Febrile Seizures

Medscape

Background

Most common seizure disorder in childhood. Divided into: simple febrile seizures, complex febrile
seizures, and symptomatic febrile seizures.

Simple febrile seizure 70-75%

- The setting is fever in a child aged 6 months to 5 years. Generalized < 15 minutes. But the
postictal time may be sleepy.
- NO other neurological abnormality.
- Fever (and seizure) is not caused by meningitis, encephalitis, or other illness affecting the
brain.

Complex febrile seizure 20-25%

- This seizure is either focal or prolonged (ie, >15 min), or multiple seizures occur in close
succession.

Symptomatic febrile seizure 5%

- The child has a preexisting neurological abnormality or acute illness.

Pathophysiology

- Elevation of temperature. The underlying pathophysiology is unknown, but genetic

predisposition clearly contributes to the occurrence of this disorder.1

Frequency

- Febrile seizures occur in 2-5% of children aged 6 months to 5 years in industrialized

countries.

Mortality/Morbidity

- Previous simple febrile seizure → febrile seizures; in 1/3 of cases.

- Children younger than 12 months at the time of their first simple febrile seizure have a
50% probability of having a second seizure.
- Children who have simple febrile seizures are at an increased risk for epilepsy. The rate is
2.4%, about twice of general population.
- Males have a slightly (but definite) higher incidence of febrile seizures.

Clinical
History

- Seizure only with fever.

- The seizure is described as either a generalized clonic or a generalized tonic-clonic seizure.

o Signs of a focal seizure during the onset or in the postictal period (eg, initial clonic
movements of 1 limb or of the limbs on 1 side, a weak limb postictally) would rule
out a simple febrile seizure.

- Simple febrile seizures often occur with the initial temperature elevation at the onset of
illness. The seizure may be the first indication that the child is ill.

Causes

Simple febrile seizures are considered a genetic disorder, but neither a specific locus nor a specific
pattern of inheritance has been described.

Differential Diagnoses

Acute Disseminated Encephalomyelitis Neonatal Seizures

Acute Stroke Management Partial Epilepsies
Anterior Circulation Stroke Posterior Cerebral Artery Stroke
Aseptic Meningitis Seizures and Epilepsy: Overview and Classification
Basilar Artery Thrombosis Simple Partial Seizures
Benign Childhood Epilepsy Tonic-Clonic Seizures
Complex Partial Seizures Viral Encephalitis
First Seizure: Pediatric Perspective Viral Meningitis
Meningococcal Meningitis
Neonatal Meningitis

Benign epilepsy syndromes.

Brain abscess.
Bacterial meningitis.
Encephalitis.
Epilepsy.

Workup

- No specific studies are indicated for a simple febrile seizure.

- Physicians should focus on diagnosing the cause of fever.
- Other laboratory tests may be indicated by the nature of the underlying febrile illness. For
example, a child with severe diarrhea may benefit from blood studies for electrolytes.

Imaging Studies
Neither computed tomography (CT) nor magnetic resonance imaging (MRI) is indicated in patients
with simple febrile seizures. EEG is not indicated in children with simple febrile seizures. Published
studies demonstrate that the vast majority of these children have a normal EEG.

Procedures

- Strongly consider lumbar puncture in children younger than 12 months, because the signs
and symptoms of bacterial meningitis may be minimal or absent in this age group.
- Consider in children aged 12-18 months, and in > 18 months clinical judgment.

Treatment

On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is
indicated for children who have experienced 1 or more simple febrile seizures.

- Continuous therapy with phenobarbital or valproate they ↑ risks and adverse effects.
- No evidence suggests that any therapy administered after a first simple seizure will reduce
the risk of a subsequent afebrile seizure or the risk of recurrent afebrile seizures (ie,
epilepsy).
- < 2 years Phenobarbital because valproate is more hepatotoxic.
- > 2 years valproate because Phenobarbital may alter neurodevelopment.
- Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is
intermittent, this therapy probably has the fewest adverse effects. If preventing
subsequent febrile seizures is essential, this would be the treatment of choice (IV or
rectal). Midazolam is another option.
- Antipyretic therapy is desirable.

Diazepam (Diastat, Valium, Diazemuls) 0.33 mg/kg PO at onset of fever; continue q8h until child is
afebrile.

Can decrease number of subsequent febrile seizures when given with each febrile episode. By
increasing activity of GABA, a major inhibitory neurotransmitter, depresses all levels of CNS,
including limbic and reticular formation.
A study reported in New England Journal of Medicine continued therapy until child was afebrile for
24 h. However, this seems excessive.

Follow-up

Prognosis for normal neurologic function is excellent.

- About one third of children who experience a single simple febrile seizure will have
another.

Patient Education

- Inform parents that these dramatic events do not indicate future neurologic dysfunction
or disease.
 - For excellent patient education resources, visit eMedicine's Brain and Nervous System
Center. Also, see eMedicine's patient education articles Seizures and Fever and Seizures in
Children.

Miscellaneous

Medicolegal Pitfalls

Not recognizing bacterial meningitis or herpes simplex encephalitis and falsely diagnosing as a
simple febrile seizure