This study was conducted to compare the risk of injuries in children with epilepsy as compared to the controls. The secondary objectives were to study the magnitude and pattern of injuries in children with epilepsy, and to assess the factors related to increased incidence of injuries in children with epilepsy.

This was a prospective cohort study conducted in a Government teaching hospital. We recruited children aged 2-16 years with a diagnosis of epilepsy [8] and on treatment with antiepileptic drugs for a minimum duration of one month, who presented to us from November 2010 to March 2012. Children who had motor disability and who were not willing for follow up were excluded from the study. The controls included siblings (unmatched) of children with epilepsy aged 2-16 years, who were chosen as they shared the similar socio-familial-cultural milieu as the cases.

Written informed consent was taken from the parent/caretaker prior to the study. Ethical approval for the study was taken from our institutional ethics committee.

Parents of children with epilepsy were interviewed with a semi-structured questionnaire and open-ended questions. Details regarding age, sex, seizure types, duration, frequencies, and treatment were noted. Approximately equal number of siblings of cases who did not have epilepsy were enrolled in the control group to study the prevalence of injury in normal population. The cases and controls were followed up prospectively for a period of 12 months through monthly follow-up visits and diary analysis, and telephonic conversation. At each follow-up visit, both the child and the parents were enquired about the occurrence of any injuries associated with or without seizures, type, number, mechanism and place of injury and also the need for hospitalization or medical aid received. Seizure-related injuries were defined as injuries occurring as a direct result of a seizure event. Physical examination was done when possible to confirm and examine the injuries reported.

A total of 272 children with epilepsy were screened, out of which 238 children met the inclusion criteria and were enrolled in the study. 243 siblings of cases were screened for inclusion. 30 cases and 31 controls were lost to follow up. A total of 420 children including 208 cases (62.5% males) and 212 controls (51% males) were finally analyzed.

The mean (SD) age of cases was 9.4 (3.8) y and of controls was 9.0 (3.8) y. Among the cases, the most common seizure semiology was generalized (49%). Other seizure characteristics are tabulated in Table I. A past history of seizure-related injury was present in 3.3% of cases. 21 children with epilepsy (10%) had injuries during the 12-month follow-up period. Among these 21 children, one child had 4 injuries, two had 2 injuries and the rest had a single injury (total 26 injuries). Nine (9/21, 42.9%) of them had seizure related injuries and 14 out of 26 injuries were seizure-related. There were no compliance issues in the study population.

TABLE I	Seizure Characteristics in Children with Epilepsy (N=208)

Ten (4.7%) children in the control group suffered injuries (all had a single injury) in the study period. Children with epilepsy had significantly higher injury rate (RR 2.1; 95% CI 1.0 to 4.4) as compared to the controls (P=0.03). However, if we excluded the seizure-related injuries in the cases, then the injury rates were similar in the two groups (Cases 12/208, 5.8%; Controls 10/202, 4.7%; P= 0.63).

Home was the most common place of injury in both the groups with majority of the injuries occurring during activities of personal care (Table II). Head and face was the most frequently affected site in cases (18/26; 69.2%) as well as controls (5/10; 50%). 34.6% (9/26) of cases and 50% (5/10) of controls with an injury sought medical attention.

TABLE II	Type and Mechanism of Injuries in the Study Population

In this hospital-based cohort study over one year, children with epilepsy had a significantly higher risk for developing injuries (10%) as compared to household controls (4.7%),

Few prospective studies in children have shown injury rates of 9 to 44% (follow-up period of 1-2 years) [9-11] and 11-21% in studies with longer follow up periods [2,12]. However, Kirsch, et al. [13] demonstrated that cognitively normal children with epilepsy did not have higher injury rates as compared to their non-epileptic peers. In our study too, the injury rates were similar in the two groups if seizure related events were removed. Data from India in this regard is absent.

The limitations of our study included use of parental reporting for ascertainment of injuries, lack of matching (although age and sex were comparable in the two groups as a whole), short follow-up period and tertiary-care hospital based study. The pre-existing or treatment emergent co-morbidities which may influence the rates of injuries were also not studied.

Previous studies have shown that most of the injuries in these children happen at home [2,9,10]. Majority of injuries in this study also occurred during activities of personal care. Hence, excessive restriction in an outdoor setting for these children may not be warranted. This would augment their social development and feeling of independence. There is; however, a need to undertake measures to modify the home environment and reduce the risk of injuries.

Contributors: SSJ, SS, SA: were involved in the concept and planning the design of the study; SSJ: collected the data; PJ: performed the analysis and interpretation of the data. SSJ and PJ wrote the first draft which was revised critically for important intellectual content by SA, SS and AS. All the authors approved the final version, and agree to be accountable for all aspects of the work. SA: will act as guarantor for the manuscript.

Funding: None; Competing Interest: None stated.

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