Febrile Convulsion Dr. Minoo Saeidi Assisstant Professor of Pediatrics Isfahan University of Medical Sciences

Definition & Criteria The single most common type of seizure seen in children between 6 months to 5 years of age With T ≥ 38˚C Don’t related to CNS infection Don’t related to abnormal biochemical values Without previous unprovoked seizure or neonatal seizure Chance of recurrence is 12% (without any risk factor) محدوده سنی شایعتر 6 ماهگی تا 3 سالگی است و اغلب موارد در سال دوم عمر روی می دهد.

Etiologies Genetics (autosomal dominant trait) Prenatal factors (subfertility, smoking, maternal illness) Perinatal factors (complicated first FC) Precipitating factors (fever, HHV6, HHV7, shigella, pneumococcal bacteremia, DTP, 8 to 14 days after MMR, roseola, otitis media)

Risk factors associated with first FC India 70 febrile child with 70 child with first episode of FC between 6 mo to 5 yr Male gender, family history of FC, peak body temperature, underlying cause of fever (URI >> UTI), antenatal complications (Hemorrhage and difficult labor(, lower serum Na, lower serum Ca, lower BS, microcytic hypochromic anemia Ref: Evaluation of Risk Factors Associated with First Episode Febrile Seizure. Sharawat IK et al. J Clin Diagn Res. 2016 May

Post natal steroids and FC Taiwan 575 preterm (<1500 g and <32 w) GA, ventilation day, APGAR, brain sonogram 6% risk of FC 14.5% versus 3% (P= 0.006) use of postnatal steroids Neurodevelopmental outcome at 2 and 5 years Steroid drugs are pro convulsive for a developing brain Ref: Postnatal Steroids and Febrile Seizure Susceptibility in Preterm Children. Tu YF et al. Pediatrics. 2016 April

Immunization and FC Australia 78 case of first FC 1.28% had recent immunization in the preceding 24 h Another order to prescription??? Ref: Prevalence of recent immunization in children with febrile convulsions. Motala L et al. World J Clin Pediatr. 2016 August

Clinical features & Categories Simple FC Complex FC Status FC Recurrent FC Epilepsy triggered by FC

Simple FC Generalized Usually tonic clonic Lasting less than 15 minute Not recurrence in 24 h تب و تشنجهای ساده حتی در صورت تکرار اثر نامطلوب بر وضعیت رفتاری، تحصیلی و شناختی کودک نمی گذارند

Complex FC Duration > 15 minutes Recurrence within 24 h Focal features نوع کمپلکس شانس مورتالیتی را طی 2 سال اول بعد از وقوع آن 2 برابر می کند که البته معمولا به علت زمینه ای آن تشنج بر می گردد

Status FC Lasting 30 minutes or more Series of seizures without full return to consciousness Hippocampal sclerosis T2 finding of hippocampus on MRI Trend to language and motor delay at one year after SFC Race, gender, phenotype of SFC, HHV6/7 Ref:Cognitive functioning one month and one year following febrile status epilepticus. Weiss EF et al. Epilepsy Behav. 2016 Nov

Recurrent FC We expect only one or two recurrence generally It may be different in type If the patient is high risk for recurrence, we should prescribe prophylaxis with Diazepam (1 mg/Kg/day, in three divided dose) for 48 h Clonazepam, nitrazepam, clobazam Continuous use of Phenobarbital or Valproate ? Antipyretic? Screening for Iron deficiency?

Risk factors for recurrence Major Age < 1 year Duration of fever < 24 h Fever 38-39 ˚C Minor Family history of FC Family history of epilepsy Complex FC Male Lower Na at presentation اگر فردی هیچ فاکتور خطری نداشته باشد 12 درصد شانس تکرار دارد اگر 1 فاکتور داشت شانس به 25 تا 50 درصد میرسد. با 2 فاکتور خطر شانس تکرار به 50 تا 59 درصد می رسد. داشتن 3 فاکتور خطر یا بیشتر با شانس 73 تا 100 درصدی تکرار همراه است. تشنجهای تبدار ساده حتی در صورت تکرار روی وضعیت شناختی اثر منفی ندارد اما اگر این کودکان به دسته صرع بروند این اختلالات دور از انتظار نیست

Epilepsy triggered by FC More than three episode of FC It is not FC but it is a seizure disorder that triggered by FC Afebrile seizure Abnormal development Antiepileptic drugs? Further investigations?

Risk factors for subsequent epilepsy Simple FC 1% Recurrent FC 4% Complex FC 6% Fever < 1 h before FC 11% Family history of epilepsy 18% Complex focal FC 29% Neurodevelopmental delay 33% 2 تا 7 درصد کودکان با تب تشنج در آینده به سمت صرع میروند. همه انواع صرع ها می توانند به صورت تابلوی تب تشنج بروز کنند. از این میان دو مورد هستند که حتما با تب تشنج خود را بروز می دهند: سندرم دراوت یا صرع میوکلونیک شدید شیرخواران، صرع لوب تمپورال ثانویه به مزیال تمپورال اسکلروزیس و GEFS+ در سندرم دراوت تشنجها میوکلونیک و یکطرفه و خوشه ای و تکرار شونده هستند در سال دوم انواع دیگری از تشنجها اضافه می شوند و تاخیر تکاملی دارند در این بیماری نوعی موتاسیون ژنی علت است و غالب موارد انسفالوپاتی بعد از واکسن را امروزه به این سندرم منتسب می کنند نه واکسن

Investigations

Lumbar puncture < 6 mo Ill appearing child Any age with signs or symptoms of meningitis Optional in 6 to 12 mo according to the vaccination state and pretreatment with antibiotic Abnormal CSF but no meningitis ?

Blood studies Not routinely recommended in the first simple FC Blood sugar in prolonged postictal or seizures Signs of dehydration? Na?

EEG Long term outcome Development of epilepsy Diagnosis of acute encephalopathy Population, timing of EEG, recording condition Not recommended for simple FC If it is abnormal don’t predict later epilepsy Ref: New guidelines for management of febrile seizures in Japan. Natsume J et al. Brain Dev. 2017 Jan

EEG Focal slowing on the EEG in 72 hrs after status FC, indicate hippocampal injury If it is indicated, do it after more than 2 wk Nonepileptic state in status FC? aim of EEG?

MRI or CT Not recommended in first simple FC Individualize in complex FC In abnormal neurological exam In status FC, unilateral hippocampal swelling, long term hippocampal atrophy They go to TLE?

Treatment Acute treatment of seizure

Treatment

Treatment Recovery position

Treatment Rectal diazepam

Prophylactic Diazepam It is effective 2/3 of children with FC don’t have another episode Assess the risk of recurrence Consider this treatment for children with status FC

Thank You Any Question???