Febrile Seizures

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FEBRILE SEIZURES

- IRASHA MALL
What is seizure?
Seizures are caused by abnormal electrical
discharges from the brain resulting in
abnormal, involuntary, paroxysmal, motor,
sensory, autonomic or sensorial activity.

About 5% children experience convulsions in the first 5


years of life. Motor movements consisting of tonic and
clonic components are the most commonly observed
phenomenon expect in infants.
• Seizure disorder is a general term that is
usually used to include any 1 of several
disorders, including epilepsy, febrile seizures,
possibly single seizures and asymptomatic
seizures secondary to metabolic, infectious, or
other etiologies.
• Conditions that can mimic seizure -

- convulsive syncope with or without cardiac


dysarrythmia
- decerebrate posturing
- psychogenic events
- dystonia
- migraine
Neonatal Seizures
They often present with-
- twitching of limbs
- fluttering of eyelids
- suckling movements
- conjugate deviation of eyes.

These should be distinguished from jitteriness,


tremors, startle response to stimuli, sudden jerks on
awakening and tremulousness of the hungry child
Causes of seizure
• Early neonatal •Neonatal period-
period- - transient metabolic :
- birth asphyxia, difficult hypocalcemia,
obstructed labour hypomagnesemia,
hypoglycemia.
- intraventricular,
- infections : meningitis,
intracerebral haemorrhage
septicemia, tetanus
- pyridoxine dependency , neonatorum, intrauterine
hypoglycemia, infections.
hypocalcemia. - metabolic errors :
- inborn errors of metabolism phenylketonuria, galactosemia,
- maternal withdrawal of urea cycle disorders.
medications
Causes of seizures
• Beyond neonatal period-

simple febrile convulsions


epilepsy syndromes

- infections : bacterial meningitis, tuberculous meningitis, aseptic meningitis,


encephalitis, cerebral malaria, intrauterine infections, Reye syndrome.
- metabolic causes : dyselectrolytemia, hypocalcemia, hypomagnesemia, inborn
errors of metabolism.
- space occupying lesions : neoplasm, brain abscess, tuberculoma, cysticercosis.
- Vascular : AV malformations, intracranial thrombosis, haemorrhage.
- miscellaneous : hypertensive encephalopathy , sequale of birth trauma or
asphyxia.
Drugs, poisons : Phenothaizines, Salicylates, Phenytoin.
Evaluation of Seizure
• Initial - assessment of adequacy of airway, breathing and
Cardiac function and BP, temperature and glucose
estimation.
• For acute evaluation, search for life threatening causes
(meningitis, sepsis, head trauma, ingestion of drugs etc.)
• Then, determine the type of Seizure
• History should determine whether an aura preceded the
convulsion and the behavior of the child after the seizure.
• Posture of patient, presence or abscense and distribution
of cyanosis, vocalization, loss of sphincter control and post-
ictal state should be noted.
• In addition to assessment of CVS n RS, examination of
a child should also be geared towards organic cause.
• Careful general and neurologic examination.
• EYEROUNDS must be examined for papilledema,
macular changes, optic neuritis, retinal hemorrhages
etc.
• Localisisng neurologic signs. Eg. A subtle hemiparesis
with hyperreflexia and downward drifting of the arm
might suggest contralateral hemisphere lesion.
• Initial acute investigatiom often includes metabolic
and CT scanning.
• For afebrile seizures, EEG can be obtained.
Febrile seizures
• Defined as seizures occuring between 6
months to 5 yrs of age in the absence of
infection of the CNS in a neurologically normal
child with a temp. of 100.4 F or higher.
• They are the commonest provoked seizures
affecting 3-5% children.
• The convulsions are not related to the degree
of temprature, but are frequent if temprature
rises abruptly.
Etiology
Not well known.-
Fever induced factors( interleukin----)
- Genetic susceptibility
- Fever associated neuronal activity.
- Hyperthermia induced alkalosis.
- Infections: bacterial and viral infections.
- Immunizations: DPT ( in the same day)
MMR( in 8-14 days).
• Genetic factors -

1. Genetic contribution is manifested by a positive
family history of febrile seizures for many patients.
2. Multiple single genes that cause disorder have been
identified such as FEB 1,2,3,4,5,6,7,8,9 and 10 genes,
however most cases disorder appears to be
polygenic.
1. GEFS syndrome autosomal dominant syndrome.
Onset in early childhood. Characterized by multiple
febrile seizures and several subsequent types of
afebrile generalized seizures.
2. Dravet syndrome - most severe of febrile seizure
associated epilepsies. Onset in infancy, characterized
by febrile and afebrile unilateral colonic seizures
recurring every 1-2 months. They are typically
induced by fever but are more prolonged, more
frequent, are focal and come in clusters.
Types-
• Simple febrile convulsions :
seizure occurs within 24hrs of onset of fever,
lasting less than 15 mins and are usually single
per febrile episode. Convulsions are
generalised clonic – atonic – tonic spells. No
postictal neurological deficit.
• Complex febrile seizures :
If seizure has focal features or last for more
than 15 mins or recurs within 24hrs or if the
child has preexisting neurologic challenges.
Convulsions in developmentally challenged
children may be precipitated by fever, as the
cerebral threshold for seizures is reduced with
the elevation of temperature.
• Febrile status epilepticus-
• Febrile seizure lasting longer than 30 mins.

• Febrile seizures recur in approximately 30% of


those experiencing first episode, in 50% after 2 or
more episodes and in 50% of infants younger than
1 yr old at febrile seizure onset.
• 2-7% of children who experience febrile seizures
proceed to epilepsy in later life.
Factors associated with the occurrence of a first-time
febrile seizure include

- prolonged hospitalization after birth


- developmental delays
- premature delivery
- maternal smoking
- day care attendance
- maternal hormonal therapy for infertility
- a surgical history, including any neurosurgical procedures, as
this may increase the risk of non-febrile seizure.
-Reduced levels of GABA in the CSF.
-Increased concentrations of neopetrin in the CSF.
- Low iron and ferritin levels.
- Genetic susceptibility:- Genetic loci.
Risk factors for subsequent epilepsy after
febrile seizure
• Simple febrile seizures • 1% risk
• Recurrent febrile seizures • 4% risk
• Complex febrile
seizures(>15 min or recur • 6% risk
within 24 hrs)
• Fever <1 hr before febrile
seizure • 11% risk
• Family history • 18% risk
• Complex febrile seizure • 29% risk
• Neuro developmental
abnormalities • 33% risk
Treatment
• Prompt reduction of temperature with antiyretics or hydrotherapy.
• Maintainence of airway ,breathing and circulation.
• IV access should be establised to maintain adequate hydration and
to administer anticonvulsant medication.
• Possibility of meningitis should be excluded by a lumbar puncture
if indicated. Lumbar puncture should be performed in the first
episode of febrile seizure, in infants below 1 yr who are not
immunised with HiB and pneumococcal vaccine , or if
immunization status is not known and where meningitis is
suspected.
• Injection of midazolam or diazepam (0.2-0.3 mg/kg/dose) is given
for control of seizures.
Febrile seizure prophylaxis
• Intermittent prophylaxis:
-indication: 3-4 febrile seizures in 6 months or 6 or more
in 1 year, febrile seizures lasting more than 15 min or
requiring pharmacological therapy to control seizures.
- prescribed during episodes of fever.
- oral clobazam (0.75 mg/kg/day) is an effective
prophylactic , given for 3 days during fever episodes.
- antipyretics, hydrotherapy and meticulous temperature
recording should be advocated for all patients.
• Continuous prophylaxis:
- indication: failure of intermittent therapy,
recurrent atypical seizures and in particular,
when parents are unable to promptly
recognize the onset of fever.
- only sodium valproate (10-20 mg/kg/day) or
phenobarbitone (3-5 mg/kg/day) are effective.
Carbamazepine and phenytoin are ineffective.
- duration of therapy – 1-2 yr or until 5 yr of
age.
Prognosis
• Recurrence risk – 30 to 50%
• Risk factors such as early age of onset (<15m), epilepsy ,
frequent fevers, fevers in 1st degree relatives and low
temprature at the onset of the febrile seizure can predict
the recurrence of the febrile seizures.
• 1-2% children with simple febrile seizures are likely to
develop epilepsy.
• 5% of those with recurrent complex febrile seizures are
likely to develop epilepsy.
• Complex partial seizures may manifest after several years
or prolonged atypical febrile convulsions.
References-
• Ghai Essential Pediatrics 8th edition
• Nelson Textbook Of Pediatrics
• Uptodate.com

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