Febrile Seizures

Definition and Classification

Any seizure, occurring in an infant or young child between 6 months and 5 years
of age, in conjunction with a fever and without evidence of an underlying cause, such as
neurologic disease, central nervous system infection, metabolic disturbance, and without
evidence of a previous afebrile seizure.
Febrile seizures can be classified as either simple or complex. A simple febrile
seizure is generalized in nature, lasts less than 15 minutes, and occurs only once in a 24
hour period. A complex febrile seizure lasts more than 15 minutes, has focal features at
any time, or recurs within a 24-hour period.

Epidemiology

Febrile seizures are the most common form of childhood seizures, affecting
between 2-5% of children in the United States. Peak incidence is at approximately 18
months of age and is slightly more common in boys. 65-90% of febrile seizures are
classified as simple.
The most consistently identified risk factor for having a first febrile seizure is
family history. There is a positive family history of febrile seizures in first degree
relatives in 25-40% of cases. Other risk factors for having a first febrile seizure include
attendance at day care, the height of fever during a febrile illness (higher fever = higher
risk), and some studies have shown two additional possible risk factors include neonatal
nursery stay of more than 30 days, as well as developmental delay.

Prognosis

The risk of recurrence after a first febrile seizure is about 30% and about 10% will
have three or more febrile seizures. The risk factors for recurrence include family history
of febrile seizures, age less than 18 months at initial seizure, temperature less than 40
degrees Celsius, brief duration of fever (< 1 hour). A family history of epilepsy is a
possible risk factor according to some studies.
The risk for epilepsy in the general population is approximately 1% by age 7
years. Overall, there is only a slightly greater risk for development of epilepsy in
children with simple febrile seizures, with the risk increased to only 2.4% by age 7 years
even in those with multiple simple febrile seizures. Thus, parents should generally be
reassured that there child is not likely to develop epilepsy. Risk factors for developing
subsequent epilepsy include underlying neurodevelopmental abnormality, complex
febrile seizure, family history of epilepsy, and brief duration of fever prior to the seizure.
Febrile seizures are overall very benign. Although there is a considerable risk of
recurrence, there is only a very slight increased risk of developing epilepsy when
compared to the general population. There is no association between simple or complex
febrile seizures and the later development of neurological deficits or changes in
intellectual, cognitive or scholastic functions. In addition, there is no increased risk in the
incidence of mortality and no association with sudden infant death syndrome.

Evaluation and Management

The overwhelming majority of febrile seizures will have terminated upon
presentation to the emergency department, and most patients will not need any
stabilization interventions except for minimal airway support during the postictal period.
An ongoing seizure on arrival in the emergency department is an indication for initiating
therapy to abort or prevent status epilepticus. Intravenous benzodiazepines are effective
in most cases. Rectal diazepam is appropriate when intravenous access is difficult.
After stabilization, one should focus most immediately on ruling out serious,
potentially life-threatening causes for seizures such as meningitis, encephalitis, trauma, or
toxic exposure. Hypoglycemia and electrolyte abnormalities need to be excluded before
a diagnosis of febrile seizure can be made. Many of the above causes can be ruled out by
a detailed history, physical examination, and clinical appearance after the seizure has
ended.
Laboratory evaluation directed towards the work-up of fever is the same as for
any child presenting with fever alone, and does not need to be done routinely in every
case. It is based on age, height of fever, and a good clinical history and physical
examination. Routine laboratory studies, such as measurement of serum electrolytes and
glucose are of very low yield. They are most beneficial in situations where there is a
suspicious clinical picture, such as a child appearing dehydrated or with a history of
diarrhea, vomiting or abnormal fluid intake.
The most common evaluation issue is whether a lumbar puncture is necessary to
exclude meningitis. In children less than 18 months the clinical signs and symptoms of
meningitis can be subtle or absent. The fear of missing a diagnosis of meningitis in a
child presenting with fever and seizure has lead to many children undergoing lumbar
punctures in years past. The clinical appearance of the child after the seizure has ended
plays a very significant role, in that the playful, active child who appears normal,
probably does not have meningitis. Also, studies have shown the yield of positive
findings from routine lumbar puncture is low in the absence of suspicious clinical
findings and risk factors associated with a higher chance of having underlying meningitis.
Therefore, it has been recommended to strongly consider lumbar puncture in a child
younger than 18 months having an apparent febrile seizure with any of the following: 1)
any physical signs of meningitis or encephalitis; 2) history of irritability, decreased
feeding, lethargy, or vomiting; 3) seizure that was prolonged, focal, or multiple; 4)
prolonged post-ictal altered consciousness or neurological deficit.
If the child is less than 12 months one should have an even lower threshold for doing a
lumbar puncture if any of the above are present. Children older than 18 months have
more reliable signs and symptoms of underlying meningitis and a lumbar puncture can be
deferred if these are absent. In addition, infants and children who were treated with
antibiotics prior to the seizure should be strongly considered to undergo lumbar puncture.
This is because antibiotics can mask the signs and symptoms of meningitis (partially
treated meningitis).
Neuroimaging is not indicated in the routine evaluation of febrile seizures. There
is no data available showing that children with febrile seizures have an increased
incidence of underlying central nervous system abnormalities, nor any evidence that
febrile seizures lead to structural brain damage. Neuroimaging may be considered in a
complex febrile seizure (especially if there are focal features), although the evidence for
any benefit from this is unclear. One should consider neuroimaging in children with
micro- or macrocephaly, evidence of an underlying neuro-cutaneous syndrome, pre-
existing neurological deficit, a prolonged post-ictal neurological deficit, or recurrent
complex febrile seizures.
An EEG is not indicated in the evaluation of the neurologically healthy child with
a first simple febrile seizure. Studies also show that even recurrent simple or complex
febrile seizures do not justify an EEG, as it is of no use in identifying a structural
abnormality or in predicting recurrent febrile seizures or the development of epilepsy.
However, one may consider an EEG in patients with developmental delay, underlying
neurologic abnormalities, or focal seizures.
Regarding the long term management of febrile seizures there is strong consensus
that prophylactic anti-convulsants not be recommended for children with one or more
simple febrile seizures. There are no published guidelines regarding prophylaxis of
complex febrile seizures, although no treatment is needed in most of these children. A
rational goal of therapy would be to prevent very prolonged febrile seizures. When
treatment is indicated, particularly in those at risk for prolonged or multiple febrile
seizures or those who live far away from medical care, rectal diazepam used at the time
of seizure as an abortive agent is a logical choice. Daily antiepileptics at the time of fever
are rarely used in the management of febrile seizures and all have significant risks and
side effects. Antipyretics have not been shown to be effective in preventing recurrence.

Counseling and Education

Counseling and education will be the sole treatment for the majority of children
with febrile seizures. Education is key to empowering parents who have just experienced
a very frightening and traumatic event. Parents need to be reassured that the child will
not die during a seizure and that keeping the child safe during the seizure is generally the
only action that needs to be taken.
General facts about febrile seizures should be presented to the family. They
should be made aware of the risk of recurrence and information should be provided about
how to manage further seizures. This should include what to do during a seizure, when it
may be necessary to call a physician, and when the child should be taken to the
emergency department.