Indian J Pediatr (February 2013) 80(2):149150

DOI 10.1007/s12098-012-0843-4

COMMENTARY

Rational Approach to Management of Febrile Seizures

Siba Prosad Paul & Ravindranath Chinthapalli

Received: 23 March 2012 / Accepted: 20 June 2012 / Published online: 6 July 2012
# Dr. K C Chaudhuri Foundation 2012

Febrile seizure (FS) is an event (i.e., seizure) in children

aged between 6 mo and 6 y associated with a fever, but
without evidence of any intracranial infection or metabolic
disturbance [13]. FS has been described centuries ago as is
evident from the work of Thomas Willis (1684) entitled Of
Convulsive Diseases [4]. The peak age for onset of FS is
18 mo; it occurs in 2 to 5% of children but more frequently
in the Asian race [3]. FS occurs in up to 10% of children of
Indian origin [5].
The exact cause of FS remains unknown. It is considered
to be multi-factorial; both genetic and environmental factors
are thought to contribute to its pathogenesis. The inheritance
is likely to be polygenic. There are a small number of
families where an autosomal-dominant pattern of inheritance has been identified and is referred to as febrile seizure
susceptibility trait. The molecular mechanism of FS needs
further understanding; however, the underlying mutations
have been found in genes encoding the sodium channel and
the gamma-aminobutyric acid A receptors. These receptors
have also been associated with another epilepsy syndrome
seen in early infancy viz., Severe Myoclonic Epilepsy of
Infancy which initially presents with prolonged fever and
subsequent seizures are precipitated by fever [5].
A child presenting with FS needs emergency stabilization
with ABC (airway, breathing, circulation) approach. It is
important to check blood glucose after the first FS [2, 6].
Further management decisions will depend on the type:
simple or complex FS [6]. Complex FS usually lasts
15 min and are characterized by multiple episodes of
seizures during the same illness, focal seizures, not
S. P. Paul (*) : R. Chinthapalli
Department of Pediatrics, Great Western Hospital,
Marlborough Road,
Swindon SN3 6BB, UK
e-mail: siba@doctors.org.uk

regaining full consciousness within 1 h and may have features of Todds paresis [2, 6].
In a fully immunized child with simple FS, investigations
such as blood tests, lumbar puncture and neuroimaging or
EEG may not be necessary [2, 6]. The first episode of FS,
especially in children <1 y of age requires a cautious
approach and it needs to be differentiated from acute symptomatic seizures due to risk of CNS infection [4]. Children
with focal FS should be considered for non-urgent MRI scan
and EEG as this may be the first sign of an epilepsy disorder.
Once a diagnosis of FS is established in a child, a further
episode of FS does not need repeat investigations.
Children with simple FS have excellent prognosis. Onethird of children with FS will have further episodes of FS
during subsequent illnesses. The risk factors for recurrence
of FS include first episode at <18 mo of age, lower body
temperature (38C) during seizure, shorter duration of
fever (<1 h) before the onset of FS and a strong family
history for FS [6].
The parents and to a certain extent the health professionals can understandably be anxious to prevent another episode of FS [2, 6]. This may necessitate the consideration for
prophylactic therapies. Vast majority of children do not need
or benefit from prophylactic anticonvulsants and is rarely
used in the UK practice [5].
The decision to initiate any prophylactic therapy should
be discussed in details with the parents and any benefit
should be weighed against the potential risk. Following
circumstances may need consideration for prophylactic anticonvulsant therapies [2, 4, 7]:
&
&
&

Frequent FS over short period of time (3 FS in 6 mo)

FS lasting >15 min or required anticonvulsant therapy to
stop the seizure
Child living in an area geographically isolated from
immediate medical access

150

Intermittent therapy during FS episodes with benzodiazepines such as rectal diazepam, clobazam or buccal midazolam has been found to be effective in arresting an
episode of FS [2, 4, 8]. However, buccal midazolam has
less sedative effect and causes less respiratory depression
but has similar efficacy. It is better accepted socially in the
community [8]. Oral phenobarbitone during febrile episodes
has not been found to be effective in arresting an episode of
FS [4].
Antipyretic therapy has not been found to be effective in
preventing FS [1, 36]. Parents need to be explained that
giving antipyretics either acutely or regularly during a
febrile episode does not reduce the risk for recurrence of
FS; the only rationale for its use is to make the child more
comfortable [1, 4]. Vigorous attempts to reduce fever, therefore, should not be recommended by the physicians.
Long term prophylaxis for FS with anticonvulsant therapy
is best being avoided. However, children with febrile status
epilepticus, complex or recurrent FS (>6 episodes of FS/year
in spite of use of intermittent abortive therapy) may be
considered for long term anticonvulsant therapy [2].
The two useful drugs are sodium valproate and phenobarbitone [24, 6]. Studies have shown that sodium valproate is better in controlling further FS and the side
effects are found to be less when compared to phenobarbitone; therefore, it may be preferred where long term therapy
is considered [4, 9, 10]. The duration of anticonvulsant
therapy remains controversial. Some authorities suggest that
it should be continued for 2 y after the last episode of FS
while others feel it should be continued till child is 6 y of
age when they are likely to grow out of this condition [11].
Close monitoring is necessary for children on long
term prophylactic anticonvulsant therapy and parents
should be made aware of the potential side effects. These
may include behavioral and subtle cognitive difficulties,
increase in appetite and problems with hepatic, hemopoetic and bone marrow changes.
FS are common in the pediatric practice with an excellent
prognosis. The role of prophylactic anticonvulsant therapy
should be carefully judged for each child. The intended
benefits and potential side effects should be weighed and

Indian J Pediatr (February 2013) 80(2):149150

clearly explained to the parents. Regular use of antipyretics

during a febrile episode does not prevent FS. Long term
anticonvulsant therapy may occasionally be necessary in a
few children with FS.

Conflict of Interest None.

Role of Funding Source

None.

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