Febrile Seizures
Management of seizure at home
1) Keep calm; 2) Lay child on back, turning head from side to side, to clear secretions; 3) Seek medical evaluation of fever.
Febrile Seizure
A seizure associated with a fever in a child usually between 6 months and 5 years of age.
Continuous therapy
Carbamazepine and Phentoin are ineffective Phenobarbital is effective in preventing recurrences. Adverse effects= behavioral and learning problems. Valproic Acid is effective in preventing recurrences. Adverse effects= fatal hepatotoxicity, pancreatitis (both more common in children less than 3 yrs old).
Risk Factors for Development of chronic seizure disorder in kid with febrile seizures
FH of chronic seizure disorder Initial febrile seizure < 9 months old Complex febrile seizure Developmental delay Abnormal neurological exam Risk of afebrile seizure disorder is 1% in the general population and patients with simple febrile seizures. Risk increases to 2% with one risk factor, and 10% with 2-3 risk factors
Simple Febrile Seizure
Generalized No associated neurological deficit Less than 15 minutes duration Only one within a 24 hour period
Meningitis and Seizures
In 13-16% of children with meningitis, seizures are the presenting sign of disease. In 30-35% of these children (primarily less than 18 months old), meningeal signs are lacking.
Approach to Child with Fever and First Seizure
May be due to a febrile seizure May be due to a chronic seizure disorder triggered by fever May be due to an intracranial infection, meningitis, encephalitis, brain abscess.
Fever Control
No evidence that fever control decreases the incidence of febrile seizures. In 10-30% of patients, the seizure is the first manifestation of the illness
Child intelligence
No long term intellectual or neurological dysfunction has been reported.
Intermittent therapy
Oral Diazepam: 1) Given at the time of a fever, reduces the incidence of seizures by 44%; 2) Adverse effects = lethargy, drowsiness, ataxia; 3) The adverse effects could mask evolving signs of a CNS infection, and make medical evaluation less accurate. Rectal diazapam or lorazepam: 1) Used in acute management of the seizure; 2) Parents can be taught to administer the drug: 3) effective in aborting prolonged seizures; 4) Still potential for adverse effects.
Clinical Features of Febrile Seizure
Seizure usually occurs within the first 24 hours of fever. Seizure is due to rapid change in body temperature, usually >39 C (102.2 F). Usually occurs in the presence of a clinically recognizable infection. Most common infectious triggers are viral URI, AOM, Roseola. 80% are simple febrile seizures, 20% are complex febrile seizures. Most often have generalized motor seizure. Less commonly have focal motor activity or may be only staring episode or eye rolling. Usually brief; only 8% last longer than 15 minutes.
Risk of death
Several large studies have not reported any deaths.
Parental Education
Simple febrile seizures are a benign event. No treatment has been shown to prevent the rare development of a chronic seizure disorder after a simple febrile seizure. 40% of children treated with phenobarbital have behavioral side effects (irritability, hyperactivity, disturbed sleep, learning problems)
Risk Factors for Abnormal CSF in Kids with Fever and Seizures
Suspicious findings on physical exam Complex febrile seizures Doctor visit w/i 48 hrs before the seizure Seizing upon arrival to ED Prolonged postictal state Initial seizure after 3 years old
Epilepsy development
There is a slight (<1% difference) increase in comparison to the general population.
AAP Practice Guideline for First Simple Febrile Seizure recommends
less than 12 months old LP should be strongly considered; 12-18 months LP should be considered.(for meningitis)
AAP Practice Guideline -1999
neither continuous nor intermittent anticonvulsant therapy is recommended for children with one or more simple febrile seizures
Neuroimaging
no need for skull films, CT or MRI
EEG eval
no predictive value
Blood studies
no routine serum electrolytes, calcium, phosphorus, magnesium, CBC, or blood glucose
Complex Febrile Seizure
Any one of the following Focality Greater than 15 minutes duration Neurological Deficit Multiple in a 24 hour period
Management of Seizing Child
Assess respiratory and CV status Gentle suction, or turn head from side to side to clear secretions Provide O2 Check dexrostix Fever control Begin IV