Febrile seizures are common cause of convulsions inyoung children.They occur in 2 to 4% of children younger than five yearsof age ( between 6 months and 6 years).The majority occur between 12 and 18 months of age.In some populations it may be as high as 15%.
Accepted Criteria-- A convulsion associated with an elevated temperaturemore than 38 ⁰ C.-- A child younger than 6 years of age.-- No central nervous system infection or inflammation.-- No acute systemic metabolic abnormality that mayproduce convulsions.-- No history of previous afebrile seizure.
CategoriesA-Simple ( benign)- The most common.- Seizures last less than 15 minutes.No focal features.- Occur in series with a total duration less than 30minutes.
B -Complex.- Episodes last more than 15 minutes.- Focal features.- Post ictal paresis.- Series with total duration more than 30 minutes.
Etiology and pathogenesis- Not well known.- Fever induced factors( interleukin----)- Genetic susceptibility.- Fever associated neuronal activity.- Hyperthermia induced alkalosis.
- Infections: bacterial and viral infections.- Immunizations: DPT ( in the same day)- MMR( in 8-14 days).
Predisposing factors-Reduced levels of GABA in the CSF.-Increased concentrations of neopetrin in the CSF.- Low iron and ferritin levels.- Genetic susceptibility:- Genetic loci.- Nonmendelian forms.- Syndromes.- Hippocampus malformation.
Clinical FeaturesA- Simple febrile:- Generalized clonic- atonic- tonic spells.- -Facial and respiratory muscles are commonly involved.- - Mostly in the first day of illness.- - In 25% of cases it occurs between 38⁰C – 39⁰C.- - It is often seen as the temperature is increasing rapidly,- but may develop as the fever is declining.
B- Complex febrile:- Focal- Longer than 15 minutes.- Multiple episodes within 24 hours.
C- Febrile status epilepticus:- Continuous seizures.- Intermittent seizures without neurologic recovery.- Lasting for a period of 30 minutes or more.
D:- Recurrent febrile seizures 30% Young age of onset History of febrile seizure in a first degree relative. Low degree of fever while in the ER. Brief duration between the onset of fever and the initialseizure.
Acetaminophen 10 -15 mg/kg/dose/4-6 hours ( maximum 800 mg) Ibuprofen 10mg/kg/dose/6hours ( maximum 40mg/kg)Switch from one drug to another.Do not combine them together.
External Cooling External cooling may be used as an adjunct to antipyretictherapy for children in whom you need rapid reductionof body temperature. Antipyretic agents should be administered 30 minutesbefore external cooling. Antipyretic agents are necessary to reset thethermoregulatory set point, without which externalcooling will result in an increase in heat production.
Diagnostic Evaluation Lumbar puncture: When there are signs or symptoms of meningitis or CNSinfection. For infants between 6 and 12 months not immunized forHaemophilus influenzae. The patient was on antibiotics before the convulsions. If the febrile seizure ocurrs after the second day of illness. In febrile status epilepticus.
Complete blood count, electrolytes, blood sugar, ureanitrogen are indicated for diagnosis of the disease only. Neuroimaging is not indicated for simple febrile seizures. EEG is not warranted in the setting of simple seizures.
Preventive TherapyBased on the risk and benefits of effective therapies,neither continuous nor intermittent anticonvulsivetherapy is recommended for children with one or moresimple febrile seizures.Recurrent episodes of febrile seizures can create anxiety insome parents and their children , and as such appropriateeducational and emotional support should be provided.
Patient Information Home treatment: Place the child on their side but do not try to stop theirmovement or convulsions. Do not put any thing in the child′s mouth. Keep an eye on the time, seizures that last for more than5 minutes require immediate treatment.
There is no evidence to support that fever ≥ 40⁰ C isassociated with increased risk of adverse outcome ( eg.Brain damage) although this belief is held by manycaregivers and clinicians.
Anticipatory guides:• Fever is not an illness , but a physiologic response.• In otherwise healthy children, most fevers are self limited• Provided that the cause is known and fluid loss isreplaced, fever does not cause brain damage.• There is no evidence that fever makes the illness worse.• The initial measures to reduce the childs tempratureinclude provision of extra fluids and reduced activity
Children with temperature elevation and possibility ofhyperthermia require treatment, but the treatment ofhyperthermia differs from that of fever. Antipyretic medications are ineffective in children withheat stroke and may exacerbate liver injury andcoagulopathy.
External cooling is the treatment of choice for heat stroke andother forms of heat illness in which rapid cooling is necessaryto prevent end organ failure. Indications for concomitant antipyretic adminestration andmechanical cooling include:-Uncertainty about the cause of elevated temperature( heat illness versus fever)- fever combined with a component of heat illness( over-rapping, hypovolemia. Drugs.- underlying neurologic disorder, in which the child may haveabnormal temperature control.
When mechanical cooling is necessary , sponging withwarm water ( 30⁰ C ) or tepid sponge is recommended. Cooling blankets can be useful in hospitalized childrenwho are critically ill or who have problems with neatcontrol( head injury)