this is a complete discussion and an approach to a child with febrile seizure / convulsion. It contains:- Case scenario Causes of Seizures in the setting of fever Definition of Febrile Seizure Age of Occurrence Types of Febrile Convulsions Risks of Recurrent Febrile Seizures Risk For Developing Epilepsy After Febrile Seizures Workup for Febrile Seizure Red Flags in Febrile Seizures Treatment Prognosis

1. FEBRILE
CONVULSION /
SEIZURES

2. Contents:-
• Case scenario
• Causes of Seizures in the setting of fever
• Definition of Febrile Seizure
• Age of Occurrence
• Types of Febrile Convulsions
• Risks of Recurrent Febrile Seizures
• Risk For Developing Epilepsy After Febrile Seizures
• Workup for Febrile Seizure
• Red Flags in Febrile Seizures
• Treatment
• Prognosis

3. Case scenario:-
• A 24 months female was brought to the ER after
developing abnormal body movement. She had fever
and cough but no skin rash.

4. Causes of Seizures in the
setting of fever:-
1. Central nervous system infections (meningitis,
encephalitis, brain abscess),
2. First presentation of epilepsy triggered by fever
3. Febrile seizures.

5. • Febrile Seizure: is a seizure occurring in infants or small
children, associated with a febrile illness who do NOT have:
1. Infection of the CNS.
2. Metabolic Disturbances.
3. Previous neonatal seizures
4. Previous unprovoked seizure.
5. Meet the criteria for other acute symptomatic seizures.
• Most Febrile Seizures last a 1-2 minutes,
• some can be as brief as a few seconds
• others last for more than 15 minutes.
• Fever is usually defined as greater than 100.4 F (38C).
• Febrile seizure occurs only once per febrile illness

6. Types of Febrile Convulsions
Simple Febrile
Seizure
• Less than 15
minutes in
duration.
• Generalised
(usually tonic-
clonic) type of
seizure.
• Does not
reoccur within
24 hours
Complex Febrile
Seizure
• Prolonged in
nature (greater
than 15
minutes).
• Focal type of
seizure.
• Reoccur >1
within a 24-hour
period.
Febrile Status
Epilepticus
• When the
seizure lasts for
>30 mins and is
associated with
fever.

7. Age of Occurrence
• Most common childhood seizure
• Incidence 2-5% in children under 5 years (US)
• Male > Female
• Family History is present in 30% of cases.
• Average Age 6 months to 5 years
• Almost all first febrile seizures occur by age 3 years
• Median Age 18-22 months

8. Risks of Recurrent Febrile Seizures:-
• Overall, around 30% have further febrile seizures.
Risk Factors:
1. Early Age of Onset (<18 months).
2. Family History of Febrile Seizures.
3. Lower Fever (<40C) at the time of the initial seizure
4. Short duration of fever (<1hr) before the initial seizure
Risk Factors = Risk of Recurrence
0 = 15%
1 = 27%
2 = 39%
3 = 65%
Must be assessed during work-up

9. Risk For Developing Epilepsy After Febrile
Seizures:-
• Overall, around 3% develop Epilepsy after febrile seizures.
Risk Factors:-
1. Epilepsy in a first-degree relative
2. Complex Febrile Seizure
3. Baseline Neurodevelopment Abnormalities (prior to first febrile
seizure)
4. Abnormal neurologic exam- ination
• Risk of Unprovoked Seizure, 2-4% after febrile seizures if no
risk factors
Risk Factors = Risk of Recurrence
0 = 1%
1 = 2%
>/=2 = 10%
Must be assessed during work-up

10. Workup for Febrile Seizure
1. History and Examination (primary goal is to determine source of
fever)
2. CBC
3. Chemistries including Na, Mg, P, and Ca
4. Appropriate Fever Evaluation (blood culture, stool culture, LP)
• Many children may have HHV6, but not clinically indicated to test
• Lumbar Puncture, only if have meningeal signs and risks.
5. Imaging not needed, only indicated if:
1. History of head trauma
2. Abnormal exam
3. Evidence of increased ICP
6. EEG is not helpful unless it is unclear if event was seizure or not,
then should be done in first 7 days, if abnormal repeat to see if
abnormalities resolve.

11. Indications for lumbar
puncture in febrile seizures:-
1. Febrile seizure in the first year of life.
2. Suspicion of meningitis – irritability, poor feeding,
meningeal signs +.
3. Pretreatment with antibiotics, because antibiotic
treatment can mask the signs and symptoms of
meningitis.
4. Not immunized
5. Exposure to another child with meningitis

12. Red Flags in Febrile Seizures
1. Hemi-Convulsive Seizures.
2. Frequent episodes of Status Epilepticus under one year of age.
3. Febrile Seizure Associated with Meningeal Signs are not
considered Febrile Seizures – must consider an infectious
process.

13. Treatment
1. ABC
2. Since Simple Febrile Seizures are “benign”, most children require NO treatment
3. Treat Underlying Cause
4. Screen and Treat Iron Deficiency Anaemia.
• Increases risk of Febrile Seizure
5. Control of Fever
• Anti-Pyretics do NOT prevent recurrent Febrile Seizure
• Administration of antipyretics during the same fever episode may reduce the risk of recurrence within that illness,
but it does not seem to impact febrile seizure recurrence during subsequent fever episodes.
6. Rectal diazepam can be administered during a seizure to abort a prolonged convulsion - anti-convulsant if
seizure > 5 minutes
7. Rescue Medications – anticonvulsant prophylaxis during subsequent febrile episodes (Rectal
Diazepam or Buccal/Intranasal Midazolam) – if:-
1. high risk for recurrent febrile seizures
2. history of prolonged febrile seizures
• The American Academy of Pediatrics recommends against prophylaxis with anticonvulsants due an
unacceptable risk–benefit ratio.
8. Long-Term Anti-Convulsant Therapy is controversial (due to its side-effects and the already good
prognosis of Febrile Seizure)

14. Prognosis
• The prognosis of children with simple febrile seizures is
excellent.
• Intellectual achievements are normal.

15. Summary
• Febrile Seizures are usually “benign”.
• Most children with Febrile Seizures do not develop
Epilepsy, although it does increase the risk of Epilepsy.

16. Q. Regarding febrile seizure, all of the following are true except:
A. Onset between 6 months and 6 years.
B. Seizures lasting less than 15 minutes.
C. Positive family history.
D. Seizure is more likely to occur with the rapid rise of temperature.
E. Lumbar puncture is diagnostic.

17. A 5-years-old male child had history of high fever for 2 days
temp reach to 39.3 C , today mother come to emergency unit
because of abnormal body movement happen twice each one last
3 to 4 minute 12 hours apart, he had a history of attack of febrile
convulsion before 1 year, and in exam his conscious and no
neurological sign the source of infection was follicular tonsillitis.
Q. What type of convulsion did he have?
A. Simple convulsion
B. Complex febrile convulsion

18. Case 1
A 2 year old girl called Becky is brought to her local
emergency department with the following history…
Her mother had left her in the living room to prepare her
meal when she heard a scream. She rushed back to the
living room. In her own words:
“Her lips were blue and she was stiff all over”
“Her eyes were rolled upwards and her breathing was
shallow”
“I went to pick her up and she began to shake all over”
The episode lasted about 15 minutes and afterwards, she
was drowsy and fell asleep.

19. Her temperature at home was 37.5 C.
She had a 12 hour history of runny nose and fever. Her
mother had run out of “Calpol” and “Brufen” and so
Becky had not had any anti-pyretics.
Her mother had stripped her clothes off, opened the
window and put a fan besides her.
Q1. What type of event do you think this is?
Q2. As a hospital doctor, how would you manage her?
Q3. Would you perform any investigations? If yes, which
ones?
Q4. Becky’s mother asks “will she develop Epilepsy?”,
how do you respond?
Q5. What advice would you give the parents, prior to
discharge?

20. THANK YOU
References:
• Nelson Essentials of Paediatrics (8th Ed.)
• Illustrated Textbook of Paediatrics (6th Ed.)