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2. Approach to febrile convulsion
Prepared by:
Dr Mostafavi N
Department Of Pediatric Infectious Disease
Isfahan University Of Medical Sciences
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3. Case 1
A 13 mo. old girl brought to emergency department with complaint of abnormal repetitive movement 30 minute ago for 5 min. Her temperature is 39.5°C.
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4. Questions Had the child a seizure? Is there any need to Admission?
Which Lab data should be requested?
Is lumbar puncture should be performed?
Is there any need to emergency brain CT scan?
Is there any need to outpatient brain MRI?
When EEG should be performed?
When prophylactic treatment with intermittent diazepam or continuous phenobarbital is needed?
Which measures could be educated to parents for probable future seizures?
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5. References 1) AAP Clinical Practice Guideline—Febrile Seizures 2011
2) Japanese guideline for febrile convulsion
3) Nelson textbook of pediatrics 2016
4) Up to date 2016
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6. Criteria for febrile seizures
T> 38°C
Seizure
Age 6mo.- 5 yr.( Reff. 2, 4: 3mo- 6 yr)
No CNS infection
No metabolic disorder( BS, Na, Ca, Mg)
No previous afebrile seizures
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7. Febrile convulsion The majority in age of 12-18 mo.
In age> 6 yr. is a diagnosis of exclusion( uptodate)
The majority on the first day of illness(>90%)
Mostly fever> 39ºC, 25% ºC (threshold convulsive temperature)
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8. Complex FC
Focal
> 15 min
> Once in 24 hr.
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9. Benign nature of first febrile seizure( AAP)
Simple febrile seizures are benign events with
excellent prognoses
No evidence of increased mortality, hemiplegia, or mental retardation
The risk of epilepsy only slightly higher than general population( 1%)
Chief risk is recurrence in one-third of the children.
No risk of decline in IQ, academic performance or behavioral abnormalities in recurrent simple FC
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10. Differentiating seizure from shaking child
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11. Shaking chills( uptodate)
Common in febrile children and can be confused with seizures
Fine rhythmic oscillatory movements about a joint
Rarely involve facial or respiratory muscles, which frequently occur during seizures
Usually involve both sides of the body simultaneously
Not associated with loss of consciousness
Suppressible by touch
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12. Need to Admission in febrile seizure
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13. Japanese guideline( for 6-8 hr.)
To exclude CNS infection
Fear of recurrence
To investigate and treat other cause of fever
To allay parental anxiety, especially if staying far from the hospital
A child that is running around normally a few hours is unlikely to have meningitis
the child should only be discharged when the underlying fever be a minor illness
the parents should be given clear instructions what to do in case the fit recurs or the fever persists.
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14. Uptodate
Most children with simple FC do not require admission and can be discharged safely to home( return to a normal baseline, parent education)
Children with focal or prolonged seizures require more observation( risk of multiple seizures)
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15. Laboratory evaluation of children with simple FC
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16. AAP in 1st simple FC
The following tests should not be performed routinely for identifying the cause: Electrolytes, calcium, phosphorus, magnesium, or blood glucose or complete blood cell count.
CBC for identifying occult bacteremia in mo.
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17. Japanese guideline
The need for BS, U/A, CXR, B/C etc., will depend on clinical assessment
Measurement of serum Ca and electrolytes are rarely necessary
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18. Uptodate
A CBC, serum electrolytes, BS, Ca, and BUN is of very low yield in patients with simple febrile seizures.
These parameters should be measured only when vomiting, diarrhea, and abnormal fluid intake, dehydration or edema exist
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19. Nelson
Blood studies (serum electrolytes, Ca, Ph, Mg, CBC) are not routinely recommended in first simple FC
BS: ⬇LOC after seizure or prolonged fasting
Na : dehydration
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20. Indications of lumbar puncture in FC
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21. AAP Should be performed: An option: Meningeal signs
Other symptoms of meningitis: LOC, focal seizures, recurrent seizures, petechial rash
An option:
age 6-12 mo. and incomplete immunization
pretreatment with antibiotics
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22. Uptodate Meningeal signs
Other symptoms of meningitis: altered consciousness, petechial rash
Status FC( possible indication)
Age< 12 mo. and incomplete immunization( considered)
FC after the 2nd day of illness( considered)
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23. Indication for emergent neuroimaging in FC
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24. AAP in 1st simple FC
Neuroimaging should not be performed in the routine evaluation of simple FC
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25. Emergency CT scan/MRI( uptodate)
Abnormally large head
Abnormal neurologic examination, particularly with focal features
Signs of ↑ ICP
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26. Indication for outpatient neuroimaging in f/u of FC
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27. Outpatient MRI and EEG( uptodate)
Focal FC
Prolonged FC
Especially if delay development
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28. Indication for EEG in FC
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29. AAP in 1ST Simple FC
EEG should not be performed in neurologically healthy child
No evidence that EEG IS predictive of either recurrence of febrile seizures or epilepsy within the next 2 years
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30. Japanese guideline
EEG shortly after the seizure or in interictal records do not help in the management
Not indicated even in multiple recurrences or in complex FCs
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31. Uptodate Focal FC Prolonged FC abnormal development
family history of epilepsy
Recurrent FC
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32. Anticonvulsant prophylaxis in FC
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33. AAP in 1ST simple FC
Phenobarbital and primidone are effective in preventing the recurrence( 25% ⇒ 5%)
Adverse effects: hyperactivity, irritability, lethargy, sleep disturbances( 20-40%), and hypersensitivity reactions
Oral diazepam (0.33 mg/kg, q8h for 48 hr decrease the risk of recurrence by 44%.
A seizure could occur before a fever
Adverse effects: lethargy, drowsiness, ataxia, masking CNS infection
Prophylactic acetaminophen during fever is ineffective in preventing FC recurrence
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34. AAP
Neither continuous nor intermittent anticonvulsive therapy is recommended for children with one or more simple FCs
Recurrent FCs can create anxiety in parents, appropriate educational and emotional support should be provided
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35. Nelson
Indication: Moderate or high risk for epilepsy, very anxious parents concerning their child’s seizures
Choice: Intermittent diazepam
Alternative: In exceptional case that seizure recurs continuous phenobarbital
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36. Moderate or high risk of epilepsy (Nelson)
Delay in development: 33%
Focal complex FC: 29%
Family history of idiopathic epilepsy: 18%
Other complex FC: 6%
Recurrent (> 3 ) simple FC: 4%
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37. uptodate
In some complex FCs careful clinical history and review of the EEG may reveal an epilepsy syndrome
The benefits of antiseizure therapy may outweigh risks in such cases
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38. Indications for providing rectal diazepam for further prolonged seizures
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39. Japanese guideline
In prolonged febrile seizure(> 15 min) or > 3 risk factor of epilepsy or recurrence of FC:
Risk of Recurrent Febrile Fits:
age< 15 mo.
Epilepsy in a first degree relative
Febrile fits in a first degree relative
Fever <40ºC during first febrile fit
Brief duration between onset of fever and initial fit
Risk factors of epilepsy:
Delay in development
Family history of idiopathic epilepsy
Complex FC
Recurrent (> 3 ) simple FC
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40. Uptodate Prolonged FC Focal FC multiple risk factors for recurrent FC:
Young age at onset
History of febrile seizures in a first-degree relative
Low degree of fever while in the emergency department
Brief duration between the onset of fever and the initial seizure
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41. Parent education for recurrence of seizure
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42. Japanese guideline Remains calm. Note time of onset
Loosen the child’s clothing
Left lateral position with the head lower
Wipe any vomitus or secretion
Not insert any object into the mouth even if the teeth are clenched
Not give any fluids or drugs
Stay near the child until the seizure is over
If more than 3 risk factors, rectal diazepam 0.5 mg/kg if > 5 min
If seizure not aborted, seek urgent medical help
If the seizure is aborted, seek medical advise for the cause of the fever
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