stroke, is commonly treated with regular medications, after a second seizure has occurred. As a first aid measure, G.E. Micheal and R.E. O’Connor noted in “The diagnosis and management of seizures and status epilepticus (a seizure lasting longer than five minutes or more than two seizures in an hour without regaining consciousness in between, per the National Institute of Neurological Disorders and Stroke, and J.W. Wheless, J. Willmore, and R.A. Brumback’s “Advanced therapy in epilepsy”, which may need the insertion of a nasopharyngeal airway to keep the airway open and protected, per the National Institute of Neurological Disorders and Stroke, and Micheal and O’Connor) in the pre hospital setting” that turning a person with a generalised convulsion onto their side helps to prevent fluids from entering the lungs. The duo added, along with P. Shearer’s “Seizures and status epilepticus: Diagnosis and management in the emergency department”, that inserting fingers, a bite block, or a tongue depressor into the mouth can make the person vomit or bite the rescuer, while Shearer noted the need to prevent further self injury.

A significant number of children in urban areas spend most of their daytime in preschools, and therefore, preschool teachers play a key role in caring for children with seizures because they are the people who first encounter a convulsion.

Hence, Peiris et al. sought to assess the knowledge regarding seizures/seizure disorders, including the identification of a convulsion and the immediate management including first aid care of a convulsion, and attitudes towards children with convulsions among preschool teachers in the Colombo District. A descriptive, cross-sectional study was carried out for the purpose by interviewing 110 preschool teachers from privately owned institutions, selected on a random basis, and representing all Medical Officers of Health (MOH) areas in the Colombo District. An interviewer administered questionnaire was utilised to gather data. The survey was conducted from April to August 2017.

The demographic characteristics were in terms of gender (106 – 96.4% female and four – 3.6% male), nationality (88 – 80% Sinhala, 14 – 12.7% Muslim, five – 4.5% Hindu, and three – 2.8% Burgher), home town (100 – 90.9% Colombo and 10 – 9.1% out of Colombo), educational status (83 – 75.5% diploma in preschool teaching, 16 – 14.5% Advanced Level, six – 5.5% Ordinary Level, and five – 4.5% graduates), marital status (70 – 63.6% married and 40 – 36.4% unmarried), having or not having children (63 – 57.3% having children and 47 – 42.7% not having children), status of the teacher (76 – 69.1% permanent and 34 – 30.9% assistant), and the duration of teaching experience (43 – 39.1% over one year, 22/20% each with five to 10 years, and 10 to 15 years, respectively, 15 – 13.6% with over one year, and four – 3.6% each with 15 to 20 years, and below 20 years, respectively).

Significant correlations were noted between the educational level and knowledge and previous training on fit management and knowledge. The majority (92%) never had any prior training regarding seizure management. The majority (81.8%) had never encountered a child with seizures. The majority (81.8%) considered a seizure to be a physical illness while 10% considered it to be a result of a mental illness or due to evil spirits. The following characteristics of teachers with regard to fits were noted; what is a fit (8.2% considered it to be both a physical and mental illness), have you heard about fits before (66.4% yes and 33.6% no), and the source of awareness about fits (23.6% from newspapers, 18.1% from books, 7.2% each from seminars, and experience, respectively, and 3.4% from the internet). The perceived adequacy of knowledge and skills to manage a fit competently was seen among 49.1%. The majority (two-thirds – 66.4%) were aware of seizures previously, and among them, 40.9% had got information from the television and the radio.

The majority (81.8%) had a good level of knowledge regarding convulsions but only 49.1% had knowledge regarding immediate first aid measures. Knowledge of first aid during a fit included the following: position of the child experiencing the fit (13.6% supine and 8.2% prone), handling secretions (29.1% do not know and 9.1% do not wipe), handling clothes (12.7% do not know and 3.6% keep the clothes the way they were), carrying the child during a fit (68.2% lateral, 13.6% supine, 10% carrying, 5.5% do not know, and 2.7% prone), and what to do after resolving the fit (15.5% send the child home, 4.5% do not know, and 0.9% inform the parents). Whilst 72.7% knew that the child should be kept in the lateral position while experiencing the fit, 5.5% did not know what position the child should be kept in during a fit; 40 – 36.4% said that they should put a spoon or finger while the child is experiencing the fit. Wiping out secretions was approved by 61.8% and 83.6% said that they have to remove tight clothes while the child is having a fit. The majority (76.4%) said that the child should be taken to medical care after every fit. Only 2.7% said that they can continue the daily normal routine of the child; 93.1% believed that a child after a fit requires special attention in tasks which can lead to injury.

Half (50.9%) did not agree that the child should be doused in water or should be given anything orally (51.8%). One-third (34.5%) said that a metal object should be given to be handled during a fit. The wrong practises during a fit included putting a spoon inside the mouth (51.8% do not put anything in the mouth, 36.4% put a spoon or a finger, and 11.8% do not know), dousing the child with water or not (33.6% do not know, and 15.5% yes), and giving oral medications (30.9% do not know, and 17.3% yes). When inquired about what should be done after a fit, 58% said that it was better not to wait at home and to seek medical advice immediately whereas 5.5% said that they can wait for 15 minutes till the fit has resolved spontaneously for medical advice to be taken; 68.2% said that the child should be carried in the lateral position. Almost all (99.1%) did not know any medication as a primary treatment modality for a fit.

Awareness about convulsions was better in 66.4%, while attitudes towards the children with convulsions were poor in 0.9%. When considering the knowledge of the evaluation of symptoms of a fit, more than 72.7% had adequate knowledge in each category of symptoms; frothing (86.4%), tonic (stiffening – a phase of muscle activity) – clonic (twitching or jerking – a phase of muscle activity) movements (82.7%), eyes rolling up (79.1%), lateral tongue bite (74.5%), rhythmic jerky movements (73.6%), and the drooling of saliva (72.7%), tonicity, loss of consciousness, and post ictal (the period of a seizure) drowsiness were identified correctly as features of a fit. A total of 41.8% did not know that staring at a point was a clinical symptom of a fit.

Discussing the findings, Peiris et al. noted that the knowledge about symptoms of a fit is adequate and satisfactory among the study group. The majority (more than 72.7%) had identified the cardinal symptoms of a fit. The majority were however not aware that staring at a point is a feature of a fit. This, Peiris et al. pointed out, is significant, as absence seizures or “looking blank” followed by “rapid eye blinking” are common among preschoolers. 

Pertaining to knowledge regarding first aid, the participants had satisfactory knowledge with regard to the position that the child should be kept (72.7%), to avoid putting metals or fingers into the mouth, to wipe out secretions from the mouth (61.8%), and the removal of tight clothing (88.6%). Even though they knew what should be done during a fit, half of the sample population did not think that they had adequate skills to manage a child experiencing a fit. This can be due to the fact that 81.8% had never encountered a child with a fit or having a fit and 92% had not had prior training in first aid for a fit. 

There is still a belief among teachers that the child should be doused in water (49.1%), metals should be given to be handled (34.5%), and oral medication should be given (17.3%). These, Peiris et al. emphasised, were wrong practises and therefore to be discouraged, in terms of the do’s and don’ts. 

“It is evident that most teachers display average to good basic knowledge regarding seizures in children. However, there is inadequate knowledge on the acute management of a seizure at their preschools. Therefore, it is recommended that teachers be given more knowledge regarding basic first aid on the management of seizures through a hands-on skill workshop,” Peiris et al. proposed.

In case of related emergencies contact:

National Hospital of Sri Lanka Epilepsy Unit: 011 2691111