Febrile seizures

Febrile seizures are one of the most common neurological complaints in

emergency and outpatient units.
The most common infection associated with FS is respiratory tract infection .

The three most common viral isolates in children with FS include influenza virus,
adenovirus, and parainfluenza virus.

In India, tropical infections such as malaria and dengue are also important causes of
febrile seizures
DEFINITION

Febrile seizures are seizures that occur between the ages

of 6 and 60 months of life (peak 12-18 months old)

temperature of 38°C (100.4°F) or higher

that are not the result of CNS infection or any metabolic

imbalance, and that occur in the absence of a history of
prior afebrile seizures
 Recurrence
• 30% of those experiencing a first episode,
• 50% after two or more episodes
• 50% of infants younger than 1 year of age at febrile seizure onset.
• Although approximately 15% of children with epilepsy have had febrile seizures,
only 5% (range 1–33%, dependent on risk factors) of children who experience
febrile seizures proceed to develop epilepsy later in life.
 Genetic factors
Genes associated with febrile seizures include
• SCN1A, SCN1B, SCN9A, and CPA6.

Pathogenesis
A dysregulation between the proinflammatory interleukin (IL)-1β, IL-6, and IL-8
cytokines and antiinflammatory ILR-1A cytokines has been associated with febrile
status epilepticus.
A decreased ILR-1A/IL-8 ratio (suggestive of an overall proinflammatory state) is
predictive of hippocampal abnormalities on MRI done after febrile status epilepticus.
 Genetic syndromes
• Generalized epilepsy with febrile seizures plus (GEFS+),
• Severe myoclonic epilepsy of infancy (SMEI or Dravet syndrome),
• Temporal lobe epilepsy secondary to mesial temporal sclerosis.
GEFS+

• GEFS+ is an autosomal dominant syndrome with a highly variable

phenotype.
• Onset in early childhood, and remission is usually in mid-childhood.
• Multiple febrile seizures ,subsequent types of afebrile generalized
seizures, generalized tonic-clonic, absence, myoclonic, atonic, or
myoclonic astatic seizures with variable degrees of severity.
 Dravet syndrome
• Caused by a de novo pathogenic variant, rarely inherited in an autosomal dominant manner or may be
inherited from a nonaffected carrier parent.
• Variants in the SCN1A gene are the most common cause of Dravet syndrome
• Rarely the GABRG2, SCN1B, and SCN2A genes may cause Dravet syndrome; however, in 10–20% of the
cases a specific gene variant is not identified.
Blood investigation

- usually not indicated in simple febrile seizures

CBC with C-reactive complex febrile seizures ,

protein (CRP) febrile status epilepticus

Routine blood sugar, febrile status epilepticus

serum electrolytes
(sodium), and serum
calcium
Serum calcium among infants (<1 year)
with simple febrile
seizures.
Micronutrient deficiency
• Routine assessment of serum phosphorus, alkaline phosphatase, and vitamin D is not required in
febrile seizures.
• These tests may be performed if the child has clinical features of rickets or if the child has
hypocalcemia.

Urine analysis
• In children with febrile seizure without any evident focus of infection, urinary analysis should be
considered among all children less than 18 months.
• In children beyond 18 months, with clinical features that suggest urinary tract infection (dysuria,
frequency, urgency)
Neuroimaging

• Indicated in children with the first episode of complex febrile seizure with
prolonged or focal features, MRI brain considered within 72 hours.
• Routine follow-up imaging is NOT required
• In children with simple febrile seizures, neuroimaging is NOT indicated.
Electroencephalography (EEG)

• Routine EEG is NOT indicated among children with simple febrile seizure.
• EEG may be considered in children with complex febrile seizures
• Indicated in children with focal findings on neuroimaging.
• Should be performed 2 weeks after febrile seizure episode
• EEG protocol should include a minimum of 30-minute record and must include
both sleep and awake state
Cerebrospinal fluid analysis (Lumbar puncture)

• children less than 12 months of age with first episode of FS, not received
immunization against Streptococcal pneumoniae and Hemophilus influenzae
type B.
• children more than 12 months who have been pretreated with antibiotics
• All children with febrile status epilepticus as the first presentation of FS
• Should be preferably preceded by neuroimaging in children with focal
neurological deficits, clinical symptoms, and signs of raised intracranial pressure.
• any age group if there are clinical features of meningitis.
Genetic testing

Genetic testing for Dravet syndrome ,considered in children with

1. recurrent febrile status epilepticus,
2. onset of prolonged hemi convulsive seizures below 1 year age.
screening for SCN1A (after consultation with a pediatric neurologist or geneticist)
with appropriate genetic counselling .
Management of febrile seizures

• Domiciliary care
• Intermittent prophylaxis
• Continuous prophylaxis
• Antipyretic medications
• Parent education
 Domiciliary care
• Care taught to parents regarding
recovery position, dose and route of abortive medication,
when to administer repeat dose, and when to bring the child to the hospital.
• Duration of seizure after which abortive medication should be instituted in the non-hospital
setting is 3-5 minutes.
• Intranasal midazolam (0.2 mg/kg) is recommended as abortive medication for domiciliary management
of acute seizures.
• Intranasal midazolam may be preferred over rectal diazepam or buccal lorazepam*
• The abortive medication can be repeated after 5 minutes in case of prolonged seizures.
 Intermittent prophylaxis
Indications

• frequent recurrent simple febrile seizures

• complex febrile seizure who have not been started on continuous
prophylaxis.
Drug of choice - clobazam (0.5-1 mg/kg/day in two divided doses for 3 days maximum dose 20 mg/day).

no need to taper the drug while stopping

should initiate intermittent prophylaxis if the child develops fever (>38 C)
• Intermittent prophylaxis is NOT recommended for the first episode of simple
febrile seizure.
 Continuous prophylaxis
Indications

● febrile status epilepticus,

● febrile seizures in a children with neurodevelopmental delay
● frequent complex febrile seizures and
● children with FS+/GEFS+ with afebrile seizures.
Drug of choice - sodium valproate.

Once initiated, the anti-seizure medication should be considered for a 2 years

seizure freedom period or guided individually based on primary syndrome
(GEFS+/Dravet syndrome).
Antipyretic medication

Paracetamol 15 mg/kg/dose 6 hourly

NOT prevent occurrence or recurrence of seizure but will make the
child comfortable.
Febrile status epilepticus

similar to management of convulsive status epilepticus.

In children who present to emergency services with febrile status
epilepticus and who are already diagnosed with Dravet syndrome, FS+,
GEFS+, sodium channel blockers (phenytoin) may be avoided.
IAP standard treatment guidelines
IAP standard treatment guidelines
Parental education

● Explanation about why febrile seizures occur and they do not constitute epilepsy
● The risk of death during the seizure is negligible
● Simple febrile seizures do not lead to epilepsy or intellectual impairment
● Explanation about the risk of febrile seizure recurrence
● Explanation on what is to be done if the child has fever, and seizure
● Basic first aid and recovery position to be taught to parents.
● Advice regarding rescue medication and when to give this medication.
● Explanation about the danger signs, and when the child should be brought to
medical attention.
Thank you