Febrile seizure

Dr Harshuti shah

Child neurologist

Rajvee hospital

Helemt char rasta

Ahmedabad

END 2012

All went Fake

Anything

which

is

frightening is

not

life threatening

How far it is common?

2-4% of pediatric population

Commonest neurological emergensy to be presented in the clinic

Peak age of onset 1-3 year-i.e. 18 months

What is febrile seizure?

As the name implies,

Seizure associated with fever

“An event in infancy or childhood usually occurring between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause”

Confirmation of febrile seizure

Age group:1 month-

Occurrence after 6 year is uncommon

Temperature is usually high>38.5*c or 100.4 F

Generalised tonic-clonic But could be partial

How to categerise?

Simple febrile seizure(60-70%)

5 f’’Generalised

Lasts <10 min.

No recurrence in 24 hours(within same illness)

3 mo-5 year

No preictal/postictal aura

Complex febrile seizure(30-40%)

Focal

Lasts>15 min.

Recur within 24 hours(within same illnes)

Beyond 6 year

Postictal deficit

FAQ

Will anything happen to my child?

Self limiting

Not brain damaging

Extremely low mortality associated with febrile seizure

Even least with febrile status epilepticus

Do I need admission?

Admission

1. to identify the cause of fever

2. To know the recurrence in case of complex seizure

Least chances of recurrence with simple febrile seizure

Why does it occur?

Age specific reaction to systemic illness

Breakdown of threshold associated with rate of rise of temperature

Herpes-6 & Herpes -7 infections have highest rate of infection

Gastroenteritis infection has lowest incidence

What are investigations?

Total count-not much significant

(There might be pleocytosis,If blood is withdrawn at the time or immediately after the onset of seizure)

Electrolytes-low serum sodium after first febrile seizure is associated with the significant risk of recurrent febrile seizure

Whether it will happen again?

Simple febrile seizure-NO

Focal,afebrile,lethargic child-high chances of recurrence

Neurodevelopmentally delayed/deranged child-high chance of recurrence

Lumber puncture

Most imp. To r/o CNS infection in children

Varied and vague presentation in infants

Need careful evaluation by experienced doctor to avoid L>P.

Imp. Points

Focal seizure

Persistent lethargy

Child had been within 48 hours prior to onset of seizures for febrile illness

Or

Recurrence of seizure in 24 hours in chld <1 year

Conclusively,

All children<12 months old need lumber puncture

Do they need EEG?

GAP between evidence-practice continues

Consistent evidence that routine EEG does not predict

febrile seizure recurrence

Or

subsequent epilepsy

Hypnagogic spike-waves

Not to be suggested if diagnosis is confirmed.

I want CT scan/MRI

X –ray skull

CT scanNo proven benefitNot justified based on anxiety

MRI:May reveal the changes of acute inflammatory reaction on T2 weighted images but usually disappears (FEBSTAT study)

Does not carry future implication

Whether my child will develop epilepsy?

2% chance only for development of epilepsy

4-12% following complex febrile seizures

One must know….

High risk of development if epilepsy is with

Focal seizures,

Prolonged seizures

Developmental dysfunction

Neurological dysfunction

Epilepsy associated with family members

What are the probability of having recurrent febrile seizures?

If first seizure occurs before 1year of age

If seizure occurred within 1 hour of onset of fever-

Fever occurred after the onset of seizure

Seizure occurred at low temperature<100.4

Developmentally delayed child

What should be done at home in acute attack

Put the child on floor in open

Turn head on one side

Do not put any hard object nearby

Remedial measures at HOME

1.intranasal spray

2. Per rectal supoositary

3. Use of per rectal inj. Diazepam/benzodiazepam

DO NOT PUT ANYTHING IN MOUTH except maintaining airway.

Use of intranasal spray

Easily operable

Put the nasal spray as soon as the onset of seizure

No. of spray =1/2 of the no. of weight

Can be used intrabucally

Can be repeated thrice at the interval of 10 min.

Use of rectal suppository

Diazepam suppository readily available

May cause drowsiness and lethargy thereafter

If nothing ,

Inj. Diazepam (0.5mg/kg)/inj.lorazepam (0.1mg/kg)can be infused per rectally using feeding tube

REDUCES DURATION OF FEBRILE SEIZURE

RELIEF TO FRIGHTENED PARENT AS SENSE OF BEING IN CONTROL

In clinic for control of acute seizure

First step,

Use of intranasal spray

Inj. Lorazepam 0.2 mg/kg to be given i.v. slowly

Inj. Diazepam0.3mg/kg to be given I.v. slowly with the watch on respiration

Rectal diazepam can be given

What for Prevention of recurrent attack?

Should I prevent the rise of temp?

Seizures occurring at the height of temp. has less chance of recurrence(22%)

Reduction of temp. or use of prophylactic antipyretic does not help in preventing the recurrence of febrile seizures

RENDERS THE CHILD MORE COMFORTABLE

Recurrent febrile seizure despite of medicines given

Misperception of febrile seizure

Febrile myoclonus

Occurs along with febrile illness

During the sleep only

Occurs in form of jerky movements involving either of limbs non rhythmic ,erratic

Syncopal attacks

Very often

Always occur in upright posture

Characterised by uprolling of eyeball and generalised stiffening sometimes followed by few myoclonus

RIGORS

Consciousness is well retained

Do they need AED if the febrile seizures are frequent?

Regular AED is not an indication for no. of febrile seizures

Regular use of prophylaxis in the high risk for recurrence of febrile seizure usually suffices

What medicines to be used to prevent the recurrence of febrile seizure

IN INDIA,

Benzodiazepine 0.1 mg/kg to be given at the time of illness/fever orally i.e. clobazam

To be given at interval of 12 hours for 2 days

Phenobarbitone(gardinal)4-5mg/kg/day-effective but behavioural issues and intellectual dulling

Valproic acid-effective-but risk of fatal toxic hepatitis

Carbamazepine and phenytoin are not effective

What in long run?

Very good prognosis

Do not develop epilepsy in most(risk2%)

Risk of development of mesial temporal lobe sclerosis is only(2%)

Can lead to normal life

NO Effect on school performance and intelligence, academic progress

Inheritance

Autosomal dominant

Polygenic pattern

Positive history of febrile seizures in first or second degree relatives increases risk 2-3 fold