MOHAMMED ALHARTHI PEDIATRIC RESIDENT R1

Contents Definition Classification Epidemiology Risk Factors CausesDifferential DiagnosisDiagnosis Management Patient Education

Definition Febrile seizures are seizures that occurs between the age of 6 months to 5 years with a temperature of 38 C (100.4 F) or higher, that are not a result of central nervous system infection or any metabolic imbalance, and in absence of a history of prior afebrile seizure.

Generally accepted criteria for febrile seizures include:◦ A convulsion associated with an elevated temperature greater than 38°C◦ A child older than 6 months and younger than 6 years of age◦ Absence of central nervous system infection or inflammation◦ Absence of acute systemic metabolic abnormality that may produce convulsions◦ No history of previous afebrile seizures

Classifications Febrile seizures are further divided into two categories, simple or complex, based on clinical features :

1. Simple febrile seizures: the most common type, are characterized by seizures associated with fever that are generalized, usually tonic-clonic, last less than 15 minutes, and do not recur in a 24-hour period.

2. Complex febrile seizures: seizures associated with fever that are characterized by episodes that have a focal onset (e.g. shaking limited to one limb or one side of the body), last longer than 15 minutes, or occur more than once in 24 hours.

Febrile Status Epilepticus : febrile seizure lasting longer than 30 min or intermittent seizure without neurologic recovery.

Epidemiology The most common neurologic disorder of infants and young children's. They are age dependent phenomenon. Occurs between the age of 6 months to 5 years Occurring in 2-4 % of children younger than 5 years. Peak incidence between 12-18 months. Male predominance with estimated male to female ratio 1.6:1

Epidemiology Febrile seizure recur in:

◦ 30% of those experience 1st episode .◦ 50% after 2 or more episodes. ◦ 50% of infants younger than 1 year at febrile seizure onset.

2-7 % of children experience febrile seizures proceed to develop epilepsy.

Risk Factors Age. High grade fever. Infections.

◦ ( Viral infections such as : HHV-6 and Influenza virus )

Immunization. ◦ ( DTP & MMR )

Genetic susceptibility.◦ Family History of febrile convulsion. ( 10-20 % ) ◦ Autosomal dominant trait .

Risk Factors for Recurrence of Febrile Seizures Major

1. Age < 1year

2. Duration of fever < 24hr

3. Fever 38-39

Minor

1. Family history of febrile seizure

2. Family history of epilepsy

3. Complex febrile seizure

4. Daycare

5. Male gender

6. Low serum sodium at time of presentation

Risk Factor for Occurrence of Subsequent Epilepsy After a Febrile Seizure

Risk Risk Factor Simple febrile seizure 1% Recurrent febrile seizures 4% Complex febrile seizures 6% Fever <1 hr before febrile seizure 11% Family history of epilepsy 18% Complex febrile seizures (focal) 29%Neurodevelopmental abnormalities 33%

Causes Upper respiratory tract infection . Roseola infantum (HHV-6) . Gastroenteritis ( Shigella or campylobacter) . Influenza Virus . Urinary tract infection .

Differential Diagnosis Central nervous system infection ( i.e. meningitis or encephalitis ). Genetic epilepsies with febrile seizures (GEFS+ or Dravet syndrome ). Shaking chills . Metabolic imbalance . Drug ingestion .

Diagnosis History . Physical Examination . Investigations .

History The type of seizure (generalized or focal) and its duration should be described to help differentiate between simple and complex febrile seizures. Focus on the history of fever, duration of fever, and potential exposures to illness. A history of the cause of fever (eg, viral illnesses, gastroentritis) should be elucidated. Recent antibiotic use is particularly important because partially treated meningitis must be considered. A history of seizures, neurologic problems, developmental delay, or other potential causes of seizure (eg, trauma, ingestion) should be sought. A family history of febrile seizure or epilepsy . History of recent vaccination.

Physical Examination The underlying cause for the fever should be sought. A careful physical examination often reveals otitis media, pharyngitis, or a viral exanthem. Full neurologic examination should be done. Serial evaluations of the patient's neurologic status are essential. Check for meningeal signs as well as for signs of trauma or toxic ingestion.

Investigations Blood Studies. o Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and complete blood count ) are not

routinely recommended in the work-up of a child with a first simple febrile seizure.

Lumber Puncture. The American Academy of Pediatrics (AAP) recommendations regarding the performance of

LP in the setting of febrile seizures, include the following: o LP should be performed when there are meningeal signs or symptoms or other clinical features that

suggest a possible meningitis or intracranial infection.o LP should be considered in infants between 6 and 12 months if the immunization status for Haemophilus

influenzae type b or Streptococcus pneumoniae is deficient or undetermined.o LP should be considered when the patient is on antibiotics because antibiotic treatment can mask the

signs and symptoms of meningitis.

Investigations Electroencephalogram (EEG) . o Routine electroencephalography (EEG) is not warranted, particularly in the setting of a

neurologically healthy child with a simple febrile seizure. o EEG may indicated in complex febrile seizure with abnormal neurologic examination or in febrile

status epilepticus .

Neuroimaging. o Neuroimaging with computed tomography (CT) or MRI is not required for children with simple

febrile seizures.o The incidence of intracranial pathology in children presenting with complex febrile seizures also

appears to be very low. o Urgent neuroimaging (CT with contrast or MRI) should be done in children with abnormally large

heads, a persistently abnormal neurologic examination, particularly with focal features, or signs and symptoms of increased intracranial pressure.

Management The majority of febrile seizures have ended spontaneously by the time the child is first evaluated, and the child is rapidly returning to a normal baseline. In such cases, active treatment with benzodiazepines is not necessary .

In children with febrile seizures that continue for more than five minutes, we recommend treatment with intravenous (IV) benzodiazepines (diazepam 0.1 to 0.2 mg/kg or lorazepam 0.05 to 0.1 mg/kg) Buccal midazolam (0.2 mg/kg, maximum 10 mg) is an alternative when IV access is unavailable.

Patients with continued seizures despite initial benzodiazepine administration (ie, febrile status epilepticus) should be treated promptly with additional anticonvulsant medications, as are other patients with status epilepticus.

Management Most children with simple febrile seizures do not require hospital admission and can be discharged safely to home once they have returned to a normal baseline and parents have been educated about the risk of recurrent febrile seizures.

Diazepam at the 1st onset of fever for duration of the febrile illness may be effective but will sedate a child and complicate the evaluation for the source of the fever .

Prophylactic anticonvulsants are not recommended after febrile seizure.

Measures to control the fever such sponging, tepid baths, antipyretics and antibiotics for proven bacterial illness are reasonable but unproven to prevent recurrent of febrile seizure .

Parent education and reassurance .

References Nelson TEXTBOOK of PEADIATRICS

Nelson Essentials of Pediatrics

Up-to-date

Medscape

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