7 steps How to prevent Thalassemia : Dr Sharda Jain & Vandana Gupta
Seizures - Febrile Seizures
1. Seizures / Febriles Seizures
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Topics
• Seizure***
• Causes / Classification
• Neonatal seizures
• Febrile seizures***
• Epilepsy & Specific epileptic syndromes***
• Status epilepticus
• Drug therapy in epilepsy
3. Seizures in children
• Common neurological disorder in children
• Do not constitute diagnosis-Is symptom of
underlying CNS disorder
4. Definition- Seizure :
• Paroxysmal alteration in behavior due to any
transient brain pathology-cerebral
dysrhythmias, Transient ischemic or anoxic
attacks (faints) - excessive and abnormal
discharge from cortical neurons
**May be manifested as Transient, involuntary
alteration or loss of consciousness, abnormal
motor activity, behavioral abnormalities,
sensory disturbance or autonomic dysfunction
5. • 10% of children have seizure
• Most seizures are provoked by somatic
disorders originating outside brain – like –
high
fever, toxins, hypoxia, arrhythmias, psychogeni
c etc.
• Less than 1/3rd of seizures are caused by
epilepsy
6. Terminology
• Fit :-
Clinical manifestation of cerebral
dysrhythmia
- Maybe convulsive-GTC
- Maybe nonconvulsive –
absence or complex partial
7. Terminology
• Convulsion:-
• Tonic clonic motor component of seizure
• When child shows sudden episode of
decerebrate posturing which is followed
by clonic jerking-
**all convulsions are not epilepsy
8. Terminology
• Epilepsy : Two 0r more unprovoked seizure occurring at
an interval greater than 24 hrs apart
– recurrent fits due to repeated primary
cerebral dysrhythmias
9. • What are nonepileptic conditions
that may mimic seizures?
11. Mimicking seizures
Jitteriness
– Absence of abnormal gaze movements
– Provoked by passive flexion or extension
– Movement to and fro shorter duration
– Normal EEG
– No increase in blood pressure or heart rate
• No postictal phase after these episodes
12. Mechanisms
• Exact cause unknown
• Basis-Failure of mechanism that aborts S
1. Excessive persistent excitation - by
excitatory neurotransmitters --
glutamate, aspartate, acetylcholine also N-
methyl-d-aspartate (NMDA)
2. Ineffective recruitment of inhibition -
dominant inhibitory neurotransmitter
gamma aminobutyric acid (GABA)
13. Mechanisms
3.Significant neuronal burst discharge-
usually by voltage dependent calcium
currents
4.Arise from areas of neuronal death-
these regions promote development of
hyperexcitable synapses that promote
seizure
18. Febrile Convulsion
**Most common seizure disorder with excellent
prognosis
• Definition:-
Seizure occurring with temp ≥38oC in absence
of detectable CNS infections but there may be
association of acute extra cranial infections
and high environmental temperatures
19. Febrile Convulsion
• Incidence – 3-5%
• Autosomal dominant pattern of inheritance
• Chromosome 19p & 8q.
• Thus , family history imp.
20. PATHOGENESIS
• Due to temporary impairment of the balance
between the convulsant and anticonvulsant
system of brain
• Threshold level of anticonvulsant system in
these genetically predisposed children is lower
21. PATHOGENESIS
• Studies in children suggests – that the
cytokine network is activated and may have a
role in the pathogenesis of febrile seizures
• Other suggestion - endogenous
pyrogens, such as interleukin 1, increasing
neuronal excitability & causing seizures
22. Causes - Febrile Convulsion
1.ARI-URTI(Otitis media )
2.LRTI
3.Viral fever- Roseola and Influenza A , other
fever with rash
4.UTI
5. Gastroenteritis
23. Typical F. Convulsion
1. Age- 6months – 5 yrs peak 14 - 18 months
2. With rapid rise of temp ≥38oC ,within 24 hrs
of onset of fever
3.Should not last more than 10 min
4. Generalized not focal
24. Typical F. Convulsion
5. Positive family history ( 50%) - AD in some
families
6. One seizure attack at each episode
7. No residual weakness of limb or disability
except a brief period of drowsiness
8.EEG between and after seizure is normal
9.Extracranial infection may be + but no CNS
infection
25. Criteria for Diagnosis
• Above features plus
• M>F
• Infections: 90% of the cases are due to viral
infections, Common infections are URTI, Otitis
Media, Pneumonia, UTI and Roseola
• Recurrence: 30- 50% under 1 year. Frequency
decreases after 5 yrs of age.
26. Classification
• SIMPLE
- Age group-6months – 5 yrs peak 14 - 18 months
- GTCS
- <10 MIN
- Single in 24 hrs1 fit per febrile episode
- Brief / no post ictal phenomenon
- EEG - N
27. Classification
• ATYPICAL/ COMPLEX
- > 15 MIN
- >1 Episode per fever - Occurs more than once in 24 hrs
- Focal
- + family history
- Pre existing CNS disorder
- Delayed devl or regression
- - Followed by Todd paralysis, but no significant other
- reason or CNS infection can not be found
- EEG may remain abnormal for 2wks or more
• Continuous prophylaxis therapy may be given
28. Risk factor for 1st episode
• + family history
• After immunization – DPT , MMR.
• INFECTIONS esp Herpes virus
• Fe def
29. Risk Factors for Recurrent Febrile
• Younger than 18 months
• Duration of fever (i.e., shorter duration of fever
before seizure - higher risk of recurrence)
• Complex febrile seizure at onset
• Family history of epilepsy
• Family history of febrile seizures
• Height of fever (i.e., the lower the peak fever, the
higher the rate of recurrence)
30. Risk factors for devp of epilepsy
1.+ family history
2. 1st F .seizure before age 9 month
3. Atypical F. seizure
4. Delayed milestones
5. Abnormal neurological findings
Risk of epilepsy increases to 9% from 1% if
above factors are ++
31. AAP Practice Parameter
• Lab testing - identifying source of fever
- part of routine evaluation
• Do blood glucose in all patients
• Blood Studies: No indication for routine testing of
electrolytes, calcium, magnesium, CBC
• Neuroimaging: No need to perform in routine
evaluation of first febrile seizure
32. Investigations - AAP Practice Parameter
• EEG: not needed for first simple febrile seizure
but done in complex febrile seizure
• LP: should be “strongly considered” in < 12
mos and “considered” between 12-18 mos.
• If older than 18 mo, rely on meningeal S&S
• Also consider LP if prior antibiotic treatment
33. Hospital care
1.Position –semi prone –ABC
2. Control fever-antipyretics, tepid sponge
3.Control convulsion-Diazepam IV/PR
4. Infection should be looked for and treated
- LP?
- CBC?
• Parents reassurance
35. Treatment
5.prophylaxis-
- Intermittent with oral diazepam -0.3mg
/kg/ dose TID
clobazam, midazolam –effective
- Long term prophylaxis- sodium valproate
36. SEIZURE PROPHYLAXIS
• Intermittent • Continuous
• Diazepam • Valproate
• Clobazam • No role of
• Midazolam phenytoin/CBZ/Ph
enobarbitone
37. • Criteria for Prophylactic anticonvulsant
therapy:
1. <18mo with previous abnormal
development or abnormal neurological
signs
2. Atypical febrile seizure
3. Recurrent febrile seizure
4. High level of parental anxiety
38. • Continuous daily prophylaxis given with
Sodium Valproate 30- 60mg/kg/day in two
divided doses to be continued for at least 2 fit
free years or until child is 6 yr old, whichever
comes earlier.
39. Patient Education
• Counsel on the benign nature of febrile seizures
• Reassured that simple febrile seizures do not lead to
neurological problems or developmental delay
• If their child has another seizure -
• To call for assistance if the seizure lasts longer than 10
minutes or if the postictal period lasts longer than 30 minutes
40. Prognosis
• 50% with single F. convulsion have no
recurrence even if untreated
• 30-50% have recurrence
• 40% in 1st episode have > one or more further
convulsions,10% will have multiple attacks
• 1% with no risk factors and 9% with risk
factors develop epilepsy by age 7 yrs
41. Thank you
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