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Background

Febrile seizures are the most common type of seizures observed in the pediatric age group.
Although described by the ancient Greeks, it was not until this century that febrile seizures were
recognized as a distinct syndrome separate from epilepsy. n 1980, a consensus conference held by the
National nstitutes of Health described a febrile seizure as, "An event in infancy or childhood usually
occurring between three months and five years of age, associated with fever, but without evidence of
intracranial infection or defined cause."
[1]
t does not exclude children with prior neurological impairment
and neither provides specific temperature criteria nor defines a "seizure." Another definition from the
nternational League Against Epilepsy (LAE) is "a seizure occurring in childhood after 1 month of age
associated with a febrile illness not caused by an infection of the central nervous system (CNS), without
previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute
symptomatic seizures".
[2]

For other information, see Medscape's Pediatrics Specialty page.
PathophysioIogy
Febrile seizures occur in young children at a time in their development when the seizure threshold is low.
This is a time when young children are susceptible to frequent childhood infections such as upper
respiratory infection, otitis media, viral syndrome, and they respond with comparably higher temperatures.
Animal studies suggest a possible role of endogenous pyrogens, such as interleukin 1beta, that, by
increasing neuronal excitability, may link fever and seizure activity.
[3]
Preliminary studies in children
appear to support the hypothesis that the cytokine network is activated and may have a role in the
pathogenesis of febrile seizures, but the precise clinical and pathological significance of these
observations is not yet clear.
[4, 5]

Febrile seizures are divided into 2 types: simple febrile seizures (which are generalized, last < 15 min and
do not recur within 24 h) and complex febrile seizures (which are prolonged, recur more than once in 24
h, or are focal).
[6]
Complex febrile seizures may indicate a more serious disease process, such
as meningitis, abscess, or encephalitis.
Viral illnesses are the predominant cause of febrile seizures. Recent literature documented the presence
of human herpes simplex virus 6 (HHSV-6) as the etiologic agent in roseola in about 20% of a group of
patients presenting with their first febrile seizures. $0, gastroenteritis also has been associated with
febrile seizures. One study suggests a relationship between recurrent febrile seizures and influenza A.
[7, 8]

Febrile seizures tend to occur in families. n a child with febrile seizure, the risk of febrile seizure is 10%
for the sibling and almost 50% for the sibling if a parent has febrile seizures as well. Although clear
evidence exists for a genetic basis of febrile seizures, the mode of inheritance is unclear.
[9]

While polygenic inheritance is likely, a small number of families are identified with an autosomal dominant
pattern of inheritance of febrile seizures, leading to the description of a "febrile seizure susceptibility trait"
with an autosomal dominant pattern of inheritance with reduced penetrance. Although the exact
molecular mechanisms of febrile seizures are yet to be understood, underlying mutations have been
found in genes encoding the sodium channel and the gamma amino-butyric acid A receptor.
[10, 11, 12]

requency
United States
etween 2% and 5% of children have febrile seizures by their fifth birthday.
[13]

nternational
A similar rate of febrile seizures is found in Western Europe. The incidence elsewhere in the world varies
between 5% and 10% for ndia, 8.8% for Japan, 14% for Guam,
[14]
0.35% for Hong Kong, and 0.5-1.5% for
China.
[15]

ortaIity/orbidity
O Children with simple febrile seizures do not have increased mortality risk. However, seizures that were
complex, occurred before 1 year of age, or were triggered by a temperature < 39C were associated with
a 2-fold increased mortality rate during the first 2 years after seizure occurrence.
[16]

O Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general
population (2% vs 1%). Risk factors for epilepsy later in life include complex febrile seizure, family history
of epilepsy or neurologic abnormality, and developmental delay. Patients with 2 risk factors have up to a
10% chance of developing afebrile seizures.
[17, 18]

#ace
Febrile seizures occur in all races.
Sex
Some studies demonstrate a slight male predominance.
Age
y definition, febrile seizures occur in children aged 3 months to 5 years.
hLLp//emedlclnemedscapecom/arLlcle/801300overvlew#a0199
Criteria

1. age 6 months - 6 years
2. thought to be associated with initial rapid rise in temperature
3. no interictal neurologic abnormalities
4. no evidence of CNS infection/inflammation or acute systemic metabolic disorder
5. no history of non-febrile seizures
6. most common seizure type is generalized tonic-clonic; however may be any type
7. risk factors include
family history of febrile seizures (40% positive)
high fever
slow development of child

ENGN FERLE SEZURES ( Pediatrics )

o most common cause of seizure in children
o 3-5% of all children, M > F

Criteria

1. age 6 months - 6 years
2. thought to be associated with initial rapid rise in temperature
3. no interictal neurologic abnormalities
4. no evidence of CNS infection/inflammation or acute systemic metabolic disorder
5. no history of non-febrile seizures
6. most common seizure type is generalized tonic-clonic; however may be any type
7. risk factors include
family history of febrile seizures (40% positive)
high fever
slow development of child

Simple Febrile Seizure

1. duration < 15 minutes (95% < 5 minutes)
2. generalized, symmetric
3. does not recur in a 24 hour period

Atypical Febrile Seizure

1. focal origin
2. > 15 minute duration, multiple (> 1 in 24 hours)
3. followed by transient neurologic deficit

Risk Factors for Recurrence

1. 33% chance of recurrence
2. age of onset < 1 year
50% chance of recurrence if < 1 year
28% chance of recurrence if > 1 year
3. risk of epilepsy is < 5%; risk factors include abnormal development of child previous to
seizures, family history of afebrile seizures and a complex initial seizure

Workup

1. history: determine focus of fever, description of seizure, meds, trauma history,
development, family history
2. exam: LOC, signs of meningitis, neurologic exam
3. R/O meningitis do LP if signs and symptoms of meningitis
4. EEG not warranted unless atypical febrile seizure or abnormal neurologic findings
5. investigations unnecessary except for determining focus of fever
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Seizure symptoms: how to assist the victim
Seizures occur because the brain becomes irritated and an "electrical storm" occurs. This "electrical
storm" occurs because the normal connections between the cells in the brain do not function
properly. This causes the brain to try to shut down because of the electrical surge. The muscle
shaking occurs because the brain is ending out signals to every muscle group, asking them to
contract. Most seizures are self-limiting and are followed by a so-called postictal period, in which the
brain can be considered to "reboot and restart" all its programs, similar to a computer when it is
rebooted.
Seizures are a common event, and 4% of people will experience one in their lifetime. The potential
to have a seizure depends upon the threshold of the brain to withstand excess electrical activity. n
infants and children, high fevers can cause this threshold to lower, resulting in febrile seizures. A
blow to the head can cause an electrical spike causing a seizure, and sometimes seizures just
happen.
The patient needs evaluation to look for the reason for the seizure. s there an infection? Are there
electrolyte abnormalities in the blood? s there a structural problem in the brain? Often there is no
obvious reason why the first seizure occurred, and CT or MR scans of the brain as well as an EEG
(electroencephalogram) may be ordered to look for a cause.
Most people get a "freebie" seizure before requiring medication (medication should not necessarily
be prescribed for every person who has had one seizure), but that doesn't mean that the event
should be ignored. The chance of having another seizure sometime in the future is approximately
20%, and that is the reason why it is required that people need to be seizure free for 3-6 months
before being allowed to drive a vehicle (the required time varies between states), scuba dive, sky
dive, or participate in other potentially risky situations in which a seizure could put the individual or
others in danger.
Generalized seizures are frightening to witness. There is loss of consciousness; the body stiffens,
arches, and may shake; and grunting sounds may be heard. ut most seizures stop themselves and
the role of the Good Samaritan, bystander, friend, or family is to protect the individual from
themselves.
Steps to take if you witness an individual having a seizure include:
O The first step is to take a deep breath and try to stay calm.
O Make certain that there is nothing nearby that can be struck by the person having the seizure.
O Don't hold the person down. A seizure is a violent and forceful event, and bystander injury is a
possibility.
O Do not put anything in the victim's mouth. A person who is seizing can't swallow their tongue and
usually are breathing adequately. Forcing open the jaw can break teeth or get fingers bitten.
O f the individual's seizure lasts more than 3-5 minutes, call 911 immediately.
O After the seizure stops, lay the person on their side and stay with them until they are awake or
until medical assistance arrives.
on what are febriIe seizures?
The foIIowing information has been provided with the kind permission of the
Febrile seizures are convulsions brought on by a fever in infants or small children.
ow common are febriIe seizures?
Approximately one in every 25 children will have at least one febrile seizure, and more than one-third
of these children will have additional febrile seizures before they outgrow the tendency to have them.
Febrile seizures usually occur in children between the ages of 6 months and 5 years and are
particularly common in toddlers. Children rarely develop their first febrile seizure before the age of 6
months or after 3 years of age. The older a child is when the first febrile seizure occurs, the less
likely that child is to have more.
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hat are the symptoms of a febriIe seizure?
During a febrile seizure, a child often loses consciousness and shakes, moving limbs on both sides
of the body. Less commonly, 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. Most febrile seizures last a minute or
two, although some can be as brief as a few seconds while others last for more than 15 minutes.
The majority of children with febrile seizures have rectal temperatures greater than 102 degrees F.
Most febrile seizures occur during the first day of a child's fever. Children prone to febrile seizures
are not considered to haveepilepsy, since epilepsy is characterized by recurrent seizures that are
not triggered by fever.
hat makes a chiId prone to recurrent febriIe seizures?
A few factors appear to boost a child's risk of having recurrent febrile seizures, including young age
(less than 15 months) during the first seizure, frequent fevers, and having immediate family
members with a history of febrile seizures. f the seizure occurs soon after a fever has begun or
when the temperature is relatively low, the risk of recurrence is higher. A long initial febrile seizure
does not substantially boost the risk of recurrent febrile seizures, either brief or long.
Are febriIe seizures harmfuI?
Although they can be frightening to parents, the vast majority of febrile seizures are harmless.
During a seizure, there is a small chance that the child may be injured by falling or may choke from
food or saliva in the mouth. Using proper first aid for seizures can help avoid these hazards (see
section entitled "What should be done for a child having a febrile seizure?").
There is no evidence that febrile seizures cause brain damage. Large studies have found that
children with febrile seizures have normal school achievement and perform as well on intellectual
tests as their siblings who don't have seizures. Even in the rare instances of very prolonged seizures
(more than 1 hour), most children recover completely.
etween 95 and 98 percent of children who have experienced febrile seizures do not go on to
develop epilepsy. However, although the absolute risk remains very small, certain children who have
febrile seizures face an increased risk of developing epilepsy. These children include those who
have febrile seizures that are lengthy, that affect only part of the body, or that recur within 24 hours,
and children with cerebral palsy, delayed development, or other neurological abnormalities. Among
children who don't have any of these risk factors, only one in 100 develops epilepsy after a febrile
seizure.
hat shouId be done for a chiId having a febriIe seizure?
Parents and caregivers should stay calm and carefully observe the child. To prevent accidental
injury, the child should be placed on a protected surface such as the floor or ground. The child
should not be held or restrained during a convulsion. To prevent choking, the child should be placed
on his or her side or stomach. When possible, the parent should gently remove all objects in the
child's mouth. The parent should never place anything in the child's mouth during a convulsion.
Objects placed in the mouth can be broken and obstruct the child's airway. f the seizure lasts longer
than 10 minutes, the child should be taken immediately to the nearest medical facility. Once the
seizure has ended, the child should be taken to his or her doctor to check for the source of the fever.
This is especially urgent if the child shows symptoms of stiff neck, extreme lethargy, or
abundant vomiting.
ow are febriIe seizures diagnosed and treated?
efore diagnosing febrile seizures in infants and children, doctors sometimes perform tests to be
sure that seizures are not caused by something other than simply the fever itself. For example, if a
doctor suspects the child has meningitis (an infection of the membranes surrounding the brain), a
spinal tap may be needed to check for signs of the infection in the cerebrospinal fluid (fluid that
bathes the brain and spinal cord). f there has been severe diarrhea or vomiting, dehydration could
be responsible for seizures. Also, doctors often perform other tests such as examining the blood and
urine to pinpoint the cause of the child's fever.
A child who has a febrile seizure usually doesn't need to be hospitalized. f the seizure is prolonged
or is accompanied by a serious infection, or if the source of the infection cannot be determined, a
doctor may recommend that the child be hospitalized for observation.
ow are febriIe seizures prevented?
f a child has a fever most parents will use fever-lowering drugs such
as acetaminophenor ibuprofen to make the child more comfortable, although there are no studies
that prove that this will reduce the risk of a seizure. One preventive measure would be to try to
reduce the number of febrile illnesses, although this is often not a practical possibility.
Prolonged daily use of oral anticonvulsants, such as phenobarbital or valproate, to prevent febrile
seizures is usually not recommended because of their potential for side effects and questionable
effectiveness for preventing such seizures.
Children especially prone to febrile seizures may be treated with the drug diazepam orally or rectally,
whenever they have a fever. The majority of children with febrile seizures do not need to be treated
with medication, but in some cases a doctor may decide that medicine given only while the child has
a fever may be the best alternative. This medication may lower the risk of having another febrile
seizure. t is usually well tolerated, although it occasionally can cause drowsiness, a lack of
coordination, or hyperactivity. Children vary widely in their susceptibility to such side effects.
hat research is being done on febriIe seizures?
The National nstitute of Neurological Disorders and Stroke (NNDS), a part of the National nstitutes
of Health (NH), sponsors research on all forms of febrile seizures in medical centers throughout the
country. NNDS-supported scientists are exploring what environmental and genetic risk factors make
children susceptible to febrile seizures. Some studies suggest that women who smoke or drink
alcohol during their pregnancies are more likely to have children with febrile seizures, but more
research needs to be done before this link can be clearly established. Scientists are also working to
pinpoint factors that can help predict which children are likely to have recurrent or long-lasting febrile
seizures.
nvestigators continue to monitor the long-term impact that febrile seizures might have on
intelligence, behavior, school achievement, and the development of epilepsy. For example, scientists
conducting studies in animals are assessing the effects of seizures and anticonvulsant drugs on
brain development.
nvestigators also continue to explore which drugs can effectively treat or prevent febrile seizures
and to check for side effects of these medicines.