Classification, presentation evaluation and management of Febrile seizures in children

1. Febrile Seizures
Definition, Epidemiology, Etiology,
Clinical Presentation, Complications,
Investigations, Management
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God Almighty speaking to Prophet Muhammad (PBUH)
The Rahman (The All-Merciful Allah) has taught the Qur‘an.
He has created man. He has taught him (how) to express himself.
The Holy Quran; surah Al-Rahman 55:1-4
In the name of Our Creator Allah, the most Gracious, the most Merciful

3. CNS

4. Brain

5. Our perceptions and Movements

6. Clinical Presentation
of
CNS diseases

7. CNS disease – Clinical Presentation
• Seizures / Convulsions / Fits
• Impaired Conscious level
• Developmental delay
• Intellectual handicap
• Neurological Paralysis / Paresis (motor weakness )
• Neuromuscular disorders / Hypotonia
• Movement disorders
• Headache
• Regression of acquired milestones
• Behaviour problems

8. Seizures / Convulsions / Epilepsy
Definition, Clinical Presentation, Etiology

9. Seizures in Children
Definition
• Seizure is a paroxysmal involuntary disturbance of brain
function that may manifest as impaired conscious level,
abnormal motor activity, behavioral abnormalities, sensory
disturbances or autonomic dysfunction
• Convulsion is a generalized seizure with increased tone and
tonic - clonic movements of the body
• Epilepsy is a disorder of the brain characterized by an
enduring predisposition to generate seizures
• Epilepsy is recurrent seizures unrelated to fever or an acute
cerebral insult

10. Seizures in Children (Clinical Presentation)

11. Convulsions

12. Seizures in Children
Etiology - Acute Symptomatic Seizures
• Febrile Seizures (age 6 months to 5 years)
• CNS infections (Meningitis / Encephalitis / Cerebral malaria)
• Intracranial hemorrhage
• Hypoglycemia / Electrolyte imbalance (Na,Ca,Mg)
• Drugs / Chemical Poisoning / Encephalopathy
• Trauma
• Hypoxia
• PNES (Psychological Non-epileptic Seizures)
• Tetanus (spasms not seizures)

13. Seizures in Children
Etiology - Recurrent Seizures
• Epilepsy
 Idiopathic Epilepsy in children has a genetic basis
 Epilepsy in children may be secondary to:
 Hypoxic-ischemic injury to Brain
 Cerebral Malformations
 Degenerative Brain diseases
 Epilepsy in children may be associated with:
Cerebral palsy
Intellectual disability / Mental handicap

14. Febrile Seizures in Children
Definition, Epidemiology, Etiology

15. Febrile Seizures
Definition
• A Febrile seizure is a seizure occurring in a child having fever
(100.4°F or greater) without central nervous system
infection or any disease predisposing to seizures
• Febrile seizures are likely to recur with next episode of fever
in 30 – 50 % of children
• Risk of developing Epilepsy in children with Febrile seizures
is 3 % in uncomplicated cases

16. Febrile Seizures
Epidemiology
• Febrile seizures are the most common seizure disorder and
most common neurological disorder in childhood
• Febrile seizures are seen in children aged 6 months to 5
years (rarely, 3 months and 6 years)
• Febrile seizures are seen in 3 % of children

17. Febrile Seizures
Etiology
• The exact underlying mechanism of febrile seizures is
unknown
• The increased activity of neurons during rapid brain
development may predispose to seizures in younger
children
• Inflammatory mediators, and cytokines, released during a
fever may contribute to the pathogenesis of febrile seizures
• There is a genetic basis to febrile seizures which are more
common in families

18. Febrile Seizures
Clinical Presentation, Types

19. Febrile Seizures
Case Scenario
• An 18 months old child presents to the pediatric emergency
with sudden onset of jerky tonic-clonic movements of body
which lasted five minutes.
• Parents say the child was having runny nose and cough since
yesterday
• On examination, his weight is 10 kg and he has a
temperature of 102 F. Now he has no seizure activity but is
lethargic
• Mother mentions that the child did not have any such event
before.
• What will be your most likely initial diagnosis in this child ?

20. Febrile Seizures
Clinical Features - Fever
• Febrile seizures are associated with an abrupt rise of fever in
genetically-predisposed children
• Fever is usually more than 102 F (39 C)
• Most febrile seizures will occur during the first 24 hours of
developing a fever
• In many children, parents may not have noticed the fever till
the seizure occurs
• The cause of fever is usually a viral infection

21. Febrile Seizures
Clinical Features - Seizure
• Febrile Seizures are usually brief, lasting less than 5 minutes
• Most commonly, it is a generalized tonic-clonic seizure.
• Child rapidly loses consciousness with open deviated eyes,
irregular breathing, increased secretions, and pallor
• Bilateral jerky movements occur
• Child may vomit or become incontinent
• After the seizure is over, child rapidly regains consciousness,
within an hour

22. Febrile Seizures
Types
• Simple Febrile Seizures (80 %) - low risk of epilepsy (2–3 %)
• Complex Febrile Seizures (20 %) – increased risk (5 – 10 %)

23. Febrile Seizures
Diagnosis, Complications, Investigations

24. Febrile Seizures
Evaluation
• History:
• Present illness – symptoms and signs
• Past History – seizures
• Development history – milestones
• Family History – epilepsy
• Physical Examination:
• General Physical Examination – cause of fever
• Neurological Examination – abnormal findings, SOMI

25. Febrile Seizures
Differential Diagnosis
• CNS infections (Meningitis / Encephalitis )
• Intracranial hemorrhage
• Hypoglycemia / Electrolyte imbalance (Na,Ca,Mg)
• Drugs / Poisoning / Metabolic Encephalopathy
• Idiopathic Epilepsy

26. Febrile Seizures
Diagnosis
• Febrile Seizures – fever often high
• Febrile Seizures – infectious cause of fever usually present
• Febrile Seizures – past history of Febrile seizures often
present in the child or siblings
• Febrile Seizures – child is neurologically normal before the
seizure
• Febrile Seizures – child regains consciousness quickly
• Febrile Seizures – child is neurologically normal after the
seizure
• Febrile Seizures – no other disease explains for the seizure

27. Febrile Seizures
Complications
• Acute complications:
• Hypoxia
• Hypoglycemia
• Hyperpyrexia
• Aspiration pneumonia
• Status epilepticus
• Chronic complications:
• Recurrence – further Febrile Seizures
• Epilepsy

28. Febrile Seizures
Investigations
• Typical case of Febrile seizures – investigations not needed
• Atypical cases or uncertain diagnosis – investigate as needed
(keeping in view other diseases)
• CBC, CRP, ICT malaria, X-ray Chest (infection)
• CSF examination and microbiology (meningitis)
• Serum glucose, electrolytes, calcium, and BUN (metabolic)
• Neuroimaging - CT / MRI Brain (neurological disease)
• EEG – electroencephalography (epilepsy)

29. Febrile Seizures
Management

30. Febrile Seizures
Acute Management
• General Management:
• Airway – Breathing – Circulation
• Oxygen by mask / nasal prongs
• Monitoring – GCS, Vitals, SaO2,
• Seizure Management:
• IV diazepam or IV midazolam (benzodiazepines)
• IV Leviteracetam (if needed)
• Fever Management:
• IV Paracetamol
• Sponging with water

31. Febrile Seizures
Long Term Management
• Control of Fever :
• Oral Paracetamol or Oral Ibuprofen (keep fever low)
• Sponging with water
• Seizure Management at home:
• Rectal diazepam
• Oral Midazolam
• Prevention of Seizures:
• Oral diazepam during febrile episodes
• Oral Phenobarbitone daily till 5 years of age