3. 1-definition
• The International League Against Epilepsy (ILAE)
defines a febrile seizure as “a seizure occurring in
childhood after one month of age associated with a
febrile illness not caused by an infection of the
central nervous system, without previous neonatal
seizures or a previous unprovoked seizure, and not
meeting the criteria for other acute symptomatic
seizures.”
4. • 2-types
B-complexA -Simple
Focaltonic clonic generalized
and tonic spells
.>15 minlast 15 minutes
prolonged period of postictal
drowsiness or be associated
with postictal transient
hemiparesis (Todd’s palsy)
Short post ictal
RecurrentOnce in febrile illness
.80–85% of all febrile seizures.
5. • C-Febrile status epilepticus
• the most severe type of complex febrile seizure, refers to
continuous or intermittent febrile seizures without consciousness
being regained at the interictal state for more than 30 minutes
• . Children with febrile status epilepticus are more likely to have
hippocampal abnormalities
6.
7. As regard age from 3 months to 6 years however the
first attack is rare after the age of 4 years and never
start after 6 years however it may continue until the
age of 7 years and 10 months and it may occur as
early as 1 month of age .
Earlier age of onset carries higher risk of recurrence
of FC .and higher risk that FC will be complex
8. • the risk factors for a first febrile
seizure
• 1-: a history of febrile seizures
• in a first- or second-degree relative,
• 2-a neonatal nursery stay of
• more than 30 days,
• 3-developmental delay,
9. • . Relation of fever to convulsion
• A-More recent studies, found that only 21% of the children
experienced their seizure either before or within 1 hour of
the onset of the fever,
• B- whereas 57% had a seizure after 1 to 24 hours of
fever,
• C-22% experienced their febrile seizure more than 24
hours after the onset of the fever.
.
• D-Although it was thought that the rate of rise of the
temperature was the key factor, more recent data suggest
that it is the actual peak temperature
10. causes
1-genetic
• A positive family history for FC could be
elicited in 25-40% of patients with FC,
• frequency in siblings of children with FC is 9-
22% with higher rates in monozygotic rather
than dizygotic twins all these factors support
genetic basis of FC
11. II-Role of endogenous pyrogens as
interleukin-1
That by influencing neuronal excitability may
link fever and seizure activity and many studies
support that the cytokine network is activated and
may have a role in the pathogenesis of FC.
12. III-Heme oxygenase –1 theory:-
Heme oxygenase (HO) is a microsomal enzyme
that oxidatively cleaves heme and produces
biliverdin, carbone monoxide and iron.
Co plays a role as neurotransmitter and
neuromodulator in the brain.
Ho have three isozymes Ho1-, Ho-2 and Ho-3.
Ho, is a member of heat shock protein family and
can be induced in the brain by various stresses
including fever and convulsions
13. Predisposing factors
• 1-infection
• A- otitis media
• B-herps simplex 6
• C-shigella
D-Rarly bacterial infections may cause particularly urinary tract infections
,pneumococcal bacteremia,
14. • 2-vaccination
• A-MMR
• The main neurologic complication of measles immunization is a
2- to 6-fold elevated risk of febrile seizures, often complex, in the
second week after immunization
15. • B- DPT
• Immunization has been associated with FS and an event occurring within 72
hours of immunization is commonly accepted as being associated with
vaccine
• A handful of vaccine-associated encephalopathy patients were found
to have an SCN1A mutation thought to explain the encephalopathy
16. 3-Diphtheria, tetanus, pertussis (DTaP
• Acellular pertussis vaccines contain substantially fewer
proteins (five) and less endotoxin than whole-cell pertussis
vaccines
• . Acellular pertussis vaccination is associated with fewer local
adverse events and systemic adverse events compared with
DwPT, including lower rates of febrile seizures and hypotonic
unresponsive events.
• No cases of encephalopathy have been identified that could
be attributable to acellular pertussis after the administration of
millions of doses of vaccines
17. vaccine contraindication FALSE
CONTRAINDICATION
Diphtheria
, tetanus,
pertussis
(DTaP)
1- Severe allergic reaction (e.g., anaphylaxis)
after a previous dose or to a vaccine
component
2- • For pertussis-containing vaccines:
Encephalopathy (e.g., coma, decreased level
of consciousness, prolonged seizures) not
attributable to another identifiable cause
within 7 days of administration of a previous
dose
3-Progressive or unstable neurologic disorder
(including infantile spasms for DTaP), uncontrolled
seizures, or progressive encephalopathy defer
until a treatment regimen
1-FEVER LESS 40 after vaccine
Previous dose
2-FAMILY HISTORY (FITS,
ADVERSE REACTION TO DPT)
3-Stable neurological disesae
18. 6-differential diagnosis
• In most cases, febrile seizures occur within first day of
the fever.
• Seizures occurring ≥3 days after the onset of a fever
should be suspect
19.
20.
21. characterdisorder
defined as a perception of cold and involuntary muscle
tremors that persist for several minutes.
In contrast to febrile seizures, there is no loss of
consciousness and no involvement of facial or
respiratory muscles.
• Shaking chills
an acute and transient confusional state with high fever.
Tonic–clonic movements of the limbs and rolling back
of the eyeballs are characteristically absent.
febrile delirium.
22. episodes of brief, involuntary cessation of breathing that occur in
children in response to stimuli such as anger, frustration, pain, or fear..
Loss of consciousness may ensure if the apneic period is prolonged.
Spontaneous recovery is the rule.
The absence of fever, tonic–clonic movements of the limbs, and
rolling back of the eyeballs distinguishes this condition from febrile
seizure.
Breath-
holding
spells
Impaired consciousness, petechial rash, neck rigidity, Kernig’s sign,
and Brudzinski’ sign, if present, give clue to the diagnosis.
Lumbar puncture is diagnostic
CNS
infection
is a benign disorder affecting children mainly 6 months to 6 years of
Affected children present with myoclonic jerks, mostly involving the
upper limbs during fever.
The myoclonic jerks may occur infrequently or several times per
minute and may last from 15 minutes to several hours
Febrile
myoclonus
26. hospital admission in the following conditions
a-child presents with red flag signs and symptoms
1-The child presents with complex FS
2-Meningeal signs are observed: a positive Kernig’s sign and/or
a positive Brudzinski sign and/or neck stiffness
3-Altered level of consciousness for more than one hour after
interruption of the FS
4-Evolving non-blanching rashes in an unwell child
5-Bulging anterior fontanelle
7-residual neurological findings (i.e., Todd’s paresis) are present2-
27. • .
(b) Child age less then 18 months to perform lumber
puncture.
(c) Unusual parental anxiety
• d-source of infection is unknown
32. 2-termination of seizures and prevention of
recurrence
disadvantageadvantageDose ,routeDrugs
hypotension,
respiratory depression
-If used within the
first 20 min of seizure
onset, termination
rates of seizures can
be as high as 70-85%
.
1-LONGER
DURATION
0.1mg/kg/IV UP TO
4 mg/dose repeat in 5
Min
0.15-0.2mg/kg IV up to
10mg/DOSE repeat in 5
min
0.2-0.5mg/kg PR up to
20mg/dose
1-benzodiazepine
A-lorazepam
B-diazepam
valium
38. 3-history
•detailed history should be taken to find out the
•1-cause of the fever,
•2-the relationship of the onset of fever to the seizure,
•3- the characteristics of fever including the peak temperature and
duration,
•4-The type of seizure (generalized or focal) and its duration should be
described to help differentiate between simple and complex febrile
seizures,
•5- duration of postictal drowsiness.10
•6-personal history of prior seizure
•7- whether the child was recently vaccinated, recent use of antibiotic
therapy is particularly important because partially treated meningitis
must be considered
•8-attended day care,
39. •9-potential exposures to infection, toxin
ingestion,
•10-CNS trauma,
•11-developmental milestones,
•12- and history of febrile and afebrile seizures in
other family members
41. General examination
A-vital signs: pulse, BP, RR,Temperature
B-Anthropometric measures: HC(canavan)
•C-Examination of the head: ant. fontanel ,skull shape hair pigmentation (in born
error of metabolism)
D-An erythematous bulging eardrum, a beefy red pharynx,
•E-enlarged and erythematous tonsils and
•F-eyes (including fundus examination)
•G-Abnormal facies(metabolic disorders)
42. •H-Skin abnormality(neurocutaneous diseases) exanthem may give clue to
the source of the fever.
•i-Search for evidence of trauma.
•J-Evidence of failure to thrive, particular body odour o
•Cardiac examination: Congenital heart diseas
43.
44. 3-INVESTIGATIONS
•A- Lab investigations:
•are not routinely recommended in the work-up of a child with a
first simple febrile seizure
1.CBC: in patients who looks like ill, suspect sepsis
2.Serum electrolytes (Na, Ca ,Mg):
A low sodium level is associated with higher risk of recurrence of
the febrile seizure within the following 24 hr.
45. B.lumbar puncture
•lumbar puncture should be performed for
•1- all infants younger than 12 mo of age who present with fever and
seizure, or if the child is ill appearing
.
•2-A lumbar puncture is an option in a child 6-12 mo of age who is
deficient in Haemophilus influenzae type b and Streptococcus
pneumoniae immunizations or for whom immunization status is
unknown.
•. 3-The procedure should also be considered in children who have the
seizure after the second day of fever, who have had prior antimicrobial
therapy,
•
•4-After complex features
•
•5-In children older than 6years febrile convulsions are rare and we must
investigate for CNS infections, electrolyte imbalance or other CNS
cause.
46. CONTRAINDICATIONS
A-ABSOLUTE
1-signs of ICP mostly infratentorial (papilledema, Signs of increased
intracrainal tension, or impending herniation as unequal pupils,
elevated blood pressure, slow heart rate, irregular breathing, focal
neurological deficit, papilledema, GCS <8/15
2-local skin infections
(3-Imaging show (midline shift, posterior fossa mass,
4-Cardiovascular or respiratory instability
B-RELATIVE
1-bleeding tendency (DIC,PLT < 50,000)
47. C-Electroencephalogram
A-role
A-If the child is presenting with the first simple febrile seizure and is otherwise neurologica
healthy, an EEG need not normally be performed as part of the evaluation.
B-An EEG would not predict the future recurrence of febrile seizures or epilepsy even if the
result is abnormal
C-- An EEG should, therefore, generally be restricted to special cases in which epilepsy is
highly suspected, and, generally, it should be used to delineate the type of epilepsy rather
than to predict its occurrence
D -At times, if 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 twilight
state
48. •B -when
A-Thus, in many cases, if an EEG is indicated, it is delayed until or
repeated after more than 2 wk have passed
B-If an EEG is done, it should be performed for at least
20 min in wakefulness and in sleep according to international
guidelines to avoid misinterpretation and drawing of erroneous
conclusions
49. •C -falasies
Spikes during drowsiness are often seen in children with febrile
seizures, particularly those older than age 4 yr, and these do not
predict later epilepsy.
EEGs performed within 2 wk of a febrile seizure often have
nonspecific slowing, usually posteriorly.
50. • D-Neuroimaging
• A CT or MRI is not recommended in evaluating the child after a first
• simple febrile seizure.
• indications;
• 1- complex febrile seizures
• 2-febrile status epilpticus
• 3-increased intracranial pressure,
• 4- focal neurologic abnormality,
• Results
• Approximately 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.
51. 4-control fever
• fever should be controlled for the comfort of the patient not to
reduce the FC as all researches proved that antipyretics have
no role in reduction of FC
• Reduction of fever is by antipyretics (paracetamol 15mg/kg) as
it is more effective and more acceptable to parents than
physical methods as sponging unwrapping, cold bathing, now
most researches don’t recommend physical methods in
reduction of temperature
52. On discharge
Patient Education
• 1-Parents should be counseled about the relative risks of
recurrence of febrile seizures and recurrence of epilepsy,
2- educated on how to handle a seizure acutely, and given
emotional support
•3- Parents should be counseled on the benign nature of febrile
seizures.
•4- Parents should be reassured that simple febrile seizures do
not lead to neurologic problems or developmental delay.
53. 10-prophylaxis
Given the relatively benign nature of most febrile seizures
the majority of children do not have recurrences, and the
significant adverse side effects associated with
anticonvulsants,
the current consensus is that ongoing prophylaxis with
anticonvulsants is not necessary for children with either
simple or complex febrile seizures
• Also, use of chronic antiepileptic therapy does not
reduce the risk of epilepsy
54. • Continuous or intermittent prophylaxis of febrile
seizure with anticonvulsants is indicated when
• 1-If 3 or more febrile seizures in 6months occurred.
• 2-6 or more in 1year.
• 3-Febrile seizure lasting more than 15minutes or requiring
pharmacologic therapy to control seizures.
• 4-If medical reassurance fails to relieve the anxiety of parents
55. • 1-intermittent prophylaxis
• Dose,duration;
• 1-intermittent oral diazepam (0.33 mg/kg every 8 hr during fever)
• 2-intermittent rectal diazepam (0.5 mg/kg administered as a rectal
suppository every 8 hr), can be given during febrile illnesses.
that it is started at the first sign of illness and for 2 days without fever,.
• .
56. • Side effects
• 1-However, some seizures occur before a fever is noticed,
rendering intermittent diazepam treatment impractical.
• 2- Adverse side effects of diazepam therapy include
lethargy, drowsiness, nausea, constipation, dry mouth,
slurred speech, ataxia, dizziness, headache, irritability,
hypotension, bradycardia, and respiratory depression.
57. 2-Continous prophylaxis:-
Indication;
1-if FC occurs at low grades or at early onset of fever
2-seizures lasting more than 5 min, febrile SE, and recurrent
seizures.
3-Failure of intermittent Rx
4-Recurrent atypical seizures
5-When parents are not able to promptly recognize the onset of
fever
.
.
58. What drug:
• A 2017 Cochrane systematic review showed that daily
administration of
• A - valproic acid (10–15 mg/kg/day in divided doses)
or
• B-phenobarbital (5–8 mg/kg/day for children <2 years
of age and 3–5 mg/kg/day for children >2 years of age
in divided doses) is effective in the prevention of
febrile seizures
• C-Other anticonvulsants such as phenytoin and
carbamazepine are ineffective in the prevention of
recurrent febrile seizures
59. • 3-Iron
•
• Iron deficiency is associated with an increased risk of
febrile seizures, and thus screening for that problem
and treating it appears appropriate.
• Iron is essential for the functioning of certain
neurotransmitters, such as monoamine oxidase and
aldehyde oxidase
60. 11-prognosis
• 1-Simple febrile seizures do not have an increased risk of mortality
• 2-. Complex febrile seizures may have an approximately 2-fold
• long-term increase in mortality, as compared to the general population,
over the subsequent 2 yr, probably secondary to coexisting pathology.
• 3- There are no long-term adverse effects of having 1 or more
• simple febrile seizures.
• 4- Compared with age-matched controls, patients
• with febrile seizures do not have any increase in the incidence of
• abnormalities of behavior, scholastic performance, neurocognitive
• function, or attention.
• 5-Typically, children outgrow the condition by 6 years of ag
• .
61. Risk of 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.
• MAJOR
• Age <1 yr
• Duration of fever <24 hr
• Fever 38-39°C (100.4-102.2°F)
• MINOR
• shorter interval (less than 1 hour) between the onset of fever and the initial seizure
• Family history of febrile seizures
• Family history of epilepsy
• Complex febrile seizure
• Daycare
• Male gender
• Lower serum sodium at time of presentation
• multiple episodes of febrile seizures
62. Children who develop later
epilepsy
• -Although approximately 15% of children with
epilepsy have had past history febrile seizures,
• only 2-7% of children who experience febrile
seizures proceed to develop epilepsy later in life
63. Risk Factors for Occurrence of
Subsequent Epilepsy After a febrile
fit Febrile
Seizure
Risk for subsequent epilpsyRisk factor
1%Simple febrile seizure
4%Recurrent febrile seizures
6%Complex febrile seizures (more
than 15 min duration or recurrent
within 24 hr)
11%Fever <1 hr before febrile seizure
18%Family history of epilepsy
29%Complex febrile seizures (focal)
33%Neurodevelopmental abnormalities
64. • Almost any type of epilepsy can be preceded by febrile
seizures, and a few epilepsy syndromes typically start with
febrile seizures.
• These are
1-generalized epilepsy with febrile seizures plus
(GEFS+),
2-myoclonic epilepsy of infancy (also called Dravet
syndrome),
3-temporal lobe epilepsy secondary to mesial
temporal sclerosis.
65. generalized epilepsy with febrile seizures
plus GEFS+
is an autosomal dominant syndrome with a highly variable
phenotype.
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.
A focal febrile seizures plus epilepsy variant, in which the
seizures are focal rather than generalized,has also been
described
66. severe myoclonic epilepsy of infancy (Dravet
syndrome),
Dravet syndrome is often considered part of the GEFS+
spectrum and is the most severe disorder in this group
.
It constitutes a distinct entity in the onset of which is in infancy
.
Its onset is characterized by febrile and afebrile unilateral clonic
seizures recurring every 1 or 2 mo
.
These early 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.
.
67. • .
• During the 2nd yr of life, myoclonus, atypical absences,
and partial seizures occur frequently and developmental
delay usually follows.
• This syndrome is usually caused by a de novo mutation,
although rarely it is inherited in an autosomal dominant
manner. The mutated gene is located on 2q24-31 and
encodes for SCN1A,(SODIUM CHANNEL N1 A) the same
gene mutated in GEFS+ spectrum
• .
68. • The majority of patients who had prolonged febrile seizures
and encephalopathy after vaccination and who had been
presumed to have suffered from vaccine encephalopathy
(seizures and psychomotor regression occurring after
vaccination and presumed to be caused by it) turn out to have
Dravet syndrome mutations, indicating that their disease is
caused by the mutation and not secondary to the vaccine.
• This has raised doubts about the very existence of the entity
termed vaccine encephalopathy.
