:MODERATOR

DR. RANGANATH
DEPT OF PAEDIATRICS

Dr. BRAMCH

,BY
PRIYANKA
G B

Contents
Definition
Classification
Epidemiology
Risk Factors
Causes
Differential Diagnosis
Diagnosis
Management

Definition
Febrile seizures are seizures that occurs between the age of 6 months
to 5 years with a temperature of 38 C (100.4 F) or higher, that are not
a result of central nervous system infection or any metabolic imbalance,
and in absence of a history of prior afebrile seizure.
Commonest provoked seizures.
Generally accepted criteria for febrile seizures include:
A convulsion associated with an elevated temperature greater than 38C
A child older than 6 months and younger than 6 years of age
Absence of central nervous system infection or inflammation
Absence of acute systemic metabolic abnormality that may produce convulsions
like hypoglycemia, hypocalcemia, dyselectrolytemia and hypomagnesemia.
No history of previous afebrile seizures

Classifications
Febrile seizures are further divided into two categories, simple or complex,
:based on clinical features
Simple febrile seizures: the most common type, are characterized by.1
seizures associated with fever that are generalized, usually tonic-clonic,
last less than 15 minutes occur within 24hr of onset of fever and are single
.per febrile episode
Complex febrile seizures: seizures associated with fever that are.2
characterized by episodes that have a focal onset (e.g. shaking limited to
one limb or one side of the body), lasts longer than 15 minutes, or occur
.more than once in 24 hours
Febrile Status Epilepticus : febrile seizure lasting longer than 30 min or
. intermittent seizure without neurologic recovery

Epidemiology
The most common neurologic disorder of infants and young children.
They are age dependent phenomenon.
Occurs between the age of 6 months to 5 years
Occurring in 2-4 % of children younger than 5 years.
Peak incidence between 12-18 months.
Male predominance with estimated male to female ratio 1.6:1

Epidemiology
Febrile seizure recur in:
30% of those experience 1st episode .
50% after 2 or more episodes.
50% of infants younger than 1 year at febrile seizure onset.
2-7 % of children experience febrile seizures proceed to develop
epilepsy.

Risk Factors
Age.
High grade fever.
Infections.
( Viral infections such as : HHV-6 and Influenza virus )
Immunization.
( DTP & MMR )
Genetic susceptibility.
Family History of febrile convulsion. ( 10-20 % )
Autosomal dominant trait .

Risk Factors for Recurrence

of Febrile Seizures
Major
1.Age < 1year

Minor
1. Family history of febrile seizure

2.Duration of fever < 24hr 2. Family history of epilepsy

3.Fever 38-39 C

3. Complex febrile seizure

4. Daycare
5. Male gender

6. Low serum sodium at time of

Having no risk factor- 12% chance of recurrence.
presentation
1 risk factor- 25-50% chance of recurrence.
2 risk factor-50-59% chance of recurrence.
3 or more risk factors- 73-100% chance of recurrence.

Risk Factor for Occurrence of

Subsequent Epilepsy After a
Febrile Seizure
Risk
Simple febrile seizure
1%
Recurrent febrile seizures
4%
Complex febrile seizures
6%
Fever <1 hr before febrile seizure
11%
Family history of epilepsy
18%
Complex febrile seizures (focal)
29%
Neurodevelopmental abnormalities

Risk Factor

33%

Causes
Upper respiratory tract
infection .
Roseola infantum (HHV-6) .
Gastroenteritis ( Shigella or
campylobacter) .
Influenza Virus .
Urinary tract infection .

Differential Diagnosis
Central nervous system infection ( i.e. meningitis .1
.or encephalitis )
Genetic epilepsies with febrile seizures (GEFS+ or .2
. Dravet syndrome )
. Shaking chills.3
. Metabolic imbalance.4
.Drug ingestion.5
Conditions that mimic seizures- syncope, breath .6
holding spells, actue psychiatric states, migraine variants,
.abnormal movement disorders

Diagnosis
History .
Physical Examination .
Investigations .

History
The type of seizure (generalized or focal) and its duration should be
described to help differentiate between simple and complex febrile
seizures.
Focus on the history of fever, duration of fever, and potential
exposures to illness.
A history of the cause of fever (eg, viral illnesses,gastroentritis)
should be elucidated.
Recent antibiotic use is particularly important because partially
treated meningitismust be considered.
A history of seizures, neurologic problems, developmental delay, or
other potential causes of seizure (eg, trauma,ingestion of toxic
substances) should be sought.

Physical Examination
The underlying cause for the fever should
be sought.
A careful physical examination often
revealsotitis media,pharyngitis, or a viral
exanthem.
Full neurologic examination should be
done.
Serial evaluations of the patient's
neurologic status are essential.
Check for meningeal signs as well as for
signs of trauma or toxic ingestion.

Investigations
Blood Studies.
o Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and complete blood
count ) are not routinely recommended in the work-up of a child with a first simple febrile
seizure.

Lumber Puncture.
The American Academy of Pediatrics (AAP) recommendations regarding the
:performance of LP in the setting of febrile seizures, include the following
o LP should be performed when there are meningeal signs or symptoms or other clinical
features that suggest a possible meningitis or intracranial infection.
o LP should be considered in infants between 6 and 12 months if the immunization status
for Haemophilus influenzaetype b orStreptococcus pneumoniaeis deficient or
undetermined.
o LP should be considered when the patient is on antibiotics because antibiotic treatment
can mask the signs and symptoms of meningitis.

Investigations
Electroencephalogram (EEG) .
o Routine electroencephalography (EEG) is not warranted, particularly in the setting of
a neurologically healthy child with a simple febrile seizure.
o EEG may indicated in complex febrile seizure with abnormal neurologic examination
or in febrile status epilepticus .

Neuroimaging.
o Neuroimaging with computed tomography (CT) or MRI is not required for children
with simple febrile seizures.
o The incidence of intracranial pathology in children presenting with complex febrile
seizures also appears to be very low.
o Urgent neuroimaging (CT with contrast or MRI) should be done in children with
abnormally large heads, a persistently abnormal neurologic examination, particularly
with focal features, or signs and symptoms of increased intracranial pressure.

Management
Goal- prompt reduction of temperature. This is done with antipyretics or
hydrotherapy.
The majority of febrile seizures have ended spontaneously by the time the child is
first evaluated, and the child is rapidly returning to a normal baseline. In such cases,
active treatment with benzodiazepines is not necessary .
In children with febrile seizures that continue for more than five minutes, we
recommend treatment with intravenous (IV) benzodiazepines (diazepam0.2 to
0.3mg/kgorlorazepam0.05 to 0.1mg/kg) Buccalmidazolam(0.2mg/kg,maximum
10 mg) is an alternative when IV access is unavailable.
Patients with continued seizures despite initial benzodiazepine administration (ie,
febrile status epilepticus) should be treated promptly with additional anticonvulsant
medications, as are other patients with status epilepticus.

Management
Most children with simple febrile seizures do not require hospital admission
and can be discharged safely to home once they have returned to a normal
baseline and parents have been educated about the risk of recurrent febrile
seizures.
Diazepam at the 1st onset of fever for duration of the febrile illness may be
effective but will sedate a child and complicate the evaluation for the source
of the fever .
Prophylactic anticonvulsants are not recommended after simple febrile
seizure.
Measures to control the fever such as sponging, tepid baths, antipyretics
and antibiotics for proven bacterial illness are reasonable but unproven to
prevent recurrence of febrile seizure .
Parent education and reassurance .

Prophylaxis
PROHYLAXI
S
INTERMITTE
NT

CONTINUOU
S

Intermittent Prophylaxis
Indications:
1. 3 or more febrile seizures in 6 months./
2. 6 or more febrile seizures in 1 year./
3. Febrile seizure lasting more than 15 min or requiring pharmacological
therapy.
.When to give? During episodes of fever.
.Drug of choice- Clobazam(0.75-1mg/kg/day) for 3 days during fever. This is
done along with antipyretic therapy and tepid sponging.

CONTINUOUS PROPHYLAXIS
Indication:1. Failure of intermittent therapy.
2. Recurrent atypical seizures.
3. When parents are unable to recognize the onset of fever.
.Drug of choice- 1. sodium valproate-10-20mg/kg/day
.

2.phenobarbitone- 3-5mg/kg/day.

.Duration of therapy- 2 years or until 5 years of age.

APPROACH TO FEBRILE
SEIZURES
STEP
1

.History
.Examination
.First aid and management of acute febrile seizures
.Determine risk of recurrence

STEP Counsel parents about risk of recurrence and how to manage fever
.and provide first aid
2

STEP .Determine risk factors for later epilepsy

3
LOW RISK no therapy or investigation required
STEP HIGH RISK- Investigate(EEG/imaging), intermittent or continuous
4 .prophylaxis

References
Nelson TEXTBOOK of PEADIATRICS
O.P GHAI ESSENTIAL PEDIATRICS

Thank
You