presentation on clinical approach to Febrile Srizure

2. Definition of seizure
• A sudden transient neuronal activities manifested by
involuntary motor , sensory , autonomic or psychic
phenomenon, alone or in combination, which may or
may not be accompanied by alteration or loss of
consciousness.

3. Febrile seizure
National institute of health (1980) :
‘an event in infancy and early childhood usually
occurring between six months and five years of age
associated with fever but without evidences of
intracranial infection or defined cause for the seizure.’
ILAE (International League Against Epilepsy)
“ 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 previous unprovoked seizures”

4. Epidemiology
• Most common cause of seizure in children up to 5 yrs.
Asian countries : 7-14 % of children
• Age group
involved : (6/12 – 5 yrs)
peak onset : 14 mths – 18 mths
less likely : before 6 months
• Sex : boys> girls
• Race : all

5. Risk Factors for 1st Episode
 Positive family history
– 1st degree or relatives – 4.5 times risk
 Ante and perinatal factors
– Maternal preeclampsia, infections, proteinuria
– Prematurity, LBW, neonatal jaundice, asphyxia, birth
injuries
 Immunizations
– Following DPT or MMR vaccinations
 Infections
– Human herpes virus 6 infection
 Miscellaneous
– Iron deficiency anemia
• Despite these RF, 50% pts with FS have no identifiable RF.

6. Genetic predisposition:
H/o FS in parents , risk for a child is 4 × gen pop.
H/o FS in siblings , risk for a child is 3.5 × gen
pop.
H/o FS in sibling & parents, risk for a child is
50%.
higher concordance in twins.
mode of inheritance : AD ( most likely )

7. Precipitating Factors:
 Fever of any cause can precipitate seizure in a
predisposed child.
 Infections commonly found in a child with FS
Acute Otitis Media
UTI
URI
Roseola
GI Infections

8. Types
1. Simple febrile seizure (Typical)
 96.9% of FS
 age group: 6/12 -5 yrs
 generalized ( 4 -18% focal)
 duration lasts usually for few seconds and max<15 mins
 single attack / febrile episode( within 24 hrs of onset of
fever )
 focus of fever other than CNS infections
 positive family history
 no post- ictal neurological deficit but brief post-ictal
drowsiness may be present

9. 2. Complex febrile seizure ( atypical)
- 3.1 % of FS
- focal seizure
- duration >15 mins
- multiple attacks in close succession
-post- ictal neurological deficit may be present

10. Clinical approach to Febrile Seizure
 If child is having seizure – semiprone position - stabilize
with attention to ABCs and immediately control seizure
(diazepam)
 History:
o confirm the event was seizure
o detailed history regarding
• events & circumstances it took place (association
with fever ,types, duration)
• serious illness (meningitis , encephalitis)
• cause of fever
• recent antibiotic use (partially treated meningitis)

11. o past history of seizure
o birth history and developmental history
o immunization history
o family history of seizure
o other potential causes of seizure ( head trauma,
diarrhea, medication/toxins)

12. General physical examination
with special attention to
– signs of meningitis
– CNS examination for neurological deficit, focal
signs
– focus of infection ENT & systemic examination
– any dysmorphism

13. Investigations:
 no specific investigations
 blood sugar – hypoglycemia
 routine investigations – search for the source of fever
 other investigations – nature of underlying febrile
illness
 Lumbar puncture (LP)
- controversial
- only<5% of children with fever & seizure have
meningitis
- First attack seizure – LP :
- <12/12 child – strongly recommended
- 12-18/12 child – consider
- >18/12 child – consider on clinical grounds

14.  Imaging study (CT, MRI)
– no role in SFS
– May help if atypical features or risk factors for
future epilepsy present (+)
 Electroencephalogram (EEG):
– Not indicated in routine evaluation of first FS

15. Management
 Pre hospital care:
 pts with active seizure → place on his/her side to
prevent aspiration , maintain airway
 if fever → remove blankets, heavy clothings
 postictal pts → supportive care , antipyretics
(SOS)

16. Hospital (ER) care:
• active seizure → proper positioning, maintain airway,
oxygen, anticonvulsant ( diazepam 0.3mg/kg/dose
IV,PR )
• postictal patients → frequent monitoring
• other causes of seizure should be ruled out
• consider antipyretics / tepid sponging if febrile
• cause of fever should be sought and treated
• parental anxiety needs to addressed, proper
counseling

17.  Further inpatient care :
should a patient be hospitalized ?
admission usually not required
most pts should be observed in ER till awake and alert
 reasons for admission
more than one seizure in 24 hrs,
unstable clinical status,
high possibility of meningitis (<18/12 children),
Lethargy beyond postictal period,
uncertain home situation,
doubtful follow-up care

18. Further outpatient care:
 F/U within 24 - 48 hrs for medical reevaluation and
parental counseling ( no brain damage , possibility of
recurrence , first- aid if recurred at home)
 neither long term nor intermittent antiepileptic is not
indicated for SFS.
 treatment of febrile seizures with antiepileptic
medications does not change the risk of developing
epilepsy (Knudsen et al. 1996, Rosman et al. 1993).

20. Prevention
 prophylaxis for possible recurrence of FS –
controversial
 Continuous therapy /prophylaxis with
phenobabital(3-5mg /kg /day) or valproate (10-20mg
/kg /day)↓es recurrences
 But the potential risk outweigh the potential benefit
 Used in recurrent atypical febrile seizure or family h/o of
epilepsy
 No role of phenytoin and carbamazepine in prophylaxis
 Duration – 1-2 yrs or until 5yrs of age whichever comes
earlier

21.  Intermittent prophylaxis:
- Oral diazepam at the onset of fever@
0.3mg/kg/dose
q8hr for 2-3 days (DOC)
- Oral clobazam@ 0.3-1.0 mg/kg/day for 2 days
(better)
- antipyretics –no evidences that it prevents
recurrence

22. Prognosis
• Benign nature - excellent normal neurological
functions.
• Neuro-developmental outcome :
patients with febrile seizures generally have normal
neuro-developmental outcome

23. Recurrence
 occur in 1/3 of children(30-50%)
 recurrence occur within 12 to 24 mths (max within
6/12)
 37% show single recurrence
 30% show two recurrences
 17% show three or more recurrences

25. Risk of epilepsy
• complex febrile seizure
• family history of epilepsy
• neurological abnormalities
• developmental delay
• initial febrile seizure before 9 mths of age
 pts with risk factors : 9% chances of epilepsy
 pts with no risk factors: 1% chances of epilepsy