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Pattern of diagnostic and therapeutic care of childhood epilepsy in Alexandria, Egypt

DOI: http://dx.doi.org/10.1093/intqhc/14.4.277 277-284 First published online: 1 August 2002


Objectives. To evaluate the quality of care delivered to children with epilepsy and study the predictors of seizure recurrence after initial control.

Design. A cross-sectional study was conducted during 4-month period (1 January to 30 April 1999).

Setting. Children’s hospitals providing out-patient and in-patient services to the majority of children in Alexandria, Egypt.

Outcome. Seizure recurrence after at least 6 months from anti-epileptic drug (AED) adjustment.

Results. Electroencephalogram was performed in 82.1% of cases, whereas plasma assay was performed in only 7% of cases. AEDs were initiated after the first seizure rather than the first reccurrence of seizure. Carbamazepine was the most frequently prescribed drug, followed by valproate, except for generalized absence type, which was mainly managed by valproate. Suboptimal quality of care consisted mainly of poor diagnostic assessment of children with epilepsy, underuse of plasma monitoring for AED levels, unjustified use of oral AEDs during breakthrough fits, and defective health education to the caregivers of children with epilepsy that was manifested by non-compliance with AEDs in 30.1% of cases. The outcome of the current healthcare was a 71.6% recurrence of seizures after initial control. Continuous seizures before treatment, a polytherapy regimen, and non-compliance with management procedures were significant predictors for seizure recurrence.

Conclusions. More specialized neurological care and health education programs for the caregivers of children with epilepsy are warranted. By exploring the details of medical practice, a foundation is provided upon which to build a quality improvement program, using the parameters in our study as an initial framework.

  • developing countries
  • predictors of seizure recurrence
  • quality of care


Epilepsy is one of the diseases the course of which can be dramatically modified by the quality of accessible care. The first 2 years of treatment seem to be crucial and long-term prognosis is influenced by how many seizures have occurred before treatment [1]. The contrast between the efficacy of the same drugs in newly diagnosed patients and those with chronic disease is striking. In the later stages of epilepsy, new drugs or alternative treatments as such surgery are needed [1]. The rational use of the recommended drugs is a major component and an indicator for a broader strategy of turning attention to problems of ease of accessibility to health resources.

However, paediatricians have to face the conflict of the harmful impact of anti-epileptic drugs (AEDs) versus the risk of relapse, which accounts for 20% of cases after drug withdrawal [2].

Thus, the goal of treatment includes minimizing both the risk of recurrent seizures and the deleterious side-effects sometimes associated with AED therapy, and maintaining normal psychosocial and vocational adjustment [3]. In developing countries there is evidence that the morbidity burden of the disease is particularly heavy at lower socio-economic levels [4,5]. Therefore, assessment of the quality of health care provided to these children is of crucial importance. Quality of care is defined as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’. Quality assessment activities may examine whether (i) efficacious health services are being provided (process quality), (ii) observed outcomes are what would be expected (outcomes), and (iii) practices are consistent with professional standards (guideline adherence) [6]. Low-income children are not only at a higher risk for a number of health problems, but also represent a vulnerable group subjected to inequity in health care that may affect their long-term growth and development [4]. The present work therefore sought to assess the quality of health care delivered to the disadvantaged sector of children with epilepsy in Alexandria, Egypt.

Materials and methods


The Egyptian health care system consists of public (funded by the government) and private health services.

Public hospitals providing out-patient and in-patient services for the majority of children in our community include: the University Hospital; three Ministry of Health hospitals, delivering medical care to preschool and children not attending regular schools (uninsured); and the Students’ Health Insurance Hospital, providing medical care to school children.

The Egyptian school health insurance system consists of health clinics in schools, health units for each district, and the Students’ Health Insurance Hospital for more specialized services. Children with epilepsy regularly receive their medication from the health units, while routine assessment of their condition is carried out every 3 months by specialists at the Students’ Health Insurance Hospital.


Recent guidelines for optimal care of childhood epilepsy were formulated by reviewing the literature. Determination of appropriate treatment for a child with epilepsy must be individualized based on the specific type(s) of seizure, the child’s age, and the likelihood of significant side-effects. Anti-convulsant monotherapy is preferred when possible, and is effective in a majority of children [7,8].

Generalized seizures may be controlled using a variety of medications, including barbiturates, phenytoin, sodium valproate, or ethosuximide.

Phenobarbital may be effective in the treatment of both generalized and simple partial seizures, including status epilepticus. Phenytoin is also effective in the treatment of both generalized and partial seizures, and may be administered intravenously as treatment for status epilepticus. Sodium valproate is useful in treating a variety of generalized (tonic-clonic, absence) and partial seizure disorders as well as some myoclonic epilepsies. It is particularly useful in treatment of mixed seizure disorders.

Ethosuximide is used primarily in the treatment of absence (petit mal ) epilepsy and occasionally as an adjunctive agent in other generalized seizure disorders.

Partial seizures often respond to many of the anti-convulsant medications used for generalized seizures, including phenytoin and sodium valproate. Another first-line agent used in the treatment of partial seizures is carbamazepine, which is effective against both partial and secondarily generalized seizures [7,8].

A questionnaire was prepared in collaboration with the clinicians in charge of children with epilepsy in all specialized children’s hospitals. The interview was conducted by the clinicians, who were also asked to write down the details of daily practice, i.e. how seizures in these children were managed on a routine basis as well as in an emergency situation.

A cross-sectional study was conducted over a 4-month period (1 January to 30 April 1999), during which cases were recruited from the ambulatory and hospital settings of all specialized children’s hospitals in Alexandria. A systematic random sample was selected from children with epilepsy visiting the ambulatory settings of the public children’s hospitals (out-patient neurology clinics): every fourth child was selected on two randomly chosen days each week. All children with epilepsy admitted to the neurology wards of the children’s hospitals during the study period were included.

The questionnaire

Informed consent was obtained before starting the interview. The questionnaire was a full 30-minute interview of the parents. The response rate was 100%, probably due to the fact that these children are managed in crowded public hospitals where their caretakers (mainly the mothers) are usually not given enough time to talk about their children’s conditions. Therefore, through these interviews mothers were given an opportunity to discuss their problems and difficulties with their children. The questionnaire included information about demographic variables (age, sex, residence, education, occupation), diagnostic procedures performed, and drugs taken by the patients on a routine basis and in emergency situations. Clinicians were guided by medical records for the details of drug prescription.

The out-patient clinics’ records for ambulatory and hospitalized cases were reviewed in order to assess the degree of compliance with the prescribed management prior to the index visit.

Compliance with AEDs was judged by the number of tablets consumed within a certain period of time relative to the dose prescribed. AED withdrawal is considered justified in our material only when freedom from seizures has been achieved for a sufficiently long period (2 years) [7]. Therefore, any abstinence from intake of AEDs (as recorded in the medical records) within a period <2 years from the time of being seizure-free was defined as unjustified in our study, and was classified as non-compliance with management procedures. Epileptic seizures were classified according to the International League Against Epilepsy classification [8].

Seizure recurrence, as an outcome of disease management, is defined as the return of seizures despite adjustment of the AED according to the individual patient’s condition. In order to obtain a proper asssessment of this outcome, only children with epilepsy with a disease duration of ≥6 months prior to the index visit were included in the study. Judgment of seizure recurrence was based on the medical records within the last 6 months prior to the index visit, as well as on the caregivers’ interviews.

Statistical analysis

Proportions were compared simultaneously by the χ2 test. Statistical analysis was performed using the statistical packages EPIINFO version 6 and SPSS for Windows version 9. To account simultaneously for the potential confounding effect of several identified predictors for seizure recurrence, multivariate logistic regression analysis was performed.


The study included 229 children aged 1–15 years, with a mean age of 6.5 ± 4.3 years and a male to female ratio of 1.5. Both parents were illiterate (unable to read and write) in almost one-quarter of cases. Children with epilepsy were less likely to be managed in the Student’s Health Insurance Hospital than in the University Hospital or Ministry of Health Hospital. Pediatric neurologists were in charge of children with epilepsy in only 36.2% of cases (Table 1).

View this table:
Table 1:

Characteristics of children (n = 229) with epilepsy in public children’s hospitals

Characteristics n %
Age (years)
 0–4 9943.2
 5–9 8135.4
 10–15 4921.4
 Female 9139.7
Parental literacy rate1
 Both literate11048
 One of the parents literate 6729.3
 Both illiterate 5222.7
Health facility
 Students’ Health Insurance Hospital 6628.8
 University Hospital 8738
 Ministry of Health Hospital 7633.2
Health care provider
 General pediatrician 7231.4
 Pediatric neurologist2 8336.2
 Adult specialist neurologist3 7432.4
  • 1Literacy was used as a dichotomous variable. No categories or levels of literacy were used.

  • 2In 13 cases care was shared with adult specialist neurologists and neurosurgeons.

  • 3In seven cases care was shared with neurosurgeons.

Regarding diagnostic care provided to the children with epilepsy, the electroencephalogram (EEG) was the main diagnostic test, performed in 88.8% of cases in the ambulatory setting and in 62% of cases in the hospital setting, while liver function tests and electrocardiogram monitoring for children with status epilepticus were perfomed on a limited number of hospitalized patients (36.2 and 24.1%, respectively). Plasma assay was performed in only 7% of ambulatory and hospitalized cases.

Up to two-thirds of cases (66.1%) were diagnosed on the basis of both clinical and EEG findings, while clinical judgement was the only criterion for diagnosis in the rest of the cases.

Anti-epileptic management was initiated following the first seizure rather than the first recurrence of seizure in more than half of cases (Table 2).

View this table:
Table 2:

Diagnostic care and timing of AEDs management for children with epilepsy in public hospitals (n = 229)

Quality of care variables n %
Diagnostic care
 Ambulatory setting (n = 171)
  CT 2414
  MRI  4 2.3
  Plasma assay 11 6.4
 Hospital setting (n = 58)
  EEG monitoring 3662
  EKG monitoring 1424.1
  Pulse oximetry monitoring  2 3.4
  Liver function tests 2136.2
  Plasma assay  5 8.6
Timing of AED initiation
 1st seizure13357.9
 2nd seizure 9642.1
  • AED, anti-epileptic drug; CT, computed tomography scan; EEG, electroencephalogram; EKG, electrocardiogram; MRI, magnetic resonance imaging.

Regarding the clinical description of seizure, the generalized tonic-clonic type constituted 63.6% of diagnosed cases, the frequency of other types was as follows: absence seizures (6.7%), myoclonic seizures (8.9%), simple partial type (8%), partial seizures secondarily generalized (2.2%), multiple seizure types (2.2%), and unclassified epilepsy (8.4%). Neurological deficits were diagnosed in 116 cases (50.7%) and these consisted of mental handicaps, speech disorders, cerebral palsy, learning disorders, hearing disorders, and visual problems in decreasing order of frequency.

Table 3 shows that monotherapy appears to be the most frequent management strategy across all diagnostic categories, with the exception of the small group with generalized myoclonic seizures, where cases are almost equally distributed between mono- and polytherapy. Uniformly, the different health care providers and health facilities tended to adopt monotherapy rather than polytherapy as the management strategy. However, neurologists treating adult patients recorded higher rates of polytherapy regimen (31.1%) compared with the rates for general pediatricians and pediatric neurologists (20.8 and 25.3%, respectively).

View this table:
Table 3:

Drugs prescribed to children with epilepsy on a routine basis correlated with the type of epileptic seizure

Seizure typechildren1% Monotherapyn (%)n (%)n (%)n (%)n (%)
Generalized143 73.4102 (71.3)50 (35)12 (8.4)7 (4.9)2 (1.4)
Absences 15 80  3 (20)11 (73.3) 2 (13.3)n.p.2 (13.3)
Myoclonic 20 55  8 (42.1)10 (50) 5 (26.3)3 (15.8)3 (15.8)
Simple partial 18 77.8 13 (72.2) 6 (31.6) 1 (5.3)1 (5.3)1 (5.3)
Partial seizure,  5100  4 (80) 1 (20)n.p.n.p.n.p.
Multiple  5 80  7 (80) 1 (20) 1 (20)n.p.n.p.
seizure types
Unclassified 19 78.9  9 (47.4) 3 (15.8) 7 (36.8)4 (21.1)n.p.
  • Note: total number of drugs prescribed may exceed total number of children as more than one drug may have been prescribed for one child.

  • n.p., not prescribed; CBZ, carbamazepine; CZP, clonazepam; PHT, phenytoin; VPA, sodium valproate.

  • 1Four cases were undiagnosed and have been omitted.

  • 2Other drugs: adrenocorticotropic hormone, benzodiazepine, ethosuximide, and lamotrigine.

  • 3Phenobarbital was prescribed for eight subjects with generalized tonic-clonic seizures.

  • 4Carbamazepine was prescribed for all cases (four children) with complex partial seizures.

Carbamazepine was the most frequently prescribed drug (64.9%), followed by sodium valproate (36.4%) for all types except the generalized absence type, which was managed mainly with valproate (in 73.3% of generalized absence cases). Drugs reported to affect children’s behavior (phenytoin and phenobarbital) were prescribed in a minority of cases. Other AEDs such as adrenocorticotropic hormone, benzodiazepine, ethosuximide, and lamotrigine were rarely prescribed.

AED use during breakthrough seizures

The history of domestic management of breakthrough fits was recorded. AEDs were given according to a previous prescription or through taking over-the-counter drugs from the pharmacy. They consisted of parenteral benzodiazepine in 76.2% of cases, followed by parenteral phenobarbital in 23.8% of cases. Forty cases (17.5%) were given oral AED during these fits, which consisted of benzodiazepine (19 cases, 47.5%), phenobarbital (12 cases, 30%), and clonazepam (nine cases, 22.5%). Other lines of therapy were provided to 44 out of 116 of cases with neurological deficits, and these were mainly physiotherapy with or without training to cope with the deficits.

The index visit led to a change or adjustment of therapy in only 12.9% of cases.

Clinical control and outcome of management

Table 4 shows that seizure recurrence within at least 6 months after AED adjustment occurred in three-quarters of cases (71.6%). Children with frequent or continuous seizures before treatment were at a significantly higher risk (3.72-fold) of having a seizure recurrence. Polytherapy was also proved to be a significant predictor for seizure recurrence [odds ratio (OR) 2.58; 95% confidence interval (CI) 1.13–5.89]. Children non-compliant with AED were at significantly higher risk for seizure recurrence as compared with compliant children (OR 3.5; 95% CI 1.45–8.42).

View this table:
Table 4:

Predictors of seizure recurrences in children with epilepsy (n = 229) after initial seizure control with AEDs (≥6 months)

RecurrenceCrude ORAdjusted OR
n %(95% CI)(95% CI)
Parental literacy rate1
 Both literate211062.711
 One of parents literate 6773.11.62 (0.79–3.32)1.24 (0.53–2.89)
 Both illiterate 52751.78 (0.81–3.99)1.65 (0.64–4.24)
Health insurance
 Yes2 6659.111
 No16372.41.82 (0.96–3.45)0.82 (0.37–1.83)
Type of seizure
 Partial 25640.74 (0.28–1.96)2.11 (0.67–6.67)
 Others 4763.80.73 (0.35–1.54)0.65 (0.26–1.61)
Seizure frequency before treatment
 ≤22 9157.111
 >2 7770.11.76 (0.88–3.52)1.91 (0.85–4.30)
 Continuous 6183.63.83 (1.63–9.18)3.72 (1.52–9.07)
Presence of deficits
 Yes11676.72.18 (1.19–4.03)1.44 (0.69–2.99)
Management strategy
 Polytherapy 6780.62.38 (1.15–5.01)2.58 (1.13–5.89)
Compliance to AED3
 No 5278.82.72 (1.2–6.23)3.50 (1.45–8.42)
  • AED, anti-epileptic drug; OR, odds ratio; CI, confidence interval.

  • 1Literacy was used as a dichotomous variable. No categories or levels of literacy were used.

  • 2Reference category.

  • 3Fifty-six patients could not be assessed for compliance.


This study attempts to describe the strategies adopted by Egyptian hospital-based clinicians who took an active role in the overall conception and implementation of the program. Our data are only partially comparable with those for other published populations because of the different sampling procedures and contexts of care [9]. Therefore, the dominance of the diagnostic category of the generalized tonic-clonic type is consistent with certain reported studies [1012], but at variance with studies performed in other countries that reported the predominance of partial seizures [9]. Furthermore, the under-representation of children with complex partial seizures and partial seizures secondarily generalized might reflect a less frequent access of children with partial seizures to the hospital because of the less frightening aspect of these seizures, and under-ascertainment of this seizure type by doctors, who might fail to detect secondarily generalized seizures by more sophisticated diagnostic approaches [video-encephalogram, telemetry, computed tomography (CT) scan, and magnetic resonance imaging]. Secondarily generalized types may be managed mainly in the private sector rather than in these public hospitals, or even by home management using non-prescribed medication or repetition of a previous prescription. Use of over-the-counter drugs is one of the main aspects of health care delivery in developing countries. Therefore, this study was not aimed at determining the prevalence of the different seizure types within the Egyptian population, but at describing what types are likely to be managed in the public health facilities, and whether their management conforms with the recent guidelines.

An interesting finding from our study is that while a certain degree of diagnostic delay between the onset of a seizure and the start of AED management was expected as the most appropriate scenario for health care delivery in a developing country, in contrast there was a tendency to start AED management from the first seizure, which was the case in more than half of our patients. This use of medication was unjustified, as the recent guidelines recommend AED management from the first recurrence of seizure [7,8].

As regards the health care providers, although children with epilepsy were managed mainly by pediatricians (both generalized and specialized), adult specialist neurologists were the health care providers in one-third of cases. However, there are several reports highlighting the importance of children being managed by or referred to specialized pediatricians (pediatric neurologists) [13,14]. As expected, the adult specialist neurologists recorded higher rates of polytherapy regimen use, as general pediatricians refer difficult cases that fail to be controlled by a monotherapy regimen to neurologists, whether adult or pediatric specialists.

Two-thirds of patients were diagnosed based on a detailed description of events experienced by the patient and on EEG findings, while clinical description of seizures was the basis of diagnosis in the remaining number of patients. As regards the tests that were performed on the patients, EEG was performed for the majority of cases. This gives valuable information that may add to the clinical diagnosis, aid in classification of the epilepsy type and subsequent choice of the AED, as well as show changes that may increase suspicion of an underlying structural lesion [7]. Other investigations, such as a CT scan, are only justified in the presence of focal lesions in order to diagnose cerebral tumors [7], and CT scans were only performed in a small percentage of cases. Abuse of certain health services was manifested in the performance of liver function tests, needed primarily for patients on Depakote, and these were performed in 36.2% of cases in the hospital setting.

Monitoring of serum drug concentrations provides a useful guide to dosage adjustments, particularly in case of phenytoin, which shows dose-dependent kinetics within the therapeutic range [15,16]. However, although phenytoin was prescribed in 12.2% of cases, plasma assay was performed in only 7% of cases (16 of 229) (6.4 and 8.6% of ambulatory and hospitalized subjects, respectively). Nevertheless, poor compliance is a major cause of treatment failure in epilepsy [17], and non-availability of a routine method for measuring plasma drug concentrations complicates management when non-compliance is suspected (30.1% in our series).

Three-quarters of our cases were on a monotherapy regimen, which is in agreement with the recommended guidelines and recent reports [8,9,12,17]. Furthermore, for most patients the choice was between carbamazepine and sodium valproate. It is noteworthy that these most expensive first-line drugs, carbamazepine and sodium valproate, are used for poor children with epilepsy. This can be explained by the fact that one-third of the children receive their medicine free of charge from the school health insurance system, even if they are not attending regular schools. In this context, the first-line drugs prescribed for childhood epilepsy in Egypt differ from those prescribed in other developing countries, where phenobarbital is acceptable as the first-line drug [18].

As a general rule, carbamazepine was prescribed for the majority of children with epilepsy, regardless of the type of childhood epilepsy except for the generalized absence type. It was prescribed for 71.3% of children with generalized tonic-clonic epilepsy. It has been generally regarded as the drug of choice for patients with partial seizures, whereas sodium valproate is usually recommended for initial treatment of most forms of generalized epilepsy [16,19,20]. On the other hand, sodium valproate has been used for the majority of generalized absence form of the disease, which is in agreement with the recent therapeutic guidelines [20]. Ethosuximide, another drug of choice for absence epilepsy with fewer side effects than sodium valproate [20,21], was rarely prescribed.

Within epileptic seizure types, however, there are no hard and fast rules about the choice of first-line drug. The different therapeutic decisions adopted by many authors [22,23] and the existence of wide regional differences in prescribing patterns [24,25] reflect uncertainties faced in making a rational drug selection. Although several trials have failed to detect major differences in efficacy among the main AED in patients with various seizure types [26,27], there are important differences in tolerability between individual agents, and it is the latter that normally determines drug selection in the individual patient [20]. Ultimately, AED selection must be individualized; no ‘drug of choice’ can be named for all patients. The expected efficacy for the seizure type, the importance of the expected adverse effects, the pharmacokinetics, and the cost of the AEDs must all be weighed and discussed with the patient before a choice is made. A number of new AEDs with unique mechanisms of action, pharmacokinetic properties, and fewer adverse effects hold important promise of improved epilepsy treatment. With classic AEDs at least 25% of children remain resistant to appropriate therapy. The past decade has allowed the introduction of a number of newer AEDs for treatment of both adults and children with epilepsy. These include felbamate, gabapentin, lamotrigine, topiramate, tiagabine, and vigabatrin. Limited data are available that define the optimal use of new AEDs in pediatric patients [28]. In our study, lamotrigine was the only new AED prescribed for a limited number of cases, despite a proven efficacy, comparable to carbamazepine and with better tolerance [27], and despite the fact of the over-the-counter availability of drugs in Egypt, there is no specific formulary in these public hospitals.

Regarding AED use during breakthrough fits, there was an unjustified intake of oral AED in a limited proportion of cases, which is an indicator of defective health education of the caregivers concerning the appropriate domestic management of these fits with parenteral or rectal AEDs.

In an analysis of the different predictors for seizure recurrence as an outcome of the previously described quality of care, there were two unavoidable predictors for seizure recurrence, related mainly to the disease entity as the presence of continuous seizures before treatment and a polytherapy regimen. On the other hand, non-compliance with AED was the only avoidable predictor for seizure recurrence after initial control of seizures.

In fact, medical anthropologists classify the determinants of compliance with preventive or therapeutic management into two main domains.

  1. Patient factors such as health beliefs, the patient’s personal, social and cultural identity and health knowledge.

  2. Healthcare provider factors. In this assumption it is concluded that compliance can only be achieved if the healthcare provider takes over by educating the patient, and, if possible, by meeting the patient halfway regarding the complexity of the regimen. The relationship between healthcare provider and patient can also strongly influence compliance [29]. Non-compliance therefore reflects the quality of delivered care in terms of defective health education, rather than problems in the availability of medications in the local market as in many other developing countries [30], or problems in access to the pharmacy or health services.

Recently, there has been an overwhelming amount of published evidence of the low quality of care in developing countries [31]. Sauerborn et al. [32] analyzed maternal and child health services in a rural district of Burkina Faso. They found that communication in both curative and preventive clinics was poor. Research from Ghana, Mali, and Burkina Faso showed that the perceived low quality of health care was one of the main reasons why people did not attend primary health care services in cases of illness [33,34]. On the other hand, in industrialized countries, quality of care is widely debated in the context of health care reform [35]. A wealth of literature reflects the progress made in developing tools to monitor and improve the quality of health care. Quality monitoring is therefore one of the main health priorities to make comparable quality assessment results routinely available to a variety of audiences (providers, health plans, consumers, purchasers) and to identify potential deficiencies in health care provision that can be corrected through quality improvement activities [6].


With respect to the declared main goal of the study, the most interesting findings can be summarized as follows.

Two-thirds of the patients were diagnosed based on clinical and EEG findings, while clinical description of seizures was the basis of diagnosis in the remaining number of patients. An EEG was performed in 82.1% of cases during the course of the disease.

The majority of children with epilepsy were on a monotherapy regimen, mainly in the form of carbamazepine or sodium valproate, regardless of the diagnostic categories or the specialties of the health care providers in the different health facilities. The new AEDs were rarely prescribed.

Suboptimal quality of care consisted mainly of the poor diagnostic assessment of children with epilepsy, underuse of plasma monitoring for AED levels with unjustified use of other investigations such as liver function tests and electrocardiograms, unjustified use of oral AED during breakthrough fits, and defective health education to the caregivers of children with epilepsy, which manifested in non-compliance with AED in 30.1% of children with epilepsy.

The outcome of the current pattern of care provided to children with epilepsy was a 71.6% recurrence of seizures after adjustment of the AED.

Finally, we emphasize the need for more specialized neurological care for children, better organization and delivery of neurological services, as well as organization of health education programs for the caregivers of children with epilepsy. By exploring the details of medical practice provided to children with epilepsy, we have provided a foundation on which to build a quality improvement program, using the parameters in our study as an initial framework.


We are indebted and thankful to Dr Claudia Gandin, coordinators, and all Consorzio per lo Sviluppo della Medicina Tropicale (CMT) staff for their help and contribution to this work. This project was generously funded by the Italian Ministry of Foreign Affairs, through the CMT.

Members of the Egyptian–Italian Collaborative Group on Paediatric Chronic Diseases are as follows. Coordinating center: Amal Bassili (Medical Research Institute, Alexandria University); Gianni Tognoni (Laboratory of Clinical Pharmacology and Epidemiology, Mario Negri Institute, Milan, Italy); and Tarek Omar (Children’s University Hospital). Collaborating clinicians: F. El-Moghazi, S. Gabra, M. Attar (Anfushi Children’s Hospital); A. Makram (Wengat Children’s Hospital); I. Ibrahim (Fawzi Maaz Children’s Hospital); and S. Morsi, S. Deraz, M. Michael (Students’ Health Insurance Hospital).


  • Address reprint requests to Amal Bassili, 18 Sharawy Street, Wataneya Plaza no. 3, Loran, Alexandria, Egypt. E-mail: amalot{at}yahoo.com

  • *Members of the Egyptian–Italian Collaborative Group on Paediatric Chronic Diseases are listed in the Acknowledgements.


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