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KEY MESSAGE

  • Febrile seizures (simple and complex) are almost always benign and generally are not associated with neurological consequences.
  • The mainstay of investigation and treatment is to rule out bacterial infection.
  • There are limited indications for investigations including blood work, neuroimaging or electroencephalography (EEG).
  • Clear explanation to and reassurance of caregivers is key in the management of the child

Recommended Checklist for Pediatricians/Family Physicians

FEBRILE CONVULSIONS

BY DR. SABAHAT NAZIM

PEDIATRICS RESIDENT

In mild cases, the child's eyes may roll or his or her limbs may become rigid (stiff). During a febrile seizure, children are unable to respond (i.e., unresponsive) and may lose consciousness. If the child is standing, he or she will fall.

Other symptoms of febrile seizures include the following:

  • Breathing difficulty (e.g., apnea; the child may turn bluish in color)
  • Contraction of the muscles of the face, limbs, and trunk
  • Fever (usually higher than 102°F)
  • Illness (e.g., upper respiratory infection)
  • Involuntary moaning, crying, and/or passing of urine
  • Shaking
  • Twitching
  • Vomiting
  • An accurate description of the convulsion, including its duration
  • Information about the nature of the episode
  • A record about the family history with regard to febrile and non-febrile convulsions
  • The age at first convulsion
  • The temperature on admission
  • Whether signs of meningitis are present or absent
  • An assessment of the cause of the fever
  • The child's neurodevelopmental state when recovered
  • The blood glucose concentration, if the child was seen during a convulsion
  • Other serum chemistry as indicated (electrolytes, calcium)
  • An estimate of the likely prognosis, advice to the parents about what to do if further convulsions occur, and advice about future immunization
  • What the parents were told at admission and before discharge

FEBRILE SEIZURE OVERVIEW

DEFINITION

Symptoms

A febrile seizure refers to an event in infancy or childhood, usually occurring between six months and five years of age, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded from this definition. Febrile seizures are not considered a form of epilepsy, which is characterized by recurrent nonfebrile seizures

CAUSES OF FEBRILE SEIZURES

Febrile seizures are convulsions that occur in a child who is between six months and five years of age and has a temperature greater than 100.4ºF (38ºC). The majority of febrile seizures occur in children between 12 and 18 months of age.

Febrile seizures usually occur on the first day of illness, and in some cases, the seizure is the first clue that the child is ill. Most seizures occur when the temperature is higher than 102.2ºF (39ºC).

Febrile seizures occur in 2 to 4 percent of children younger than five years old, but do not cause brain damage or affect intelligence. Having a febrile seizure does not mean that a child has epilepsy; epilepsy is defined as having two or more seizures without fever present.

  • Infection — Febrile seizures can occur as a result of the fever that accompanies bacterial or viral infections, especially human herpesvirus-6 (also called roseola or sixth disease).
  • Immunizations — Fever can occur as a side effect of certain vaccines, particularly after measles mumps rubella (MMR) vaccination. The fever typically occurs 8 to 14 days after the injection.
  • Risk factors— A family history of febrile seizures increases a child's risk of febrile seizures.
  • The home use of rectal diazepam to abort seizures in children with convulsive disorders has been shown to be effective.
  • There is now evidence that buccal midazolam is as safe and effective in controlling febrile seizures as rectal diazepam
  • Current guidelines do not recommend the use of continuous or intermittent therapy with neuroleptics or benzodiazepines after a simple febrile seizure.

Parental Education

Studies have shown that many parents witnessing a child's first convulsion think that their child is dying. Try to decrease parental anxiety by counseling. Reassurance and education is thus very important. Instructions on the future management of possible recurrences should be given with emphasis on practical issues of how to manage a child with febrile convulsion at the scene

Current recommendations include consideration of a lumbar puncture, especially in children younger than 18 months, because meningeal signs are less reliable in this group. The prevalence of meningitis among patients with a febrile seizure was 1 to 2 percent, and the absence of any remarkable findings on the history or physical examination makes bacterial meningitis unlikely as the cause of the fever and seizure.Other laboratory studies such as measurement of serum electrolyte levels, are most beneficial in situations with clear symptoms or signs of a concurrent illness, such as diarrhea or vomiting.

Hospital Admission Is individualized &

depends on the experience of the practitioner

After a first convulsion, the following factors favor admission :

1. complex convulsion:

- lasting longer than 15 minutes or

- with focal features or

- repeated in 24 hours of first convulsion or

- with incomplete recovery after 1 hour;

2. the pediatrician is suspicious of possibility of meningitis and encephalitis;

3. a child aged <18 months;

4. anxious parents or inadequate home care.

2. MMR:

There is no contraindication to Measles, Mumps and Rubella (MMR) vaccination for children with history of febrile convulsion. Parents should be advised about the management of fever after giving MMR vaccination. Keep the child under close observation. Rectal diazepam is recommended to be given in case convulsion lasting >5 minutes occurs.

FEBRILE SEIZURE EVALUATION

IMMUNIZATIONS

1. DTP:

Diphtheria, tetanus, pertussis, and poliomyelitis immunization have already been given to children at 2-4 months. Thus this should be before the usual onset of febrile convulsions. If a child has febrile convulsion before immunization against diphtheria, pertussis, and tetanus due to delay in immunization, the child could be immunized provided the parents have been instructed about the management of fever and the use of rectal diazepam.

Complications

Special Considerations

Febrile Convulsion should be distinguished from "convulsion with fever“ which includes any convulsion in any child with fever of any cause. Thus, children with meningitis, encephalitis, or cerebral malaria do not have febrile convulsions but have convulsions with fever. The same is true for children with severe neurologic disorders and/ or severe mental retardation.

STATUS EPILEPTICUS

A convulsing child who is comatosed should receive neuroimaging before LP

‘Recurrence’ in this context means more than one episode of febrile convulsions, as opposed to ‘multiple’ which means more than one convulsion during an episode of fever. The overall risk of a recurrence is 34.3%.

Predictors of recurrence are:

  • the child's first seizure resulting from a low fever.
  • the period between the start of the fever and the seizure was short.
  • Young age at onset (one year or less),
  • family history of febrile seizures
  • Focal, prolonged and multiple convulsions.

Most recurrences occur within three years of the first.

In rare cases, a condition called status epilepticus can occur during a febrile seizure. Status epilepticus is a medical emergency in which a seizure lasts longer than 30 minutes or seizures recur without recovery for 30 minutes or longer. This condition is more common in children under the age of 1 year. Status epilepticus can cause brain damage and may be fatal.

Acute Management of Febrile Convulsion:

Febrile seizures are classified as being simple or complex.

Simple — Simple febrile seizures are the most common. Typically, the child loses consciousness and has a convulsion or rhythmic twitching of the arms or legs. Most seizures do not last more than one to two minutes, although they can last up to 15 minutes. After the seizure, the child may be confused or sleepy, but does not have arm or leg weakness.

Complex — Complex febrile seizures are less common and can last more than 15 minutes (or 30 minutes if in a series). The child may have temporary weakness of an arm or a leg after the seizure.

After a simple febrile seizure, most children do not need to stay in the hospital unless the seizure was caused by a serious infection requiring treatment in the hospital.

After the seizure has stopped, treatment for the fever is started, usually by giving oral or rectal acetaminophen or ibuprofen and sometimes by sponging with room temperature (not cold) water.

  • Maintain a clear airway.
  • Protect the child from injury.
  • Place the child in a semi-prone position.
  • Loosen clothing or remove excess clothing.
  • Give oxygen if available.
  • Apply suction for nasal or oral secretions if facility available
  • Treat fever by sponging with tepid water and antipyretics (e.g. acetaminophen).

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