A short Review For Ped-Med students

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Pediatric Febrile
Seizures
Dr. Mujeebullah Mahboob
Resident doctor at FMIC
07/01/2016

2. Objects of presentation
• Introduction and History of febrile convulsion
• Pathophysiology of
• Epidemiology of
• Etiology of
• Evaluation of
• Treatment of
• Prevention of
• Conclusion

3. Historical background
• Although Febrile seizure was described by the
ancient Greeks but until this century it was
not recognized that febrile seizures are
distinct syndrome separate from epilepsy.
• In 1980, a consensus conference held by the
National Institutes of Health(US) described
febrile seizure.

4. Introduction
• Febrile seizures are seizures that occur
between the age of 6 and 60 mo(3mo-5y).
• with a temperature of 38°C (100.4°F) 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 seizures.

5. Introduction
• Another definition from the International
League Against Epilepsy (ILAE) is:
• "a seizure occurring in childhood after 1
month of age associated with a febrile illness
not caused by an infection of the CNS, without
previous neonatal seizures or a previous
unprovoked seizure, and not meeting the
criteria for other acute symptomatic seizures."

6. Classification

7. SFC
generalized
not
recurrent
within a
24-hr period
lasting for a
maximum of
15 min
associated
with fever
tonic–clonic

8. Complex febrile seizure
More
prolonged
(>15 min)
Focal
Reoccurs
within 24
hr

9. • is a febrile seizure lasting longer than
30 min
Febrile
status epilepticus
• recurrent febrile seizures within 24 hrsimple febrile
seizure plus
• Age and fever are the same as for
simple febrile seizure
• The child has a preexisting neurologic
abnormality or acute illness
Symptomatic
febrile seizure

10. Postictal state
• Most patients with simple febrile seizures
• have a very short postictal state and usually
return to their baseline normal behavior and
consciousness within minutes of the seizure.
• postictal period of sleepiness, headache or
confusion can extend beyond the 15-minute
maximum.
• A weak limb postictally will role out SFC.

11. Exclusion to the diagnosis
• Hx of previous afebrile seizure
• CNS infection or inflammation
• Acute systemic metabolic abnormality causing
seizure.

12. Pathophysiology
• Febrile seizures occur in young children at the
time of their development when the seizure
threshold is low.
• Younger children are susceptible to frequent
infections such as upper respiratory infection,
otitis media, viral syndromes, and they
respond with comparably higher
temperatures.

13. Pathophysiology
• Animal studies suggest a possible role of
endogenous pyrogens, such as interleukin
1beta, that, by increasing neuronal excitability,
may link fever and seizure activity.
• Hypothesis is present that during febrile
illness the cytokine network is activated and
may have a role in the pathogenesis of febrile
seizure.

14. Etiology
• As Febrile seizures tend to occur in families
this strongly suggests genetic predisposition.
• In most cases the disorder appears to be
polygenic.
• A small number of families are identified with
an autosomal dominant pattern of inheritance
of febrile seizures.

15. Etiology
• Underlying mutations have been found in
genes encoding the sodium channel and the
gamma amino-butyric acid A receptor.
• If there is one child with febrile seizure in the
family the risk of febrile seizure in other
siblings is 10%
• and 50% for the siblings if a parent has febrile
seizure.

16. Etiology
• ARI are most commonly associated with febrile
seizures (otitis media or pharyngitis), pneumonia.
• AGE, especially caused by Shigella or campylobacter
and UTI are less common causes.
• Viral rather than bacterial infection causes
disturbance of cerebral electrical activity.
• Roseola infantum is rare but classic cause.
• One study implicated viral causes 86% in of cases.
• After vaccination of DPT or MMR (Starting
MMR/MMRV vaccination earlier may reduce seizure
risk)

17. Etiology
• Viral causes:
– Roseola and
– Human herpesvirus (HHV-6B) and HHV-7 infection
• No data support the theory that a rapid rise in
temperature is a cause of febrile seizures.
• Simple febrile seizures often occur with the initial
temperature elevation at the onset of illness. The
seizure may be the first indication that the child is
ill. While no clear cutoff is known, a rectal
temperature under 38°C should raise concern
that the event was not a simple febrile seizure.
Seizures are not related to the degree of temperature

18. Epilepsy syndromes typically start
with febrile seizures
• generalized epilepsy with febrile seizures plus
(GEFS+)
• severe myo-clonic epilepsy of infancy (also
called Dravet syndrome)
• temporal lobe epilepsy secondary to mesial
temporal sclerosis due to prolonged febrile
seizure.

19. generalized epilepsy with febrile
seizures plus
• GEFS+ is an autosomal dominant syndrome.
• Clinical feature is highly variable.
• Onset is usually in early childhood and remission
is usually in mid-childhood.
• It is characterized by multiple febrile seizures and
by several subsequent types of afebrile
generalized seizures, including generalized tonic–
clonic, absence, myoclonic, atonic, or myoclonic
astatic seizures with variable degrees of severity.

20. Dravet syndrome
• Dravet syndrome is the most severe form of
febrile seizure-associated epilepsies.
• Onset is in infancy as febrile and afebrile
unilateral clonic seizures.
• Seizures recurring every 1-2months.
• seizures are typically induced by fever, but
they differ from the usual febrile convulsions
in that they are more prolonged, are more
frequent, are focal and come in clusters.

21. Dravet syndrome
• Seizures typically occurs with low grade fever and
then without fever.
• developmental delay usually follows.
• Patients who have got Vaccine
encephalopathy(seizures and psychomotor
regression occurring after vaccination ) are now
turn out to have Dravet syndrome mutations,
indicating that their disease is caused by the
mutation and not secondary to the vaccine.

22. Epidemiology
• Febrile seizure is the most common cause of
childhood convulsion disorder.
• Between 2% and 5% of neurologically healthy
infants and children experience at least 1,
usually simple, febrile seizure.
• Febrile seizures are twice as common in boys
than girls.

23. Mortality
• SFC do not have an increased risk of mortality
• Seizures that are Complex 0ccured before age
1year or were triggered by Tem of <39c were
associated with a 2-fold long-term increase in
mortality probably secondary to coexisting
pathology
• There are no long-term adverse effects of
having 1 or more simple febrile seizures

24. Morbidity
• Age-matched controls studies showed that
patients with febrile seizures do not have
any increase in the incidence of
abnormalities of behavior, scholastic
performance, neurocognitive function, or
attention.

25. Recurrence
• Febrile seizures recur in approximately 30%
of those experiencing a first episode, in 50%
after 2 or more episodes, and in 50% of
infants younger than 1 yr old at febrile seizure
onset.

27. Risk of epilepsy
• only 2-7% of children who experience
febrile seizures proceed to develop epilepsy
later in life

29. EVALUATION OF A PATIENT
WITH FEBRILE SEIZYRE

31. History
• The type of seizure (generalized or focal)
and its duration should be described to
help differentiate between simple and
complex febrile seizures.
• Focus on the history of fever, duration of
fever, and potential exposures to illness.
• A history of the cause of fever (e.g., viral
illnesses, gastroenteritis) should be
elucidated.

32. History
• Recent antibiotic use is particularly
important because partially treated
meningitis must be considered.
• A history of seizures, neurologic
problems, developmental delay, or other
potential causes of seizure (e.g., trauma,
ingestion) should be sought.

33. Physical Examination
• The underlying cause for the fever should
be sought.
• A careful physical examination often
reveals otitis media, pharyngitis, or a
viral exanthema.
• Serial evaluations of the patient's
neurologic status are essential.
• Check for meningeal signs as well as for
signs of trauma or toxic ingestion.

36. DDx
• Meningitis and Encephalitis are important
causes of seizure and fever in pediatrics.
• To differentiate a febrile seizure from these
two types of CNS infection the only way is CSF
analysis when clinical suspicion is present.

37. WORKUP FOR FEBRILE SEIZURE

38. Work Up
• Blood Studies
• C.S.F analysis (Lumbar Puncture)
• Electroencephalogram (EEG)
• Neuroimaging (CT&MRI)

39. Blood Studies
• Serum electrolytes, calcium, phosphorus,
magnesium, and CBC) are not routinely
recommended in the work-up of a child
with a first simple febrile seizure.
• Blood glucose should be determined in
children with prolonged postictal state or in
case of poor oral intake (prolonged fasting).

40. Blood Studies
• Any need for doing blood studies in a patient
with a SFC should be suggested by the History
or physical examination.
• A low sodium level is associated with higher
risk of recurrence of the febrile seizure within
the following 24 hr.

41. Indications of CSF analysis
• All infants younger than 6 mo.(some
references mentioned less than 12mo) of age
who present with fever and seizure(because
the signs and symptoms of bacterial
meningitis may be minimal or absent in this
age group.).
• If the child is ill-appearing.
• At any age if there are clinical signs or
symptoms of concern.

42. Indications of CSF analysis
• A lumbar puncture is an option in a child 6-12
mo of age who is deficient in Haemophilus
influenza type b and Streptococcus
pneumonia immunizations or for whom
immunization status is unknown.
• A lumbar puncture is an option in children
who have been pretreated with antibiotics (it
can mask signs and symptoms of meningitis ).
• Generally a minimal suspicion for meningitis.

43. Indications of CSF analysis
• Children less than 18mo old in whom the
cause of fever is unknown.
• Presence of fever for more than 48-72hrs
before occurring of seizure.
• In children older than 6years febrile
convulsions are rare and we must investigate
for CNS infections, electrolyte imbalance or
other CNS cause.

44. Risk factors for meningitis
• A visit to a healthcare setting within the
previous 48 hours
• Seizure activity at the time of arrival in the ED
• Focal seizure, suspicious physical examination
findings (e.g., rash, petechiae) cyanosis,
hypotension, or grunting
• Abnormal neurologic examination
• Pretreatment with antibiotics, as it can mask
signs and symptoms of meningitis

45. Electroencephalogram (EEG)
• An electroencephalogram (EEG) is not
necessary in the routine evaluation of a child
with a first simple febrile seizure and is
otherwise neurologically healthy.
• Generally EEG is restricted to special cases in
which epilepsy is highly suspected, and,
generally, it should be used to specify the type
of epilepsy rather than to predict its
occurrence.

46. Electroencephalogram (EEG)
• Another indication for EEG is when the
patient does not recover immediately from a
seizure, then an EEG can help distinguish
between ongoing seizure activity and a
prolonged postictal period, sometimes termed
a nonepileptic twi-light state

47. Electroencephalogram (EEG)
• children with febrile status epilepticus (severe
type of complex febrile seizure) within 72
hours of presentation had an abnormal EEG
with focal slowing seen maximally over the
temporal areas and were highly associated
with MRI evidence of acute hippocampal
injury

48. Electroencephalogram (EEG)
• An EEG would not predict the future
recurrence of febrile seizures or epilepsy even
if the result is abnormal.
• EEGs performed within 2 wk of a febrile
seizure often have nonspecific slowing,
usually posteriorly. Thus, in many cases, if an
EEG is indicated, it is delayed until or repeated
after more than 2 wk have passed.

49. Neuroimaging
• A CT or MRI is not recommended in evaluating
the child after a first simple febrile seizure.
• The work-up of children with complex febrile
seizures needs to be individualized. This can
include an EEG and Neuroimaging,
particularly if the child is neurologically
abnormal.

50. Neuroimaging
• 11% of children with febrile status
epilepticus are reported to have (usually)
unilateral swelling of their hippocampus
acutely, which is followed by subsequent long-
term hippocampal atrophy. These patient may
or may not developed Temporal lobe epilepsy.
• MRI will help to detect this swelling of the
hippocampus acutely.

51. TREATMENT
• Prehospital Care
• Emergency Department Care
• Inpatient Care
• Patient Education

52. Prehospital Care
• Patients with active seizures should be treated
with airway management, high-flow oxygen,
supportive care, and anticonvulsants as
necessary. Acute treatment such as rectal
diazepam (0.5 mg/kg) and buccal 0.4-0.5 mg/kg)
or intranasal (0.2 mg/kg) are effective and can
be given at home for a seizure lasting longer than
5 minutes.
• Patients who are postictal should receive
supportive care and antipyretics as appropriate.

53. Emergency Department Care
• Patients presenting with status epilepticus
should be treated with airway management
and anticonvulsants as necessary(ABC).
• Patients presenting with history and physical
examination findings consistent with a simple
febrile seizure should have frequent
neurologic examinations to monitor mental
status.
• Other causes of seizure should be ruled out.

54. Emergency Department Care
• The cause of the febrile illness should be
sought and treated.
• Antipyretics should be considered.
Acetaminophen and ibuprofen are often used.
• Parental anxiety and fear that their child may
die or will develop brain damage needs to be
addressed with reassurance and education.

55. Inpatient Care
• The decision to admit should be
individualized, but admission usually is not
necessary for patients with febrile seizure.
• Most patients should be observed in the ED
until awake and alert.

56. Inpatient Care
• Conditions requiring admission of the patient
include the following:
More than 1 seizure within 24 hours
Unstable clinical status
Lethargy beyond the postictal period (slow
recovery)
If close follow up is not possible.

57. Medication
• Antipyretics
• Anticonvulsant agents

58. Antipyretics
• Antipyretics can decrease the discomfort of
the child but do not reduce the risk of
having a recurrent febrile seizure, probably
because the seizure often occurs as the
temperature is rising or falling.

59. Anticonvulsant agents
• In general, antiepileptic therapy, continuous or
intermittent, is not recommended for children
with 1 or more simple febrile seizures.
• If the seizure lasts for longer than 5 min, acute
treatment with diazepam, lorazepam, or mid-
azolam is needed, best route of administration is
Rectal or buccal and nasal.
• IV benzodiazepines, phenobarbital, phenytoin, or
valproate may be needed in the case of febrile
status epilepticus.

60. Patient Education
• Parents should be counseled about the
relative risks of recurrence of febrile seizures
and recurrence of epilepsy, educated on how
to handle a seizure acutely, and given
emotional support.
• Parents should be counseled on the benign
nature of febrile seizures.
• Parents should be reassured that simple
febrile seizures do not lead to neurologic
problems or developmental delay.

61. Febrile seizure prophylaxis
• Continuous or intermittent prophylaxis of
febrile seizure with anticonvulsants is
indicated when:
If 3 or more febrile seizures in 6months occurred.
6 or more in 1year.
Febrile seizure lasting more than 15minutes or
requiring pharmacologic therapy to control
seizures.
If medical reassurance fails to relieve the anxiety
of parents.

62. Febrile seizure prophylaxis
• Intermittent prophylaxis with drugs that attains
drug levels quickly can reduce, but do not
eliminate, the risks of recurrence of febrile
seizures can be given during febrile illnesses:
– intermittent oral diazepam (0.33 mg/kg every 8 hr
during fever)
– intermittent rectal diazepam (0.5 mg/kg as a rectal
suppository every 8 hr)
– nitrazepam, clobazam, and clonazepam (0.1
mg/kg/day) clobazam(0.75-1mg/kg) have also been
used.

63. Febrile seizure prophylaxis
• Continuous prophylaxis is indicated:
Failure of intermittent Rx
Recurrent atypical seizures
When parents are not able to promptly recognize the
onset of fever.
• Continuous phenobarbital (4-5 mg/kg/day in 1
or 2 divided doses),
• Continuous valproate (20-30 mg/kg/day in 2 or 3
divided doses).
• Phenytoin and carbamazepine are ineffective for
prophylaxis.

64. Febrile seizure prophylaxis
• Iron deficiency(IDA) is associated with an
increased risk of febrile seizures, and thus
screening for that problem and treating it
appears appropriate.
• A study found the European children with
febrile seizures have lower Ferritin than those
with fever alone, and iron deficiency, but not
anemia, is associated with recurrence.

65. Conclusion
• Simple febrile seizures may slightly increase the
risk of developing epilepsy, but they have no
adverse effects on behavior, scholastic
performance, or neurocognition. The risk of
developing epilepsy is increased further in
children with a history of complex febrile
seizures.
• A strong association exists between febrile status
epilepticus or febrile seizures characterized by
focal symptoms and later development of
temporal lobe epilepsy. Children with febrile
seizures have a slightly higher incidence of
epilepsy compared with the general population
(2% vs. 1%).

66. References
• Nelson TEXTBOOK of PEDIATRICS EDITION 20
• Current pediatrics diagnosis and treatment 17th
edition
• Ghai OP,gupta piyush ,Paul ,VK2004.Essentials
Pediatrics Edition 8th edition
• Akbar khan ,parvez ,kundizafarullah ,2002 Basis
of pediatrics 8th Edition
• http://www.medscape.com
• https://www.google.com

69. Prepared By
• Dr. Mujeebullah mahboob
• 1st year resident of Ped-Med at
FMIC, Kabul, Afghanistan
• 10/01/2016
• W_mahboob@yahoo.com
• (+)93 798984142