Febrile Seizures

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Febrile Seizures: 

Febrile Seizures

Febrile Seizures: 

Febrile Seizures Definition “a seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures”

Febrile Seizures: 

Febrile Seizures Epidemiology 2 to 5 % of children in the US Most common form of childhood seizures Peak at 18 months Simple = isolated, brief, generalized Complex = focal, multiple, or prolonged

Simple Febrile Seizures: 

Simple Febrile Seizures < 15 minutes Generalized-tonic-clonic Fever > 100.4 rectal to 101 F (38 to 38.4 C) No recurrence in 24 hours No post-ictal neuro abnormalities (e.g. Todd’s paresis) Most common 6 months to 5 years Normal development No CNS infection or prior afebrile seizures

Risk Factors for 1st Feb Sz: 

Risk Factors for 1 st Feb Sz Febrile seizure in 1 st /2 nd degree relative Day care Neonatal nursery stay of >30 days Developmental delay Height of temperature

Risk Factors for Recurrent FS: 

Risk Factors for Recurrent FS 1/3 will have a recurrence 10% will have 3 or more FH of febrile seizures Age <18 months Height of temperature Duration of fever

Risk Factors for Epilepsy: 

Risk Factors for Epilepsy 2 to 10% will go on to have epilepsy Developmental delay Complex FS (possibly > 1 complex feature) 5% > 30 mins => ¼ of all childhood status FH of epilepsy Duration of fever

Evaluation in Febrile Seizures: 

Evaluation in Febrile Seizures Exclude acute etiologies HCT, lytes/cbc if history/PE suggests Strongly consider LP < 12 months old Prior antibiotic therapy Suspicious findings on history/PE Not absolutely necessary in > 18 mos

Evaluation in FS (2): 

Evaluation in FS (2) EEG Does NOT predict recurrence or epilepsy More likely to be abnormal in: Older children Neurodevelopmental abnormalities Family history of febrile seizures Complex febrile seizure

Febrile Seizures—Treatment: 

Febrile Seizures—Treatment May reduce short-term recurrence But NO effect on occurrence of epilepsy AND the side effects ! The approach is based on epidemiological data that FS are benign, so Prevent status epilepticus

FS—Treatment (2): 

FS—Treatment (2) Antipyretics No data that this reduces risk FS at onset of fever => highest recurrence Benzodiazepines Rectal diazepam (Valium) 2-5 y/o 0.5 mg/kg 6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) Oral diazepam 0.33 mg/kg q8 hrs x 48 hrs during illness

FS—Treatment (3): 

FS—Treatment (3) Daily medications NOT recommended Phenobarbital Drowsiness, sleep problems, hyperactivity, IQ Valproic acid Hepatotoxicity Phenytoin and carbamazepine Not effective

Seizures—Exam: 

Seizures—Exam Temp, BP, HC Skin (rash, neurocutaneous lesions), Neck Evidence of dysmorphisms, developmental delay Evidence of increased intracranial pressure Bulging anterior fontanelle Depressed level of consciousness Pupillary asymmetries Downgaze/sunsetting eyes Abducens palsy Papilledema

Seizures—Exam (2): 

Seizures—Exam (2) Evidence of focal deficits Weakness Intracranial lesion versus Todd paresis Tone or reflex asymmetry ? Chronic versus acute

Seizures—Evaluation: 

Seizures—Evaluation Lumbar puncture “Strongly consider” in patient <12 mo with first febrile seizure Kernig’s, Brudzinski’s, nuchal rigidity low sensitivity (Thomas 2002) But usually more than isolated seizure History of irritability/lethargy Complex febrile seizure Slow postictal clearing of mentation

Seizures—Evaluation (2): 

Seizures—Evaluation (2) Neuroimaging “Emergent” HCT Concern of acute focal lesion, mass effect I.e. persistent paresis or change in MS MRI (nonurgent) Focal sz Cognitive/motor impairment Focal EEG findings EEG Not if simple febrile seizure

Patient and Family Education: 

Patient and Family Education An integral part of the management of a first febrile seizure is helping the family to cope with a frightening experience. Parents may believe that their child is dying during a first febrile seizure. The challenge is to help the family deal with the emotional trauma and to understand the excellent prognosis of febrile seizures. It is important that the family understand that there is no increased risk of intellectual delay or school difficulties and that febrile seizures less than 30 minutes do not result in brain damage.