Febrile seizures are the most common type of seizure seen in children under 5 years old. While they can be alarming for parents, the majority are benign and have an excellent prognosis. Febrile seizures are classified as simple or complex based on features like duration, recurrence, and onset. Investigations are usually not needed but may include lumbar puncture in young infants to rule out infection. Treatment focuses on controlling fever and preventing prolonged seizures. Parents should be reassured that febrile seizures rarely cause neurological issues and most children outgrow them. Recurrence risks are highest for those under 18 months, with family history or complex initial seizures. Prophylaxis may be used to prevent recurrence but does not impact later epilepsy risk.

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