Febrile seizures are non-epileptic seizures triggered by fever between ages 6 months to 5 years. They are generally brief and self-limiting, resolving within 15 minutes. Febrile seizures are classified as simple or complex depending on duration and recurrence. While frightening, febrile seizures typically cause no long term issues and have a low risk of developing epilepsy. Proper management involves antipyretics, observation, and reassurance of parents on typical prognosis.

1. Febrile Convulsions/
Febrile Seizures
By; Godwin Ivan Candia & Ndibarema Muhimbura

2. Outline for today’s discussion
• Introduction to seizures
• Definition and classification of febrile seizures
• Etiology and epidemiology
• Clinical features and differential diagnosis
• Risk factors for recurrence and epilepsy
• Diagnosis and management

3. Seizure/ Convulsion
Definition: A seizure is a transient recurrence of signs and/ or
symptoms resulting from abnormal excessive or synchronous neuronal
activity in the brain.
• Seizures are of two types;
1. Epileptic
2. Non-epileptic

4. Epileptic Seizures
• Have no apparent trigger (they are unprovoked) and they occur two or
more times.
• One seizure is not considered epilepsy.
• Epileptic seizures are referred to as a ‘Seizure disorder’ or Epilepsy.
• They have no known cause, but may be caused by various brain
disorders such as strokes and tumors.
• This is called symptomatic epilepsy, and is most common among new-
borns and older people.
NB: Epilepsy is defined as recurrent seizures unrelated to fever or to an
acute cerebral insult in a time frame of more than 24 hours.

5. Non-epileptic Seizures
• These seizures are triggered (provoked) by a reversible disorder or a
temporary condition that irritates the brain.
• Some of these conditions include infection, head injury or reaction to
a drug.
• In children, a fever can trigger a non-epileptic seizure, known as a
febrile seizure.

6. Febrile Convulsions or Seizures
• Febrile seizures are seizures that occur between the age of 6 and 60
months with a temperature of 38°C or higher, that are not the result
of central nervous system infection or any metabolic imbalance, and
that occur in the absence of a history of prior afebrile convulsions.
Or
• Febrile seizure is a generalized tonic-clonic seizure associated with a
rapid rise in temperature due to an extracranial illness. (Uganda
Clinical Guidelines)

7. Criteria for Febrile convulsions
• Age of 6 months to 60 months
• Most febrile seizures occur between the ages of 12-24 months
• Fever of 38°C or more
• Non central nervous system infection or metabolic imbalances

8. Exclusion to diagnosis
• A history of previous afebrile convulsions
• CNS infection or inflammation
• Cerebral malaria
• Acute systemic metabolic abnormality causing convulsions e.g.
cerebral folate deficiency

9. Classification of Febrile Seizures
They are classified into three types:
I. Simple febrile seizure
II. Complex febrile seizure

10. Cont.
I. Simple febrile seizure: This is a primary generalised, usually tonic-
clonic, attack associated with fever, lasting for a maximum of 15
minutes, and not recurrent within a 24 hour period.
II. Complex febrile seizure: This is more prolonged (>15 minutes),
focal and/or recurs within 24 hours.
• Febrile status epilepticus is a complex febrile seizure lasting > than 30
minutes

11. Etiology
• The exact mechanism is unknown
• Although, a rapid increase in body temperature has been postulated
to be the cause.
• Viral, rather than bacterial infections cause disturbance of electrical
activity. The common infections include malaria, UTIs, otitis media,
roseola and human herpesvirus 6 (HHV6). May also be due to shigella.
• It has also been associated with genetic factors

12. Genetic factors
• This is manifested by a positive family history of febrile seizures
• The disorder is inherited as an autosomal dominant trait in some
families
• Many singles genes have been identified e.g. FEB 1,2,3,4,5,6 and 7
genes. Only the function of FEB 2 is known: it is a sodium channel
gene
• In most cases, the disorder is polygenic and the genes responsible are
unknown

13. Epidemiology
• They are the most common cause of childhood convulsive disorder
• Occurs in about 2-5% of neurologically healthy infants and children.
They experience at least one, usually simple febrile seizure.
• They are twice as common in boys than girls
• Simple febrile seizures have no increased risk of mortality
• Complex febrile seizures may have a 2 fold increase in mortality
compared to general population over subsequent 2 years

14. Clinical features
• Elevated temperature (> 38°C )
• Convulsions, usually brief and self-limiting
• No neurological abnormality in the period between convulsions
• Generally benign and with good prognosis

15. Differential diagnosis
• Epilepsy
• Brain lesions
• Meningitis
• Encephalitis
• Head injury/ trauma
• Hypoglycemia
• Hyponatremia
• Cerebral malaria

16. Points to note
• More than 90% of seizures are generalised, are less than 5 minutes
duration, and occur early in an illness (e.g. otitis media, roseola,
pharyngitis)
• A strong family history of febrile convulsions in siblings and parents
suggests a genetic predisposition
• Complex febrile seizures have a higher risk of epilepsy or recurrent
non-febrile seizures.

17. Risk factors for recurrence of F. Seizures
Major
• Age less than 1 year
• Duration of fever less than 24 hours
• Low grade fever less than 38°C
Minor
• Family history of febrile seizures
• Family history of epilepsy
• Complex febrile seizure
• Day care
• Male gender
• Lower serum sodium

18. Risk factors for subsequent Epilepsy
• Simple febrile seizure (1%)
• Neurodevelopmental abnormalities (33%)
• Focal complex febrile seizures (29%)
• Family history of epilepsy (18%)
• Fever <1 hour before febrile convulsion(11%)
• Complex febrile seizure, of any type (6%)
• Recurrent febrile seizures (4%)

19. Clinical Work-up
I. Take a detailed history
• How long the seizure lasted, what happened during the seizure (body
stiffening, twitching of the face, arms and legs, staring, loss of
consciousness), did the child recover within 1 hour, have they had a
seizure before?
II. Do thorough general and neurological exam
III. Do investigations

20. Investigations
1. CBC
2. Blood: Slide for malaria parasites
3. Lumbar puncture if required (in children <12 months is an absolute
indication to rule out meningitis due to subtle clinical symptoms)
4. Blood glucose and electrolytes
5. Urinalysis, culture and sensitivity
6. An electroencephalogram is indicated only when epilepsy is highly
suspected. EEG should be done at least 2 weeks after illness to prevent
transient findings in EEG due to fever or seizure itself.
7. Neuroimaging, to check for neurological abnormalities

21. Meningitis must be ruled out
Lumbar puncture must be performed in children:
• With any suspicion of meningitis
• Under 1 year of age is an absolute indication
• When recovery from a febrile convulsion is slow
NB: Lumbar puncture in children 12-18 months is a relative indication
and is performed only if meningitis is suspected.
• DO NOT do a lumbar puncture in children older than 18 months
unless they show signs of meningitis. E.g. positive Kernig’s or
Brudzinski's sign.

22. Management
• Use tepid sponging to help lower the temperature
• Give an anti-pyretic: paracetamol 15mg/kg every 6 hours until fever
subsides.
• Diazepam has no role in the treatment of febrile seizures.
• Place nothing in the child’s mouth
• Maintain ABCs if child is unconscious
• Place the child on their side (recovery position) to prevent aspiration.
• Observe the child in the emergency room for 6-12 hours and then
revaluate.
• Admit the child if the clinical situation is not stable after observation e.g.
when an underlying condition like meningitis is present.

23. Cont.
• After observing the child, discharge if clinical condition is stable.
• On discharge, counsel & reassure parents using the parameter below
The seizure is frightening but it does not cause brain damage
The possibility of the child developing epilepsy is very low
There is a possibility that the seizure may recur in the next 24 hours
If the seizure recurs, place the child on their side and observe for
recovery
If the seizure takes longer than 5 minutes, parent should return with
child to hospital
Long term therapy with anticonvulsants is not recommended

25. References
1. Kliegman, Robert. Nelson Textbook of Pediatrics. Edition 21.
Philadelphia, PA: Elsevier, 2011.
2. https://www.nhs.uk/conditions/febrile-seizures/
3. https://www.msdmanuals.com/home/brain,-spinal-cord,-and-
nerve-disorders/seizure-disorders/seizure-disorders
4. Uganda Clinical Guidelines. 2016 edition. Ministry of Health,
Uganda, 2016.