Febrile Seizures

• 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