Febrile convulsion

1. MOHAMMED ALHARTHI
PEDIATRIC RESIDENT R1

2. Contents
 Definition
 Classification
 Epidemiology
 Risk Factors
 Causes
Differential Diagnosis
Diagnosis
 Management
 Patient Education

3. Definition
 Febrile seizures are seizures that occurs between the age of 6 months to 5
years with a temperature of 38 C (100.4 F) or higher, that are not a result of
central nervous system infection or any metabolic imbalance, and in absence of
a history of prior afebrile seizure.
 Generally accepted criteria for febrile seizures include:
◦ A convulsion associated with an elevated temperature greater than 38°C
◦ A child older than 6 months and younger than 6 years of age
◦ Absence of central nervous system infection or inflammation
◦ Absence of acute systemic metabolic abnormality that may produce convulsions
◦ No history of previous afebrile seizures

4. Classifications
 Febrile seizures are further divided into two categories, simple or complex, based on
clinical features :
1. Simple febrile seizures: the most common type, are characterized by seizures
associated with fever that are generalized, usually tonic-clonic, last less than 15
minutes, and do not recur in a 24-hour period.
2. Complex febrile seizures: seizures associated with fever that are characterized by
episodes that have a focal onset (e.g. shaking limited to one limb or one side of
the body), last longer than 15 minutes, or occur more than once in 24 hours.
Febrile Status Epilepticus : febrile seizure lasting longer than 30 min or intermittent
seizure without neurologic recovery.

5. Epidemiology
 The most common neurologic disorder of infants and young children's.
 They are age dependent phenomenon.
 Occurs between the age of 6 months to 5 years
 Occurring in 2-4 % of children younger than 5 years.
 Peak incidence between 12-18 months.
 Male predominance with estimated male to female ratio 1.6:1

6. Epidemiology
 Febrile seizure recur in:
◦ 30% of those experience 1st episode .
◦ 50% after 2 or more episodes.
◦ 50% of infants younger than 1 year at febrile seizure onset.
 2-7 % of children experience febrile seizures proceed to develop epilepsy.

7. Risk Factors
 Age.
 High grade fever.
 Infections.
◦ ( Viral infections such as : HHV-6 and Influenza virus )
 Immunization.
◦ ( DTP & MMR )
 Genetic susceptibility.
◦ Family History of febrile convulsion. ( 10-20 % )
◦ Autosomal dominant trait .

8. Risk Factors for Recurrence
of Febrile Seizures
Major
1. Age < 1year
2. Duration of fever < 24hr
3. Fever 38-39
Minor
1. Family history of febrile seizure
2. Family history of epilepsy
3. Complex febrile seizure
4. Daycare
5. Male gender
6. Low serum sodium at time of presentation

9. Risk Factor for Occurrence of
Subsequent Epilepsy After a Febrile Seizure
RiskRisk Factor
Simple febrile seizure 1%
Recurrent febrile seizures 4%
Complex febrile seizures 6%
Fever <1 hr before febrile seizure 11%
Family history of epilepsy 18%
Complex febrile seizures (focal) 29%
Neurodevelopmental abnormalities 33%

10. Causes
 Upper respiratory tract infection .
 Roseola infantum (HHV-6) .
 Gastroenteritis ( Shigella or campylobacter) .
 Influenza Virus .
 Urinary tract infection .

11. Differential Diagnosis
 Central nervous system infection ( i.e. meningitis or encephalitis ).
 Genetic epilepsies with febrile seizures (GEFS+ or Dravet syndrome ).
 Shaking chills .
 Metabolic imbalance .
 Drug ingestion .

12. Diagnosis
 History .
 Physical Examination .
 Investigations .

13. History
 The type of seizure (generalized or focal) and its duration should be described to help
differentiate between simple and complex febrile seizures.
 Focus on the history of fever, duration of fever, and potential exposures to illness.
 A history of the cause of fever (eg, viral illnesses, gastroentritis) should be elucidated.
 Recent antibiotic use is particularly important because partially treated
meningitis must be considered.
 A history of seizures, neurologic problems, developmental delay, or other potential
causes of seizure (eg, trauma, ingestion) should be sought.
 A family history of febrile seizure or epilepsy .
 History of recent vaccination.

14. Physical Examination
 The underlying cause for the fever should be sought.
 A careful physical examination often reveals otitis media, pharyngitis, or a viral exanthem.
 Full neurologic examination should be done.
 Serial evaluations of the patient's neurologic status are essential.
 Check for meningeal signs as well as for signs of trauma or toxic ingestion.

15. Investigations
Blood Studies.
o Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and complete blood count ) are not
routinely recommended in the work-up of a child with a first simple febrile seizure.
Lumber Puncture.
The American Academy of Pediatrics (AAP) recommendations regarding the performance of
LP in the setting of febrile seizures, include the following :
o LP should be performed when there are meningeal signs or symptoms or other clinical features that
suggest a possible meningitis or intracranial infection.
o LP should be considered in infants between 6 and 12 months if the immunization status
for Haemophilus influenzae type b or Streptococcus pneumoniae is deficient or undetermined.
o LP should be considered when the patient is on antibiotics because antibiotic treatment can mask the
signs and symptoms of meningitis.

16. Investigations
 Electroencephalogram (EEG) .
o Routine electroencephalography (EEG) is not warranted, particularly in the setting of a
neurologically healthy child with a simple febrile seizure.
o EEG may indicated in complex febrile seizure with abnormal neurologic examination or in febrile
status epilepticus .
 Neuroimaging.
o Neuroimaging with computed tomography (CT) or MRI is not required for children with simple
febrile seizures.
o The incidence of intracranial pathology in children presenting with complex febrile seizures also
appears to be very low.
o Urgent neuroimaging (CT with contrast or MRI) should be done in children with abnormally large
heads, a persistently abnormal neurologic examination, particularly with focal features, or signs
and symptoms of increased intracranial pressure.

17. Management
 The majority of febrile seizures have ended spontaneously by the time the child is first
evaluated, and the child is rapidly returning to a normal baseline. In such cases, active treatment
with benzodiazepines is not necessary .
 In children with febrile seizures that continue for more than five minutes, we recommend
treatment with intravenous (IV) benzodiazepines (diazepam 0.1 to 0.2 mg/kg or lorazepam 0.05
to 0.1 mg/kg) Buccal midazolam (0.2 mg/kg, maximum 10 mg) is an alternative when IV access is
unavailable.
 Patients with continued seizures despite initial benzodiazepine administration (ie, febrile status
epilepticus) should be treated promptly with additional anticonvulsant medications, as are other
patients with status epilepticus.

18. Management
 Most children with simple febrile seizures do not require hospital admission and can be
discharged safely to home once they have returned to a normal baseline and parents have been
educated about the risk of recurrent febrile seizures.
 Diazepam at the 1st onset of fever for duration of the febrile illness may be effective but will
sedate a child and complicate the evaluation for the source of the fever .
Prophylactic anticonvulsants are not recommended after febrile seizure.
 Measures to control the fever such sponging, tepid baths, antipyretics and antibiotics for
proven bacterial illness are reasonable but unproven to prevent recurrent of febrile seizure .
Parent education and reassurance .

19. References
 Nelson TEXTBOOK of PEADIATRICS
 Nelson Essentials of Pediatrics
 Up-to-date
 Medscape

20. Thank You