Febrile seizures

Introduction

About 1 in 20 children will have at least one febrile

seizure at some point.

Mostly occurs between the ages of six months and

six years. The average is 18 months.

The cause is unknown, although it appears to run in

some (but not all) families. Around 1 in 4 children

who are affected by febrile seizures will have a family

history of the condition. In half of all cases, there

are no obvious causes or risk factors.

Definition

Having a seizure when the child’s body temperature

is high i.e. 38°C or above.

Usually caused by infection, but exclude intracranial

infection (bacterial meningitis/viral encephalitis)

Occur between 6 months and 6 years

Associated infections

Viral infections e.g. chickenpox and influenza

Otitis media

Tonsillitis

Gastroenteritis

LRTI e.g. pneumonia, bronchitis

Types of febrile seizures

Simple febrile seizure

The most common type of febrile seizure (~90% of

cases)

Features:

Tonic clonic seizure

Does not last >15 minutes

Does not reoccur within 24 hours or during the period

in which the child has an illness.

Tonic clonicseizure

Body stiffness

Loss of concious-

ness

Limbs twitching

Urinary inconti-nence

Complex febrile seizure

Less common than simple febrile seizures (~10% of cases)

Has one or more of the following features:

Seizure lasts >15 minutes

Partial or focal seizure

Seizure reoccurs within 24 hours of the first seizure or during the period in which they have an illness

The child does not fully recover from the seizure within one hour

Febrile seizures and epilepsy

Epilepsy: repeated seizures without fever

Children who have a history of febrile seizures have an increased risk of developing epilepsy. However, it should be stressed to the parents that the risk increase is still quite small.

Simple febrile seizures: 1 in 50 chance of developing epilepsy in later life.

Complex febrile seizures: 1 in 20 chance of developing epilepsy in later life.

Outlook

Almost all children make a complete recovery.

Studies on febrile seizures showed that children with

a history of febrile seizures has no evidence of an

increased risk of death in later childhood or

adulthood.

Simple seizures no brain damage. Subsequent

intellectual performance similar as other children

Symptoms

Febrile seizures often occur during the first day of a fever.

Temperature: 38°C or above.

Seizures may also develop:

After a mild temperature. It may not develop at all with an extremely high temperature.

Rapid rise in temperature

Rapid drop in temperature

More Symptoms…

Body stiffness

Limbs twitching

Lose of conciousness

Urine incontinence ± soiling

Vomiting

Foam at the mouth

Lasting <5 minutes

Sleepiness/drowsiness after seizure ~1 hour

BEWARE!!Signs of dehydration Other alarming signs

•Dry mouth

•Sunken eyes

•Lack of tears when crying

•Sunken fontanelle

•Seizure >5 minutes, no

sign of stopping

•Non-blanching rash

•SOB

•Focal CNS lesion/CNS

abnormality

•Previous h/o epilepsy

•>1 attack in 24h

Differential Diagnosis...which

we need to be aware of

Meningitis

Encephalitis

CNS lesion

Epilepsy

Trauma

Hypoglycaemia

Hypocalcaemia

Hypomagnesaemia

Investigations Source of infections! Do not forget ear and throat examinations!!

FBC

BUSE, Ca2+

Glucose level

Urinalysis

CXR

ENT swab

Further investigations:

EEG

Lumbar puncture (particularly if the child is <12 months old)

Contraindications for LP

Cardiorespiratoryinstability

Focal neurological signs

Increased ICP

Coagulopathy Thrombocytopenia Local infection at LP site

Procedure delays Abx administration

Management Assess ABCDE

If seizure >5 min, rescue therapy diazepam PR/ buccal midazolam

Antipyretics? Not been shown to prevent febrile seizures. But, important to reduce temperature:-

PCM

Ibuprofen

Remove unnecessary clothes or bedding

Remember, NO ASPIRIN for <16 YO (REYE’S SYNDROME)

Further Management Parents education

10 first aid steps when your child has a seizure:

1. Stay calm

2. Look around, assess the environment

3. Note the time

4. Stay with them.

5. Cushion their head.

6. Don’t hold them down

7. Don’t put anything in their mouth

8. Check time again. If > 5mins, call 999

9. Recovery position if seizure stops. Check airway & breathing

10. Stay with them until full recovery

Complications

Risk of developing epilepsy ~1.5%

Risk rises to 2.5% if the child was under 12 months old when they had their first seizures (in those who had multiple simple seizures.

Risk also increases with:

Neurological abnormalities, or a developmental delay before the onset of febrile seizures.

A family history of epilepsy.

A brief fever (<1 h) before the seizure.

Complex seizures.

Short case History:

a clinical context GH, 2 years old girl admitted due to fever with fits.

This is her 1st episode of fever with fits.

Seizure lasted for 1-2 minutes.

Seizure came from a rapid increase of temperature on the 1st day of fever after visiting her grandfather who is warded in HSI (due to chronic illnesses e.g. DM, HPT).

Generalised tonic-clonic seizure. Eyes rolling upwards. No tongue biting, no mouth frothing.

Just once within 24 hours. No subsequent episode.

Source of infection?

Fever was NOT associated with:

Sore throat

Coughs

Shortness of breath

Changes in urinary/bowel habit

Rashes

Ear discomfort, discharge, hearing loss

Neck stiffness

On examination, otitis media was found to be the cause.

Family history of epilepsy. Uncle is epileptic with

medication.

ICE:

Mum thinks that it may be due to the hot weather.

Mum is worried if she’ll get another febrile seizures.

Worried if she will develop epilepsy in the future.

Risk of:

Getting another seizure?

Developing epilepsy?

Risk of getting another febrile fit?

30-40% will have further febrile fits.

More likely if:

The younger the child

The shorter the duration of illness before

seizure

The lower the temperature at time of seizure

Positive family history

Risk of developing epilepsy later?

Increased risk of 1.5%

Family history of epilepsy

Brief fever (<1h) before the seizure

Simple versus complex? Simple: 1 in 50,

Complex: 1 in 20.

Risk increase by 2.5% if under 12month old

when had 1st seizure.

Neurological abnormalities/Developmental

delay.

Quiz!!

1. The followings are features of complex febrile

convulsion

a) Duration of seizures > 15 minutes (T , F)

b) Presence of focal convulsion (T ,F)

c) Recurrence of seizure within the same day (T , F)

d) Children with preexisting neurological disease (T ,F)

e) Age of onset before 12 months (T , F)

2. The risk of recurrent febrile seizures is higher for these children except:

a) young (less than 15 months)

b) Have frequent fevers

c) Have a parent or sibling who had febrile seizures or epilepsy

d) Have a short time between the onset of fever and the seizure

e) Had a high degree of fever before the seizure

3. Answer true or false

a) Prophylactic antiepileptic drug treatment is recommended

b) Patients with early age of onset have higher risk of recurrent

febrile convulsion

c) Lumbar puncture is indicated in patients with even subtle clinical

features suggestive of CNS infection

d) Rescue therapy using PR Diazepam during seizure attack is

recommended provided parents are adequately counseled

4. A 2-year-old boy presents to the emergency department for evaluation following a witnessed seizure. The seizure was described as generalized, lasting less than 5 minutes with a short post-ictal period. The child has no history of seizures, no family history of seizures, and no history of head injury. His exam currently is normal, except for a red, bulging right tympanic membrane and a temperature of 39 C. What is the most appropriate management for this patient?

a)Urgent CT scan of the head

b) Antibiotics and antipyretics and monitored at home

c) Admitted to hospital and EEG is performed

d) Start on phenobarbital and sent home

e)LP and Blood culture performed and start anticonvulsant in hospital

Frightening but harmless!!

Thank you.