8/29/2011

Objectives

Review the diagnosis and management
of Febrile Seizures
Madeleine Grace M. Sosa, MD., FPPS, FPNA,FCNSP, MSCE
Faculty & Consultant De La Salle Health Science Institute ,
College of Medicine, Dasmarinas, Cavite

To give an update in the preventive and

therapeutic management of children
with Febrile Seizures

Vignette

Febrile Seizures

2 month old male, came in at the ER for convulsions.

HPI: Child was having on and off fever, about 38 deg
cent since 8 hours PTC, described as generalized, with
tonic movements of both UE and LE for 5 mins, with
drooling of saliva, thus rushed to the ER. He was
having URTI and fair appetite since onset of fever.

PE: T: 39C RR:34/min HR: 97/min BP: 80/60

Heart, Lungs, Abdomen, extremities : Unremarkable

Neuro: irritable, with equivocal neck rigidity

An event in infancy or childhood, usually occurring

between 3 months and 5 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 non-febrile seizure are excluded.

Febrile seizures are to be distinguished from epilepsy,
which is characterized by recurrent non-febrile
seizures.
Rev Assoc Med Bras 2010; 56(4): 489-92

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Febrile Seizures

Vignette

Febrile seizures have defined by The International

League Against Epilepsy (ILAE) 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 criteria for other acute symptomatic seizures

2 month old male, came in at the ER for convulsions.

HPI: Child was having on and off fever, about 38 deg
cent since 8 hours PTC, described as generalized, with
tonic movements of both UE and LE for 5 mins, with
drooling of saliva, thus rushed to the ER. He was
having URTI for 3 days and fair appetite since onset of
fever.

PE: T: 39C RR:34/min HR: 97/min

BP: 80/60

Heart, Lungs, Abdomen, extremities : Unremarkable

Neuro: irritable, with equivocal neck rigidity

Febrile Seizures
Symptoms
Duration
Recurrence in first 24 hours
Focal signs in post-ictal
period

Simple

Complex

Generalized
<15 minutes
No recurrence
Absent

Focal
>15 minutes
May recur
Present

While the majority of febrile seizures are simple (7075%)

9-35% of febrile seizures are complex

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Epidemiology

Epidemiology

Incidence , worldwide : 114% (Hauser,1994).

Febrile seizures recur in approximately 30% of
patients, most commonly between the ages of six
months and three years.

Why should rise in

temperatures cause seizure?

Children who have had febrile seizures also have

increased odds of developing epilepsy (2% to 7%) than
the general population

Risk Factors

early age at first seizure

Hyperthermia (>38.3C) can

decrease gamma aminobutyric
acid A (GABA(A) receptormediated inhibition to a greater
extent than it decreases
excitation, which may shift the
balance towards excitation and
contribute to seizure generation

This appears to be mediated by

reducing GABA release from presynaptic terminals, but
hyperthermia may also decrease
post-synaptic GABA(A) receptor
function

While this phenomenon has only

been studied in hyperthermic
models, it also likely occurs when
temperature is increased from
physiologic fever

family history of febrile seizures, temperature

(inversely proportional to grade),

duration of febrile illness (the shorter the febrile
period)

presence of prior neurological abnormalities and a

history complex febrile seizures

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Risk Factors

Risk Factors

The risk of initial febrile seizures has also been studied

after receipt of pediatric vaccinations such as
diphtheria-tetanus-whole cell pertussis (DTP) and
Measles, Mumps and Rubella (MMR)

Studies by Barlow and associates (2001) and Walker

and colleagues (1988) found a 4-fold increase in

therisk of febrile seizures within 1-3 days of receipt of
DTP vaccination.

With regard to MMR vaccination, the risk of febrile

seizures increases by 1.5 and 3.0 fold, with the peak
occurring 1-2 weeks after vaccination an additional 2534 febrile seizures have been estimated to occur per
100,000 doses of MMR administered

Int. J. Med. Sci. 2007, 4

Int. J. Med. Sci. 2007, 4

Risk factors of the first febrile seizures in Iranian

children. Mahyar A, Ayazi P, Fallahi M, Javadi A.Int J
Pediatrics 2010

Source: Int J pediatrics2010;2010:862897. Epub 2010 Jun 24

Department of Pediatrics, Quds Children Hospital, Qazvin University of Medical

Sciences, Quds Square, Qazvin 34159-1-4595, Iran.

Abstract

Objective. Febrile seizures are the most common type of convulsion in children. The

identification of influencing factors on incidence of the first febrile seizures is of prime

priority. The aim of this study was to identify the risk factors of the first febrile seizures in
Iranian children.

Methods. In this case-control study 80 children aged 9 month to 5 years with their first
febrile seizures were compared with 80 children with fever without seizure based on
different risk factors in 2007.

Results. There was significant difference between two groups regarding the
gender, family history of febrile seizures, breast-feeding duration, and the body
temperature (P < .05).

Conclusion. Our study showed that factors including the gender, family history of febrile
seizures, breast-feeding duration, and the body temperature are among the risk factors in
occurrence of the first febrile seizure. Preventive measures to remove such risk factors
could lead to lower the incidence of febrile seizures.

Predictors of recurrent febrile seizures include:

a history of focal, prolonged, and multiple seizures

Influenza A viral infection

family history of febrile seizures

onset of febrile seizure <12 months of age

temperature <40C (<104 F) at time of seizure

and a history of complex, initial febrile seizures

A low proportion (2-4%) of children who experience at

least one febrile seizure event go on to develop recurrent
afebrile seizures (epilepsy)
Int. J. Med. Sci. 2007, 4

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Role of Genetics in the Pathogenesis

Genetic aspects have been clearly established in the
etiology and pathogenesis of febrile seizures. A history
of febrile seizures in first-degree relatives is common,
and concordance rates of febrile seizures are much
higher in monozygotic than in dizygotic twin pairs

Reports in the literature have described a connection
between febrile seizures and various chromosomes,
including 2q, 5q, 5, 8q, and 19, which appear to be
associated with changes in neuronal sodium channel
function.

Febrile Seizure Evaluation

CNSP Recommedation
Are these tests necessary?

Lumbar Puncture

Practice guidelines have recommended

that lumbar punctures be strongly considered in
children experiencing their first simple febrile seizure,
particularly if < 18 months of age

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Febrile Seizure Evaluation

CNSP Recommendation

EEG

Febrile Seizure Evaluation

CNSP Recommendation

Neuroimaging - does not have any role for FS

CNSP Guidelines used for complex type of FS

Antipyretic for Febrile Seizures

Antipyretic Agents for Preventing Recurrences of Febrile Seizures

Is it necessary to give RTC Antipyretics to

children with febrile seizures?

Randomized Controlled Trial ; Teemu Strengell, MD et alo

Objective: To evaluate the efficacy of different antipyretic
agents and their highest recommended doses for preventing febrile
seizures.

Participants: A total of 231 children who experienced their first
febrile seizure between January 1, 1997, and December 31, 2003. The
children were observed for 2 years.

Interventions: All febrile episodes during follow-up were
treated first with either rectal diclofenac or placebo. After 8 hours,
treatment was continued with oral ibuprofen, acetaminophen, or
placebo

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Antipyretic Agents for Preventing Recurrences of

Febrile Seizures Randomized Controlled Trial ; Teemu
Strengell, MD et al

Results: The children experienced 851 febrile episodes, and

Antipyretic Agents for Preventing Recurrences of

Febrile Seizures Randomized Controlled Trial ; Teemu
Strengell, MD et al

89 of these included a febrile seizure.

Febrile seizure recurrences occurred in 54 of the 231 children

(23.4%).

There were no significant differences between the groups in the
main measure of effect, and the effect estimates were similar, as
the rate was 23.4% (46 of 197) in those receiving antipyretic
agents and 23.5% (8 of 34) in those receiving placebo (difference,
0.2; 95% confidence interval, 12.8 to 17.6; P=.99).

Fever was significantly higher during the episodes with seizure
than in those without seizure (39.7C vs 38.9C; difference,
0.7C;95%confidence interval, 0.9C to 0.6C; P.001), and this
phenomenon was independent of the medication given.

Conclusions: Antipyretic agents are ineffective for

the prevention of recurrences of febrile seizures and
for the lowering of body temperature in patients with a
febrile episode that leads to a recurrent febrile seizure

Antipyretic agents act mainly by the alteration of

prostaglandin synthesis.

It has been found in animal studies that some
prostaglandins inhibit seizures (eg, prostaglandins D2,
E1, and E2) and that some provoke seizures (eg,
prostaglandin F2).

Elevated levels of prostaglandins E2 and F2 in the
cerebrospinal fluid have been found to be associated
withfebrile seizures.

Because antipyretic agents have different effects on
prostaglandin synthesis, it may be that some would, in
fact, provoke seizures

Is it necessary to give anticonvulsants to prevent

recurrence of FS after the first febrile seizures?

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INTERMITTENT DIAZEPAM AND CONTINUOUS PHENOBARBITAL TO TREAT

RECURRENCE OF FEBRILE SEIZURES. A systematic review with meta-analysis
Arq Neuropsiquiatr 2003;61(4):897-901

According to Nelson and Ellenberg, 50% of children

experience a second febrile seizure within six months
of the first, 75% within a year and 90% within two
years of the first episode.

ABSTRACT - Convulsions triggered by fever are the most common type of

INTERMITTENT DIAZEPAM AND CONTINUOUS PHENOBARBITAL TO TREAT

RECURRENCE OF FEBRILE SEIZURES. A systematic review with meta-analysis
Arq Neuropsiquiatr 2003;61(4):897-901

seizures in childhood, and 20% to 30% of them have recurrence. The

prophylactic treatment is still controversial, so we performed a systematic
review to find out the effectiveness of continuous phenobarbital and
intermittent diazepam compared to placebo for febrile seizure recurrence.
Method: Only randomized, double-blind, placebo-controlled trials were
analyzed. The recurrence of febrile seizure was assessed for each drug.
Results: Ten eligible clinical trials were included. Febrile seizure recurrence was
smaller in children treated with diazepam or phenobarbital than in placebo
group. Prophylaxis with either phenobarbital or diazepam reduces recurrences
of febrile seizures. The studies were clinical, methodological, and statistically
heterogeneous.
Conclusion: The effectiveness of phenobarbital and diazepam could not be
demonstrated because clinical trials were heterogeneous, and the
recommendation for treatment recurrence should rely upon the experience of
the assistant physician yet.

Febrile Seizure Information & Education

What is Febrile
Seizure?

The link between fever

and
febrile seizures (FS) in
children.

What may happen to

the
child during the febrile
seizure?

Febrile seizures are convulsions brought on by a fever in infants or small children. Most febrile seizures
occur within the first 24 hours of an illness/fever.
Febrile seizures may last from a few seconds
to more than 15 minutes.

Febrile Seizures occur in 3% -5 % of otherwise healthy children 6-60 months of age.

It is debated by experts whether it is the quickness of the rise in temperature or the height of the temperature
which triggers the seizure.
The seizure is often the first sign of a fever.

During a febrile seizure, a child may lose consciousness or responsiveness, shake and move limbs on
both sides of the body.
The child becomes rigid or has twitches in only a portion of the body, such as an arm or a leg, or on the right or
the left side only.
The child may vomit or pass urine.

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Febrile Seizure Information & Education

What measure(s)
should be
taken or avoided
during the
febrile seizure event

Do stay calm. Focus your attention on bringing the fever down. Insert rectal acetaminophen (Tylenol)
(if available). Apply cool washcloths to the forehead and neck. Sponge the rest of the body with
lukewarm (not cold) water. Loosen any restrictive clothing.
Dont try to hold or restrain the child or stop the seizure movements. Don't try to force anything into
his mouth to prevent him from biting his tongue as this increases the risk of injury. Move the child
only if in a dangerous situation. Remove any objects that may injure him.

When to consult a
healthcare
provider, when to call
911
and when take the
child directly
to an ER

1. Children should consult a healthcare provider as soon as possible after the first febrile seizure.
2. Call 911 if the seizure lasts more than a few minutes.
3. Contact a healthcare provider or go to the ER if any other symptoms occur before or after the seizure:
nausea, vomiting, rash, tremors, abnormal movements, problems with coordination, drowsiness, agitation,
confusion, sedation, etc.

Blood and urine tests may be examined to detect infections. Typically, a full seizure workup including an EEG, head CT,
What does not
happen to the
childs brain during a
febrile
seizure?

The likelihood of
reoccurrence

There is no evidence that simple febrile seizures (<10 minutes) cause death, brain damage, epilepsy,
mental retardation, a decrease in IQ, or learning difficulties.

A third of children will have another febrile seizure with a subsequent fever.
Of those who do, about will have a 3rd seizure. If there is a family history, if the first seizure happened before 12
months of age, or if the seizure happened with a fever below 102, a child is more likely to have >1 febrile seizures.

What may occur

during the
healthcare
providers
evaluation
and/or testing of the
child

What are the

possible sequelae
of febrile seizures?

and lumbar puncture (spinal tap ) is not warranted

Injuries caused by falling or bumping into objects.

Biting oneself
Pneumonia secondary to fluid aspiration.
Injury from prolonged or complicated seizures.

Febrile Seizures Information & Education

What are the
possible sequelae
of febrile seizures?

Medication side effects related to the treatment and prevention of seizures (if prescribed).
Complications if a serious infection, such as meningitis caused the fever.
Seizures unrelated to fever (afebrile seizures)
Parental perception of increased child vulnerability to medical or developmental problems.

The list of epilepsy medications used depends on clinical plan devised

What treatments
may be
prescribed

Summary

Childhood febrile seizures, although primarily benign, can be frightening and anxiety-provoking
events for parents and caregivers. It is important that health care providers understand potential
parental misconceptions, anxieties and fears about fever and febrile seizures so that they may
allay those fears effectively.