febrile seizures in children latest information about approach to febrile seizures in children

1. FEBRILE SEIZURES -REVISITED
Presented by – Dr Gururaja R
MD,DNB(Paed)

2. Introduction
• Most common seizure in children below 5 yrs
• Diagnosis may pose dilemma
• Benign?
• Epilepsy?
• CNS infection?
• Spectrum – from Benign to Dravet syndrome and GEFS+
• Detailed knowledge of febrile seizures essential to all
pediatricians
• Majority of febrile seizures are benign with excellent
prognosis

3. Febrile Seizures- Background
• Commonest type of
seizure disorder
observed in pediatric
age group
• One of the commonest
causes of pediatric
emergency visits
worldwide

4. IS THIS SEIZURE IS SIMPLE FEBRILE
SEIZURE OR DUE TO ANY OTHER
SERIOUS CAUSE?

5. Febrile Seizures- Background
• Generally have a good
prognosis
• Sometimes may also indicate
acute CNS –Infection
• Admission ----to ---- discharge
• So many questions by anxious
paretns
• Detailed knowledge of febrile
seizures is essential for all
pediatricians

6. Febrile Seizures- Background
some Historical aspects
• First described by Greeks
• Thought be some form of
epilepsy before 1980
• 1980 – consensus
conference held by NIH –
(National institute of
health)---defined FEBRILE
SEIZURES which is
currently accepted

7. Febrile Seizures- Background
some Historical aspects
• Some definitions given
by NIH – not accepted
• Rectal temp 38 degree
Celsius
• Did not specify the
neurological status of
child

8. Febrile Seizures- Present Definition
• Seizure accompanied by fever
• 6 months to 5 yrs of age
• Peak age 18 months
• In the absence of acute
intracranial infection or
defined cause of a metabolic
disturbance or previous
afebrile seizure
• Only neurologically normal
children included in defn of
febrile seizure

9. • Febrile seizures are not
epilepsy
• Provoked seizures -
fever
• Epileptic children are
prone to seizures during
fever

10. • NO SPECIFIC LEVEL OF
DEGREE OF FEVER IS
REQUIRED TO
DIAGNOSE FEBRILE
SEIZURES

11. CLASSIFICATION

12. Simple febrile seizure
• Generalizes seizures at onset
• <15 minutes
• Single episode during single
illness
• Most common 70-80%
• Early in course of illness
• 90% viral infection- cause of fever
• Short post ictal period --- Normal
behaviour

13. Complex febrile seizures
• Partial onset
• Prolonged duration
• >15 minutes
• Multiple episodes during
single illness
• 15-20%
• May indicate serious disease
process- CNS Inf

14. Febrile status
• Febrile seizures >30 minutes
• One long lasting seizure
• Or series of short seizures
without regaining
consciousness interictally
• Seen in 5% patients
• 25% of all childhood status
epilepticus
•

15. Spectrum of febrile seizures
• Simple
• Complex
• Febrile status
• Late age presentation
• GEFS+
• Dravet syndrome
• Temporal epilepsy

16. • In past two decades
discussion on febrile
seizures has moved on from
their natural history to their
treatment
• Now we recognize majority
of febrile seizures are
Benign in nature
• Aim of ideal management is
Parental reassurance

17. Basic knowledge required for rational
parental advice
• Epidemiology
• Causes
• Recurrence
• Prognosis

18. Epidemiology
• 3-5% OF CHILDREN
• Peak age of onset 14 -18 months
• Recurrence rate – 33-50%
• More recurrence rate if first
episode <12 months, seizure at
low grade and family H/O febrile
seizures
• Febrile Seizure and subsequent
cause of temporal lobe epilepsy –
cause and effect relationship
uncertain

19. Epidemiology
• Male > female
• Higher incidence of
epilepsy when
compared to general
population - - 2% v/s 1%
• Remission of febrile
seizures by 5 yrs of age

20. Pathophysiology
• Unclear etiology
• Age specific susceptibility to
low seizure threshold by
fever
• Rate of rise of temperature
• Nature of illness –
URTI,Diarrhoea,UTI
• Hypothalamic
dysregulatuon
• HHV6-HHV7 Virus infection
• Shigella gastroenteritis
• Following vaccination (?)

21. Pathophysiology
• Hyper excitability induced by fever
• Very Strong Genetic predisposition
• Family history
• Channelopathies affecting sodium channels
and GABA receptor genes
• FEB1 and FEB2 - Chromosome 8 and 19p
• Chromosome 2,19q and 5 involve GEFS Plus
• Autosomal dominant
• Variable penetrance
• polygenic

22. Genetics
• Play clear major role
• Family history
• Concordance rate of 56%
in monozygotic twins
• 14% in dizygotic twins
• Multifactorial mode of
inhritance
• Subset of pts – autosomal
dominant inheritance
• Gene on chromosome
8and 19 linked

23. Approach to child with Febrile seizures
• Once diagnosis is sure
of febrile seizure
• RULE OUT CNS INF
• FIRST EPISODE
• Delay in diagnosis of
CNS INF – Long term
neurological
disability/death

24. Approach to child with Febrile seizures
• Look for cause of fever
• Control seizure
• Reduction of body temp/fever
• Common causes of fever –
VIRAL URTI/LRTI/Otitis
media/acute
GE/Pneumonia/UTI/Malaria/E
nteric
• Head injury Hx
• Seizure semiolgy
• Treatment Hx – antibiotics
• Past Hx of seizures
• Developmental milestones
• Family Hx of seizures

25. Approach to child with Febrile seizures
• Clinical exmn
• ABC(C-A-B)
• Vitals
• Signs of CNS INF and
raised ICT
• Detailed GPE and
Systemic exmn
• Look for focal
neurological deficits
• Serial monitoring of
patients neurological
status -IMPORTANT

26. Investigations
• Investigate for common
causes of fever
• Do RBS, Serum
electrolytes (sodium,
calcium and
magnesium)
• LUMBAR PUNCTURE

27. Febrile seizures – requirement of
Lumbar puncture?
• Children <12 months of age
• Age b/w 12- 18 months
Require careful evaluation
• In young infants typical signs of
meningitis may be subtle
• Children with first episode of
complex febrile seizures
• Children with febrile seizures who
received antibiotics – LP????

28. EEG and Neuroimaging
• Not required routinely
• Abnormal spike wave
patterns indicate
genetic nature
• EEG should be done if
fever triggered epilepsy
or risk factors for
epilepsy are present
• Routine neuroimaging
not required

29. EEG and Neuroimaging
• Considered in complex
febrile seizures
• In children with
neurological disability
and developmental
delay

30. Treatment
• Febrile seizures are benign
• Focus is to abort seizures, control
Fever and prevent status epilepticus
• Hospital setting – child with seizures--
--- diazepam -0.3-0.5 mg/kg rectally
• Lorazepam – 0.1 mg/kg i.v
• Midazoalm – 0.1 mg/kg i.v
• Midazolam – nasal – as puff both
nostrils
• Dose - 0.2 mg/kg
• Each spray – 0.5 mg
• If seizures continues – status
epilepticus protocol

31. Antipyretics
• Paracetamol – 15 mg/kg/dose
• Ibufrofen 5mg/kg/dose
• Tepid sponging
• Avoid aspirin
• Antipyretics does not prevent the
recurrence of febrile seizures
• Definitely adds to giving comfort to
patient
• Rational use of Antibiotics – as
indicated

32. WHAT TO TELL PARENTS?

33. Long term outcome of febrile seizures
• Brief and benign
• No residual neurological deficits
• Keep thermometer at home
• Antipyretics – dose
• Risk factors for epilepsy
• 9% if complex febrile seizures
• Febrile seizure below one yr of age
• Family H/O febrile seizures
• Abnormal neonatal history
• 2% risk in the absence of above risk factors
• Prophylaxis does not alter risk of epilepsy

34. Home management of febrile seizures
• Reduction of body temperature
• Antipyretics
• Rectal diazepam (0.3-0.5
mg/kg/dose)
• Nasal midazolam (0.2 mg/kg/dose –
each puff contains – 0.5 mg)
• Prevention of aspiration during
seizure - keep child in lateral position
(recovery position)
• Prevention of injuries during seizure

35. Morbidity and Mortality
• Low mortality
• May happen with febrile
status epilepticus
• No or very rare residual
neurological disability
with simple febrile
seizures
• No reports of
deterioration of cognitive
disabilities
• School performance –
good

36. Guidelines for therapy
• Benign
• Simple febrile seizures –
no----- AED
• COMPLEX FEBRILE
SEIZURES (in a
neurologically abnormal
child) and FEBRILE
STATUS --- daily AED
required

37. Recurrent Febrile Seizures- risk factors
• 33% recurrence – first episode
• 50% after 2 or more episodes
• 50% in infant s younger than 1
yr
• Family h/o febrile seizure
• Younger than 18 months
• Family History
• Onset at low temperature
• Shorter duration of fever –
high recurrence
• Lower serum sodium at
presentation

38. Recurrent Febrile Seizures- risk factors
• Complex febrile seizures
– prolonged initial and
recurrent – risk of
recurrence----high risk
of residual neurololocal
deficit
• Multiple risk factors
mentioned above- high
recurrence risk

39. Prophylaxis
• For preventing possible recurrence of febrile
seizures is controversial
• Indication for prophylaxis
• Prevent febrile seizures
• To allay parental anxiety
• Two options
• Intermittent and continuous
• Prophylaxis does not alter the risk for future
epilepsy
• Duration of prophylaxis -2 yrs seizure free
period

40. Intermittent prophylaxis
• Preferred mode
• Indication - >febrile seizures in 6
months or > in one year and
PARENTAL ANXIETY
• Rectal diazepam
• Dose- 0.3-0.5 mg/kg 8 hrly(rectal
or oral)
• Oral clobazam
• Dose – 0.5 to 1 mg/kg for three
days after onset of fever

41. Continuous prophylaxis
• Frequent complex febrile
seizures
• Failed intermittent therapy
• Febrile seizures with
neurodevelopmental delay
with or without neurological
deficits
• Febrile status epilepticus
• Sodium Valproate @ 20-60 mg
/kg /day in divided doses

42. Febrile Seizures and subsequent
Epilepsy
• 2-10%
• Neurodevelopmental
abnormality
• Complex febrile seizure
• Family history
• More than one complex
febrile seizure
• Febrile status epilepticus
• Duration of fever before
onset of febrile seizure
• Age at first febrile seizure
• Height of fever at first
seizure

43. Febrile Seizures and subsequent
Epilepsy
• Type of epilepsy after first
febrile seizure – VARIABLE
• Usually those with
generalized seizures ----
generalized epilepsy
• Focal- focal epilepsy
• Age specific expression of
seizure susceptibility with
an underlying seizure
diathesis

44. Febrile Seizures and subsequent
Epilepsy
• Febrile seizure can be an
initial manifestation of
specific epilepsy
• Initial febrile seizure ---
• Simple one? Or
future epilepsy?
• Numerous studies ----
answer this question
• SIMPLE and COMPLEX
febrile seizures

45. Two epilepsy syndromes typically
start with febrile seizures
• Generalized Epilepsy
with Febrile Seizure Plus
(GEFS+)
• Dravet Syndrome
(Severe Myoclonic
epilepsy of Infancy)

46. GEFS+
• Autosomal dominant
• Onset – early childhood
• Remision – mid-
childhood
• Initially multiple febrile
seizures ----subsequently
afebrile seizures
• GTCS
• Absence
• Myoclonic
• Focal variant also
described

47. Dravet syndrome
• Severe phenotypic
spectrum of febrile seizures
• Onset – infancy
• Initially febrile seizures ----
afebrile seizures---unilateral
clonic seizures recurring
every month
• Prolonged,frequent,focal
• Myoclonic and atypical
absence seizure variety
• Autosomal dominant
• SCN1A mutation

48. Relationship with Mesial Temporal
Sclerosis (MSL)
• Whether prolonged febrile seizures causes MSL?
• There is definite relationship with MSL and febrile
seizures(retrospectively – adults diagnosed with MSL had
febrile seizure in childhood ( and reverse is not true)
• Many had h/o prolonged atypical febrile seizurs
• Febile seizures and Temporal lobe epilepsy
• High risk with focal seizures
• Most had seizue duration>100 minutes
• Possibility of a pre existing focal pathology
• May be a subtle neuronal migration defect
• Controversial
• More studies needed

49. Take Home Message
• Febrile seizure s are common in children
• Vast majority are benign
• Detailed history and exmn is diagnostic
• Mainstay of treatment is antipyretics and
management of cause of fever
• Always rule out CNS Infection
• Parental counseling is very important
• Risk of recurrence and risk of developing epilepsy
should be clearly explained to parents

50. •THANK YOU