FEBRILE CONVULSION

Osuntoye Sunday Damilare

CLI/2017/116
 OUTLINES

Introduc Classific Pathoge Manage Conclusi

tion ation nesis ment Prognosis on

Epidemi Risk Clinical Treatme Differential

ology factors features nt diagnosis
and
aetiology
INTRODUCTION
Convulsion
associated
with fever
Febrile convulsion is a (>38oC)

convulsion in children between

the ages of 6 to 60 months
that occur with a temperature Not due to
Occurs CNS
FEBRILE
of 38oC (100.4oF) or higher, not between 6–
CONVULSION
infection/
60 months metabolic
disorder
as a result of CNS infection, a
metabolic disturbance, or
history of an afebrile seizures.
No prior
history or
afebrile
seizures
INTRODUCTION

SEZURES
DISORDERS

Based on seizure Based on the

Based on types syndrome
etiology

Febrile
Metabolic Infection Trauma Toxicity Epilepsy
seizures
INTRODUCTION (DEFINITION OF TERMS)
Seizure is a clinical condition in which there is a sudden disturbance of neurological function caused by an abnormal or excessive
neuronal discharge which manifests as motor, sensory, psychic or autonomic abnormalities.

Convulsion is the motor manifestation of a seizure and it manifests as a series of extreme jerky movements of the muscles that
repeatedly contract and then relax. In a convulsions episode, the muscles contract abnormally because of rapid firing or brain
activity that usually transpires during a seizure episode.
Tonic seizures are characterized by increased tone or rigidity

Atonic seizures are characterized by flaccidity or lack of muscle movement during convulsions.

Clonic seizures consist of rhythmic muscle contraction and relaxation

Myoclonus seizure is most accurately described as shock-like contraction of a muscle

EPIDEMIOLOGY

Febrile seizures are the most common type of seizure in children between the ages of 6 months to 5 years.

Febrile seizures are the most common type of seizures in childhood, with a slight male predominance of 1.6:1.

Febrile seizures have an incidence of 2% to 5% of US and European children, which peaks between 12 to 18 months of age.
CLASSIFICATION

SIMPLE FEBRILE SEIZURES COMPLEX FEBRILE SEIZURES

Lasts <15mins Last > 15mins

Not more than one episode in 24 hours More than one episode in 24 hours

Generalized seizures Focal seizures

No associated loss of consciousness Associated loss of consciousness

RISK FACTORS FOR FIRST FEBRILE SEIZURE

Family history of
Neurologic febrile or afebrile Maternal smoking and
viral infections
impairment seizure ( genetic stress
predisposition)

Deficiencies of zinc,
High fever iron, vit. B12, folic acid,
Developmental delay Low seizure threshold
temperature calcium, selenium and
magnesium
AETIOLOGY

Upper Respiratory
Malaria (60%) Otitis Media Tonsillitis/Pharyngitis
tract infection (30%)

Urinary tract
Gastroenteritis (5%) Sepsis Typhoid fever
infections

Osteomyelitis Cellulitis
AETIOLOGY

Malaria
Upper
Typhoid Respiratory
fever Tract
Infection

FEBRILE
Urinary
Tract SEIZURES Otitis Media
infections

Gastro Tonsillitis/
enteritis Pharyngitis
PATHOGENESIS

Complex genetic
predisposition

Immaturity and
vulnerability of the
central nervous
Environmental factor
system ( reduced
(the fever)
seizure threshold/
fever-enhanced
neuronal excitation)
PATHOGENESIS

GENETIC PREDISPOSITION FEVERS AND SEIZURE INDUCTION

• Neuron Excitation
• Recent studies have proposed that prenatal and early
Hippocampal Atrophy postnatal stressors may influence mechanisms that
lead to limbic epileptogenesis, by altering the
developing brain's neuroplasticity.
Mutation in Voltage-Gated • Early-life trauma (such as maternal infection, prenatal
Sodium Ion Channels maternal or environmental stress, perinatal hypoxic-
ischaemic injury or postnatal infection, seizure or
traumatic brain injury) is thought to lead to
Mutation in modification of circuit excitability by recruiting
Hyperpolarisation Activated astrocytes and microglia at the site of insult.
Cyclic Nucleotide-Gated
Channels • Following this reduction in seizure threshold in the
developing brain, a “second-hit” (e.g., a fever) may
be sufficient to trigger seizure activity
CLINICAL FEATURES

Most children who present with convulsions to the emergency room have a generalised seizure though
some present with focal seizures involving a part of the body.

Generalised or focal seizures may be tonic, tonic-clonic or clonic in nature. Rarely some present with
atonic and myoclonic convulsions.

Simple febrile seizures usually have a single episode of generalized tonic-clonic movements, often
involving facial and respiratory muscles, lasting less than 15 minutes with a short period of
postictal drowsiness.

Conversely, complex febrile seizures are characterized by focal seizures, usually limited to one side of
the body, lasting 15 minutes or more, that can recur within 24 hours. Complex febrile seizures are
frequently followed by postictal weakness or paralysis on one side of the body (ie, Todd paralysis).
 MANAGEMENT

Position the
Commence Take history Treat
Admit the patient Stop the Control the Counsel and Counsel on
ABC and underlying
child during seizure fever reassure the recurrence
resuscitation investigate cause
seizures parents
 Stop the seizure using:
POSITION the patient
on the left lateral
position to: • I.M paraldehyde (0.1ml/kg/dose or 1ml/yr of
• Prevent the tongue from life up to a maximum of 5 year or
falling back and blocking • IV diazepam (0.1-0.3mg/kg) or
the airways • IV/Sublingual midazolam in the absence of
• Avoid aspiration the first two
CONTROL THE TEMPERATURE

Tepid
sponging

Adequate
exposure

Antipyretics
e.g.
paracetam
ol
Clinical assessment and diagnostic studies

To characterize the type of febrile seizure

To determine the fever’s underlying cause

For simple febrile seizures, no tests should be performed unless other symptoms indicate it.
Complex febrile seizures are often a diagnosis of exclusion following an appropriate work up.
CLINICAL HISTORY

SEIZURE HISTORY
Interval between fever onset PAST HISTORY
and seizure activity, Pre-seizure
Vaccination SEIZURE PRECIPITANTS
aura – epigastric discomfort,
history, immunization status, HISTORY
feeling of fear Frequency of
family history of seizure activity,
attacks length, Longest seizure- Sleep deprivation, sensory
any recent illness, Birth and
free interval and postictal stimuli, stress, Fever, last meal
development, exposure to
symptoms – loss of time
toxins, and personal medical
consciousness, foaming at the
history.
mouth, shortness of breath,
cyanosis.
CLINICAL EXAMINATION

FOR ETIOLOGY OF THE FEVER:

Erythematous bulging eardrums, a red Neurological examination, including a
pharynx, enlarged and inflamed tonsils, fundus examination, to assess increased
nuchal rigidity, bulging or tense fontanels, intracranial pressure.
Brudzinski sign

Dermatologic signs that may indicate an

underlying etiology should also be
The presence and distribution of cyanosis,
evaluated, such as the unilateral port-wine
loss of sphincter control (particularly of
stain associated with Sturge–Weber
the urinary bladder), and post -ictal state
syndrome, hypopigmented macules
(including sleep, headache, and
indicative of tuberous sclerosis, or café au
hemiparesis) should be noted
lait spots and Lisch nodules suggestive of
neurofibromatosis.
INVESTIGATIONS

Random blood sugar

Lumbar puncture

Malaria parasite

Urine MCS and Urinalysis

Complete blood count

Blood culture

Chest radiograph
FURTHER EVALUATION
Patients who have a presentation and clinical features consistent with simple febrile seizures do not need further diagnostic studies due
to the benign nature of this type of febrile seizure. However, if a patient's history is consistent with a complex febrile seizure, a thorough
evaluation is recommended, which usually involves ruling out any structural or infectious causes and obtaining an electroencephalogram
(EEG).

Laboratory studies (eg, complete blood count, complete metabolic profile, and urinalysis) should also be performed if a
patient has signs of dehydration, poor fluid intake, vomiting, or diarrhea.

Some cases of complex febrile seizures may require hospital admission for observation and further studies.

A lumbar puncture is not necessary for a patient with simple febrile seizures and a rapid return to baseline; however, the study is
recommended when there are signs or concerns of a CNS infection. A lumbar puncture should also be considered in infants presenting
after a febrile seizure who are younger than12 months, not adequately immunized against Streptococcus pneumoniae or Haemophilus
influenza type B, had seizure 2 days after fever onset, or taking antibiotics which may mask meningitis or other CNS infection.

Magnetic resonance imaging or computer tomography studies of the head for febrile seizures are not typically
considered unless any of the following are present: Increased intracranial pressure, Focal neurologic, Suspected
structural defect in the brain, Enlarged head, Severe head injury
TREATMENT
No specific treatment for simple or complex febrile seizures is indicated other than supportive care and evaluation
for possible underlying conditions causing the fever.

It is accepted that early intervention is unnecessary for simple febrile seizures. Although most febrile seizures are a single occurrence
and spontaneously resolve, febrile status epilepticus does occasionally occur in <10% of children during the first febrile seizure. In
patients with febrile status epilepticus or seizures lasting longer than 5 minutes, intravenous benzodiazepines (eg, lorazepam), rectal
diazepam, or intranasal midazolam can be used.

Some drugs may be effective at reducing the risk of subsequent recurrence for complex and simple febrile seizures,
including phenobarbital, primidone, valproate, and intermittent diazepam . Nevertheless, the severity and incidence
of adverse effects, including the risk of respiratory depression, associated with these drugs frequently outweigh
potential benefits, so they are infrequently used.
Although most febrile seizures are a single occurrence and spontaneously resolve, febrile status epilepticus does
occasionally occur in <10% of children during the first febrile seizure. In patients with febrile status epilepticus or
seizures lasting longer than 5 minutes, intravenous benzodiazepines (eg, lorazepam), rectal diazepam, or intranasal
midazolam can be used.
Furthermore, nonpharmacological methods (eg, removing clothing, directly fanning the child, and tepid sponging)
to reduce a fever have not prevented fever recurrence.
PROGNOSIS

The majority of children who experience febrile seizures have normal developmental outcomes. Studies
suggest that around 30% of children with a history of febrile seizures are at an increased risk of having
recurrent episodes. Children younger than 12 months at the time of their first febrile seizure have a 50%
chance of experiencing a second seizure within the first year. However, this risk decreased to 30% in the
following year.
Approximately 1% to 2% of children with simple febrile seizures, which is only slightly higher than the general
population of .5% to .9%, may develop epilepsy later on. However it increases to 2-10% in those with certain
risk factors

Notably, a single febrile seizure episode does not appear to be linked to learning disabilities, lower
intelligence, behavioral problems, or executive functioning. However, in those with recurrent febrile seizures,
an increased risk of delayed vocabulary development may be present.
RISK FACTORS FOR RECURRENCE
RISK FACTORS PREDISPOSING TO AFEBRILE SEIZURES AND EPILEPSY
FOLLOWING FEBRILE SEIZURE INCIDENCE
DIFFERENTIAL DIAGNOSIS

CNS infections (eg,

aseptic meningitis, viral
Breath-holding spells Drug-induced Febrile delirium
or bacterial meningitis,
and encephalitis)

Febrile infection-related Generalized/genetic

Metabolic disturbances
Febrile myoclonus epilepsy syndrome epilepsy with febrile
such as hyponatremia
(FIRES) seizures plus (GEFS+)

Shaking chills or rigors

CONCLUSION

Febrile seizure is a pediatric emergency and occurs in children between the ages of 6months – 5 years

It is a diagnosis of exclusion.

There are specific risks for first time occurrence, recurrence and development of epilepsy.

Mainstay treatments are supportive care and treatment of the underlying cause
REFERENCES

1. Xixis KL. Febrile seizure [Internet]. U.S. National Library of Medicine; 2024 [cited 2024 Mar 23].
Available from: https://www.ncbi.nlm.nih.gov/books/NBK448123/

2. Sawires R, Buttery J, Fahey M. A review of febrile seizures: Recent advances in understanding of

febrile seizure pathophysiology and commonly implicated viral triggers [Internet]. Frontiers; 2021 [cited
2024 Mar 23]. Available from: https://www.frontiersin.org/articles/10.3389/fped.2021.801321/full#B6

3. Nelson WE, Behrman RE, Kliegman R, W. SGJ. Nelson Textbook of Pediatrics. Philadelphia: Elsevier;
2020.

4. Azubuike JC, O. NKE. Paediatrics and child health in a tropical region 3rd edition. Owerri, Nigeria:
African Educational Services.
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