FEBRILE SEIZURE

Presentor :Dr Sadiya

Senior resident
OVERVIEW
⚫ Definitions
⚫ Categories
⚫ Pathophysiology
⚫ Risk Factors
⚫ Diagnosis
⚫ Evaluation
⚫ Management
 What is it?
⚫ A convulsion associated with an elevated body
temperature more than 38 deg C

⚫ No central nervous system infection or

inflammation

⚫ No acute systemic metobolic / electrolyte

abnormality

⚫ No history of febrile seizures / any acute

neurological insult/ head trauma
⚫ Febrile seizure occurs between 6 months to
6 years of age

⚫ The most common seizure during childhood

⚫ Incidence 3 – 4% of young children
CATEGORIES
SIMPLE FEBRILE SEIZURE
⚫ Generalised tonic clonic seizure
⚫ Last less than 15 mins do not reccur within 24
hrs

COMPLEX FEBRILE SEIZURE

⚫ Focal features last more than 15 mins
⚫ Post ictal paresis
⚫ Recur within 24 hrs
FEBRILE STATUS EPILEPTICUS
⚫ Seizure lasting for 30 mins or more and series of
seizures without full recovery in between them

AFEBRILE FEBRILE SEIZURE

⚫ Seizure in an acute infectious illness
⚫ Without documented fever
⚫ Particularly in gastroenteritis
FEBRILE SEIZURE +
⚫ Febrile seizure that continue past the usual age
where they are expected to resolve around 6 yrs

GENETIC EPILEPSY WITH FEBRILE

SEIZURE PLUS (GEFS)
⚫ Febrile seizure plus with family history of febrile
seizures
 F.I.R.E.S
⚫ Febrile Infection-Related Epilepsy Syndrome
⚫ Affects 1;100,000 children,usually 3-15yrs old
⚫ Seizures happens solely during febrile illness
⚫ Explosive,prolonged,lifelong
⚫ Learning & motor disabilities, behavioural
disorders,memory issues& sensory changes
over time
⚫ May be fatal
 PATHOPHYSIOLOGY
⚫ POSSIBLE HYPOTHESIS

1. Increase in brain temperature leads to increase neuronal

firing by opening of temperature sensitive ion channels

2. Interleukin 1beta acts as pyrogen and seizure provocator

by acting on glutamate pathway ( NMDA Agonist)

3. Hyperthermia induced alkalosis makes neuron more

excitable
RISK FACTORS
⚫ Genetics (10 susceptible foci FEB1 TO 10)
⚫ AD/polygenic inheritance
⚫ Family h/0 25-40 %
⚫ Risk with
⚫ 1 parent-10-25%
⚫ 1 sibling- 10%
1parent +1sibling- 50%
⚫ Age 6months – 6yrs
⚫ Rapidly developing / high fever
⚫ VIRAL infections
( HHV6, influenza, adenovirus, parainfluenza)
⚫ Certain vaccines and age at admission
MMR but frequency is low
⚫ Other RF: micronutrient deficiency
(iron,vitamin D)
Nicu stay (OR 5.6)
Developmental delay(OR 4.9)
1st degree relatives with FS (OR 4.5)
2nd degree relative (OR 3.6)
Risk factors for recurrence of FS

MAJOR
1. Age <1yr
2. Duration of fever <24hr
3. Fever 38-39c (100.4-102.2F)
MINOR
4. Family h/o of FS
5. Family h/o of epilepsy
6. Complex febrile seizures
7. Daycare
8. Male gender
9. Low s.Na at time of presentation
⚫ Having no RF -12%
⚫ 1 RF-25-50%
⚫ 2RF-50-59%
⚫ 3RF-73-100%
PATHOPHYSIOLOGY OF FSE
⚫ Role of interleukin IL-1B (NMDA agonist)
results in neuronal hyperexcitability
⚫ IL-1B induces other cytokines IL-6, IL-8
⚫ Children with FSE have lower ratio of anti-
inflammatory to pro-inflammatory cytokines
(IL-1RA/IL-1B, IL-1RA/IL-6, and IL- 1RA/IL-
8)

* Gallentine WB, Shinnar S, Hesdorffer DC, et al; FEBSTAT Investigator Team. Plasma
cytokines associated with febrile status epilepticus in children: a potential biomarker for
acute hippocampal injury. Epilepsia 2017;58(06):1102-1111 *
CLINICAL EXAMINATION
✔ Vitals , anthropometry
✔ Obvious focus of infection
✔ Features of raised ICT
✔ Features of meningitis
✔ Neurocutaneous markers
✔ Dysmorphism
✔ Focal neurological signs
RED FLAG SIGNS
⚫ Focal neurological signs
⚫ Persistent altered sensorium after 1 hour of
seizure
⚫ Features of sepsis /shock / respiratory
distress
⚫ Features of meningoencephalitis / non
blanching rash in an unwell child
⚫ Features of ICT ( headache , papilledema ,
irregular respiration, brisk tendon reflexes )
EVALUATION
FOR SIMPLE FEBRILE SEIZURE
⚫ No role of routine lumbar puncture , CBC, CRP,
serum electrolytes , magnesium, EEG and
neuroimaging
⚫ Do calcium and iron if clinically indicated
⚫ Find focus of fever
⚫ Counsel about recurrence risk , epilepsy and
rescue medication
FOR COMPLEX FEBRILE SEIZURE

⚫ Consider CBC ,CRP, Serum electrolytes and

glucose
⚫ Consider Lumbar puncture if febrile status /
antibiotic pretreated / unvaccinated for Hib/PCV
⚫ Do calcium and iron if clinically indicated
⚫ Do MRI brain if incomplete recovery
⚫ Consider EEG , find focus of fever
⚫ Counsel about recurence risk and rescue
medications
Indications for lumbar puncture
⚫ Signs of CNS infectionsuch as meningeal
signs,altered sensorium >30min,bulging
fontanelle
⚫ <12mon meningeal signs may be absent,
consider LP (AAP recommendations)
⚫ 6-12mon not immunised with Hib /PCV
vaccine or if immunisation status
unknown
⚫ Pretreated with antibiotic(any age)
Indications for Neuroimaging
⚫ There is NO indication of neuroimaging in SFS
⚫ • In complex febrile seizure (CFS): diversity of
opinion
⚫ MRI brain is recommended among those with
• Focal neurological deficit
• Abnormal head circumference (microcephaly or
macrocephaly)
• Developmental delay
• Recurrent complex febrile seizure
• Febrile status epilepticus
⚫ FSE: to predict hippocampal injury and to rule out
other conditions like encephalitis, encephalopathy.
Role of EEG:
⚫ Predicting value of EEG in FS for subsequent epilepsy is
controversial in both simple and complex FS
⚫ There are no randomized trials to support or refute the
use of EEG and its appropriate timing in children with
complex febrile seizures (Cochrane review)
⚫ EEG needs to be considered in following children with
complex febrile seizures:
• More than one complex feature
• Abnormal neurodevelopmental state
• Family history of epilepsy
⚫ EEG performed within 1-7 days of CFS may reveal
slowing which may mask underlying IEDs inter ictal
epileptiform discharges.
MANAGEMENT
⮚ Airway, breathing and circulation are
continously assessed
⮚ Drug of choice for rescue management at
home is intranasal midazolam (0.2mg/kg ;
maximum 5mg )
⮚ Other effective drugs are intramuscular/buccal
midazolam , buccal lorazepam and per rectal
diazepam . Maximum 2 doses 5 mins apart.
In young children, in case of clinical suspicion of
meningitis and febrile status
⮚ Start 3rd generation cephalosporin till lumbar
puncture results
If diagnosed with Dravet syndrome – avoid
sodium channel blockers.
PROPHYLACTIC REGIMENS:

⚫ Neither continous nor intermittent

anticonvulsant therapy is recommended for
children with one or more simple febrile
seizures due to potential side effects

⚫ Intermittent prophylaxis - oral benzodiazepine

for children with frequent recurrent simple
febrile seizure
Intermittant therapy
⚫ Use of intermittent therapy at the onset of
febrile illness is known to reduce the risk of
febrile seizure (benefit)
⚫ Drugs used
1.clobazam 0.5 -1mg/kg/day in 2 doses * 3days
2.diazepam (0.3-0.5mg/kg)oral/rectal
⚫ Adverse effect of antiseizure medication (risk)
⚫ Limited use in FSE,recurrent FS,parental
anxiety,high risk of recurrence.
⚫ No role of intermittent prophylaxis in SFS
Long term AEDs for FS

⚫ Reduces the risk of recurrence ( benefit)

⚫ Nearly 30% of those develop adverse effects
⚫ No role in FS(risk> benefit)

Prophylactic AEDs are NOT RECOMMENDED for the rx of

simple and most cases of complex febrile seizures
⚫ Continous prophylaxis with anticonvulsants consider
among children with febrile status epilepticus ,
⚫ Febrile seizures in children neurodevelopmental delay
⚫ Antipyretics and tepid sponging if properly done may
improve comfort of child
⚫ Drugs that need special attention (association rather
causation)
✔ Use of antihistaminic agents posibbly reduces
seizure threshold
✔ Theophylline has possible role in inducing or
prolonging seizures

The anticonvulsants should be considered for 2 years

seizure free period
PROPHYLACTIC DRUGS
DOC for intermittent prophylaxis

⚫ Clobazam (0.5-1mg/kg/day in 2 divided doses

for 3 days without tapering ; maximum dose
20mg /day)

⚫ DOC for continous prophylaxis

⚫ Sodium valproate (20-40mg /kg/day)

⚫ Phenobarbital (3-5mg/kg/day)
⚫ Primidone (15-20mg/kg/day)
Should I give preventive therapy ?
⚫ Preventive use of antiseizure drugs decrease
the risk of recurent febrile seizures
⚫ But
⚫ Benign nature of simple febrile seizures
⚫ Risks of side effects generally overweigh the
benefits
⚫ Neither continuous nor intermittent
anticonvulsive therapy is recommeneded for
children with one or more SFS-AAP,RCPCH
WHAT ABOUT CHILDS FUTURE?
⚫ NEUROLOGICAL DEFICITS,
⚫ INTELLUCTUAL
IMPAIREMENT,BEHAVIOURAL
DISORDERS –NO
⚫ FSE-rarely leads to sequalae
EPILEPSY RISK ?
⚫ RISK FACTORS
⚫ Focal nature
⚫ Prolonged duration
⚫ Repeated episodes within 24hrs

⚫ 2-4% if no risk factors

⚫ 49% if all 3 of these RF present
 Risk factors for occurrence of subsequent
epilepsy after a febrile seizures

Risk factor Risk of subsequent

epilepsy
Simple febrile 1%

Recurrent febrile 4%

Complex febrile 6%

Fever <1hr before FS 11%

Family h/o of epilepsy 18%

Complex febrile (focal ) 29%

Neurodevelopmental abnormalities 33%

⚫Recurrences ?
⚫Too many…?
⚫Afebrile episodes…?
Genetic epilepsy
❑ Channelopathies- Na/ K/ Ca channel
mutations
❑ Spectrum of disorders
❑ Suspect if: Febrile seizures +
⚫ Young age at onset with multiple recurrences
⚫ Continuing beyond 6 years of age
⚫ Strong family history of FS+/ epilepsy
⚫ Change in semiology: Untriggered absence
seizures/myoclonic jerks
GEFS+= GENETIC epilepsy with FS+

⚫Unlike typical febrile seizures

⚫ Continue beyond six years of age
⚫ Afebrile tonic-clonic seizures

⚫ AD-SCN1B gene- SCN1A, GABRG (GABA receptor

gamma)2, PCDH19 (calcium channel)

⚫ Treatment: Afebrile episodes- long term AEDs- Valproate

⚫ prognosis is generally good-spontaneous remission of

seizures by age 11 years
Dravet syndrome
(severe myoclonic epilepsy of infancy SMEI )
⚫ Onset in first year of life in a previously well child

⚫ Febrile seizure progression to recurrent afebrile and

febrile, prolonged, and focal seizures

⚫ Diagnosis clinical- 80% mutation in SCN1A gene

⚫ Treatment- Valproate +/- Clobazam, Stiripentol, ketogenic

diet

⚫ Poor prognosis- developmental regression, risk of SUDEP

To sum up…
⚫ Management at home
Treating episode > 5 min- Midazolam spray
Indian context:
⚫ Prophylactic Diazepam/ Clobazam
⮚Age less than 1 year with CFS
⮚ Remote areas/ severe parental anxiety
⮚ Weigh risks vs benefit each time
To sum up…
Educating parents- key- spend time
⚫ Benign nature
⚫ Recurrence risk- appropriate management
of seizure episode
⚫ Midazolam spray use in home
⚫ Allay fever phobia- do not over treat fever
⚫ Thank you