• Seizures in the setting of fever may be caused by central
nervous system infections (meningitis, encephalitis, brain abscess), unrecognized epilepsy triggered by fever, or febrile seizures. DEFNITION • Febrile seizures are defined as a convulsion caused by a fever (temperature ) 100.4 'F or 38 'C by any method) that is without evidence of CNS pathology, inborn errors of metabolism or acute electrolyte imbalance • It occurs in children between the ages of 6 months and 60 months with a peak at the end of the second year of life). • Children with a history of epilepsy who have an exacerbation of seizures with fever are excluded. • Febrile seizures occur in 2% to 5% of children. • There is often a positive family history of febrile convulsions. • Febrile seizures is the most common cause of seizures among children between 6 months and 6 years of age • By definition, a febrile seizure occurs in the presence of fever. Infections associated with febrile seizures? • Acute viral respiratory infection (most common) • UTI • Acute gastroenteritis(salmonella,shigella) • ASOM • Encephalitis • URTI • Herpes,HHV-6 • Simple febrile seizures • generalized at onset • last less than 15 minutes • occur only once in a 24-hour period in a neurologically and developmentally normal child. • And not caused by any CNS infection • Complex febrile seizures • focal features • lasts longer than 15 minutes • recurs within 24 hours • or the child has preexisting neurological challenges Why are complex febrile seizures more worrisome than simple febrile seizures? • They suggest a more serious problem. For example, a focal seizure raises concern of a localized or lateralized functional disturbance of the CNS • An unusually long seizure (>15 minutes) also raises the suspicion of primary CNS infectious, structural, or metabolic disease • Repeated seizures within a 24-hour period likewise imply a potentially more serious disorder or impending status epilepticus. The likelihood of recurrence increases with a younger age of onset, wih a recurrence rate about I in 2 if the patient is (I year of age when the initial seizure occurs and I in 5 if the patient is >3 years of age at the time of the initial seizure. About half of recurrences are within 6 months of the first seizure; three- fourths occur within I year, and 90% occur within 2 years.. • Other risk factors for recurrence are • a lower temperature (close to 38 'C) at the time of seizure, • >15minutes • greater than 1 seizure per day • age <1 year • <1 hour's duration of fever before the seizure, • and a family history of febrile seizures. • Overall, the recurrence rate in the pediatric population is about 30%. • The prognosis of children with simple febrile seizures is excellent.
• Although febrile seizures recur in 30-50% of children,
intellectual achievements are normal.
• the risk of subsequent epilepsy is not substantially greater
than that of the general population (approximately 2%). • Factors that increase the risk for the development of epilepsy include: • abnormal neurological examination • development, family history of epilepsy, • complex febrile seizures Differential diagnosis • Electrolyte and blood glucose anomalies • Head trauma • New onset epilepsy • CNS infection • Seizures associated with breath holding spells • For an otherwise healthy child with a self-resolved, unprovoked seizure and a normal physical and neurological examinations. no laboratory evaluation is required. Children with simple febrile seizures who have recovered completely require little or no laboratory evaluation other than studies necessary to evaluate the source of the fever. Are EEG or neuroimaging studies indicated for a child with a simple febrile seizure? • No. An EEG done shortly after or within a month after a seizure does not predict either the recurrence of febrile seizures or the development of afebrile seizures/epilepsy in the ensuing 2 years
• CT or MRI studies are not indicated because children who
are neurologically healthy before a simple febrile seizure have a low likelihood of a clinically important intracranial structural abnormality. What ancillary testing should be considered in a patient with a complex febrile seizure? • Most children with their first complex febrile seizure should undergo a LP for a CSF examination to rule out intracranial infection.
• Children with focal motor seizures or postictal lateralized
deficits (motor paresis, unilateral sensory or visual loss, sustained eye deviation, or aphasia) should be considered for emergent neuroimaging to exclude a structural abnormality before the LP. A LP could result in cerebral herniation if ICP is increased because of a mass effect. • However, if the patient is neurologically normal an emergent CT may not be necessary. The immediate performance of an EEG offers limited insight into the patient's disease. Prominent generalized postictal slowing is not unexpected. Definite focal slowing suggests a possible structural abnormality. When should you consider a lumbar puncture in a child with a febrile seizure? • History concerning for meningitis • Cranky, irritable child who is difficult to console • Meningeal signs or bulging fontanel • Infants 6 to 12 months of age who are deficient in Haemophilus influenzae or Streptococcus pneumoniae immunizations or if immunization status is undetermined • Pretreatment with antibiotics In a child with suspected meningitis, what are some contraindications to performing an immediate lumbar puncture? • Focal neurologic findings on examination • Evidence of spinal cord trauma Infection in the tissues near the puncture site • Focal seizures • Coma • Papilledema • Severe coagulation defects (not corrected) Cardiopulmonary instability • In these cases, antibiotic therapy may be initiated presumptively and lumbar puncture delayed. • If the clinical presentation does not meet the criteria and acute symptomatic seizures are suspected, evaluation for potentially life-threatening causes such as: • meningitis • sepsis • head trauma • and toxins must be persued. • A complete laboratory evaluation for new onset of seizures includes : • complete blood count • Glucose • calcium, sodium, potassium, chloride, bicarbonate • urea nitrogen, creatinine, magnesium, and phosphorous • blood or urine toxicology screening. • Children with clinical signs and symptoms of meningitis (neck stiffness, Kernig sign, Brudzinski sign), or history or physical examination suggestive of intracranial infection, should undergo a lumbar puncture. • Cerebrospinal fluid (CSF) should be analyzed for cell counts, culture, protein, and glucose levels.
• In children less than 18 months old, particularly young
infants, the clinical symptoms of meningitis may be subtle.
• Neonates also may require testing for inborn errors of
metabolism; blood ammonia; CSF glycine and lactate; and a clinical trial of pyridoxine.
• Evaluation for infections, such as urine and stool cultures,
and polymerase chain reactions for herpes simplex virus, cytomegalovirus, and enterovirus should be considered. • The EEG is the most useful neurodiagnostic test for distinguishing seizures from nonepileptic paroxysmal disorders and for classifying seizures as having focal or generalized onset. • The EEG must be interpreted in the context of the clinical history; some normal children have focal or epileptiform EEG patterns. • Conversely, children with seizures may have normal interictal EEGs • . When the diagnosis is unclear, EEG with prolonged recordings and simultaneous video monitoring in an attempt to capture a typical event may be necessary. • Magnetic resonance imaging (MRI) is superior to computed tomography (CT) in showing most brain pathology, but in the emergency department setting, CT can be performed rapidly and often shows acute intracranial hemorrhage more clearly than MRI. MRI is unnecessary in patients with the primary generalized epilepsies, such as typical childhood absence and JME. What is the risk for epilepsy after a simple febrile seizure? • The risk depends on several variables. In otherwise normal children with a simple febrile seizure, the risk • for later epilepsy is about 2%. The risk for epilepsy is higher if any of the following is present: • There is a close family history of non febrile seizures. • Prior neurologic or developmental abnormalities exist. • The patient had an atypical or complex febrile seizure, defined as • focal seizures • seizures lasting at least 15 minutes, and/or multiple attacks within 24 hours • One risk factor increases the risk to 3%. If all three risk factors are present, the likelihood of later epilepsy increases to 5% to 10%. What is the long-term outcome for children with febrile seizures? • In a previously normal child, the risk for death, neurologic damage, or persistent cognitive impairment from a single benign febrile seizure is near zero. • These potential complications are more likely with complex febrile seizures, but the risk is still exceedingly low. • Impaired cognition in the latter group is more likely if afebrile seizures subsequently develop • Febrile status epilepticus has a very low mortality with proper treatment • simple febrile seizures are brief and the outcome is benign, most children require no treatment.
• Rectal diazepam can be administered during a seizure to
abort a prolonged convulsion
• it is appropriate to provide a rescue medication for children
with a history of prolonged febrile seizures
• Since antiseizure medications have side effects and children
with febrile seizures have an excellent prognosis • daily antiseizure medication such as phenobarbitone,phenytoin,clonazepam,diazepam,sodium valproate to prevent febrile seizures is not recommended
• Long-term prophylaxis does not improve the prognosis in
terms of subsequent epilepsy or motor or cognitive ability. In general, the side effects of prophylaxis (especially the hepatotoxicity and pancreatopathy associated with valproic acid therapy)outweigh the relatively minor risks of recurrence.
Administration of antipyretics during febrile illnesses does
not prevent febrile seizures So when do you use AED prophylaxis ? • Exceptions could include : • very young child if febrile • seizures recur frequently • children with preexisting neurologic abnormalities or children with recurrent • complex febrile seizures. Treatment & prophylaxis of febrile seizures • At home : for seizures >2min per rectal diazepam and buccal/nasal midazolam
• Hospital treatment: IV midazolam and IV diazepam(0.1mg/kg)
maximum upto 5mg • No response : full status epilepticus protocol
• Intermittent prophylaxis : Oral diazepam or
clonazepam(1mg/kg/day) in 2-3 divided dose for the 1st 3 days of fever GEFS + • Generalized epilepsy with febrile seizures plus • Febrile seizures beyond age 6 years • In its mildest form – febrile seizures • In severe form – intractable childhood epilepsy with generalized tonic clonic seizures(ICEGTC) TO severe cyclonic epilepsy of childhood(Dravet syndrome) • Patients with GEFS+ have multigenerational family history of febrile seizures • Patients on the more severe end of GEFS+ syndrome have intractable generalized seizure types such as myoclonic,absence,atonic seizures • Long term prognosis for seizure control and cognitive outcome is poor • Carbamezipine,lamotrigine or vigabatrin these drugs make seizures worse in them • Benzodiazepines,ethosuximide,topiramate,sodium valproate are the preferred medications used in GEFS+ KEY POINTS: FEBRILE SEIZURES • 1. Simple: Brief and lasting <15 minutes • 2. Complex: Focal, >15 minutes long, or recurrence within 1 day • 3. Risk for recurrent febrile seizure increases if positive family history or seizure occurs at <1 year of age and/or body temperature of <40°C • 4. Risk for developing future nonfebrile seizures is low (only 2% by age 7 years) • 5. Normal long-term intellect and behavior comparable with controls
• 6. Increased risk for developing epilepsy if complex febrile
seizure, prior neurologic abnormality, or family history of seizure disorder References • OP ghai 9th edition • Nelson essentials of pediatrics 8th edition • Pediatric secrets 6th edition • Pediatrics current essentials • Pediatric neurology 2nd edition oxford speciality handbook in pediatrics • Absolute pediatric neurology review Thank you • Lesions (tumors, arteriovenous malformations, cysts, strokes, gliosis, focal atrophy) may be identified in 25% of patients with other epilepsy types, even when the clinical examination and EEG do not suggest focal features.
• Identifcation of some lesions, such as focal cortical
dysplasia, hamartoma, and mesial temporal sclerosis, can assist in consideration of surgical treatment of pharmaco resistant epilepsy