lecture of 28 slides

1. Febrile Seizures
BY
DR. Magdy Shafik Ramadan
Ph.D, M.S, Diploma of pediatric
Senior pediatric consultant

2. Aetiology of fever with
convulsion in childhood
I. Febrile:
1)Febrile seizure.
2)Infection of CNS.
3)Epilepsy triggered by fever.
II.Nonfebrile:
1)Epilepsy
2)Metablic and electrolyte disorders
3)Hypoxemia
4)Drugs (theophylline, phenothiazine)
5)CNS
*Trauma *Hemorrhage
*Thrombosis *Neurocutanous syndroms
*Psychologic factors

3. *Encephalopathy
- C.S therapy
- HUS
- Reye syndrome
- Henoch- Schonlein purpura
- SLE
- IMN
*Degenerative disease
*Brain tumours

4. General accepted criteria for febrile seizure
 A convulsion associated with an elevated
temperature greater than 38 c.
 A child younger than six years of age
 No central nervous system infection or
inflammation.
 No acute systemic metabolic abnormality
that may produce convulsions.
 No history of previous a febrile seizures or
neonatal seizure and meeting criteria for
other acute symptomatic seizure

5. one half million FS per year in US.
 The incidence of FS is between 2-5%
 At least 3% to 4% of all children in North
America experiencing at least one febrile
seizure before the age of 5 year .
 Febrile illnesses in infant and children
account for 10-20% of all pediatric
emergency room visiting .
 1% of these visit involve seizures and 80%
of those seizure diagnosed as having
febrile seizure .
Natural history

6. Types
1) Simple (benign) 70-75%
2) - most common type.
- seizures that last less than 15 minutes.
- have no focal features.
-Tonic colonic which occurs once within 24- hour and It
resolve spontaneously .
2) Complex febrile seizures.9-35%
-Prolonged episodes that last more than 15 minutes.
- Have focal features or post ictal paresis
-Recurrent within the same febrile illness over 24-hour .

7. Types
1) Febrile ststus epilepticus (5%)
2) - > 30 minute duration most common type.
- More likley to have focal feature .
2

8. Etiology and pathogensis
 Occur in children between six months and six years
(12-18months)
 With temperature increasing but may develop as the
temp. is declining
 Associated with:
- Human herpes vinus-6
- After DPT on the day.
- MMR 8-14 day following MMR
 Abnormal neurotransmitters – genetic and familial
factors.
 Febrile seizure gene mapped to chromosomes 19p
and 8q13-21 ---- AD in some families

9. Etiology and pathogensis
 Mutation in sodium channel and gamma aminobuteric
acid A receptor genes have been identified in
children with FS.
 The genes coding for ion channels are likely to
underlie the syndrome .

10. Signs and symptoms
1)Simple febrile
Generalized seizures are mainly clonic, atonic and
tonic spells
Facial and respiratory muscles are commonly involved
2)Complex febrile
- Prolonged seizures with focal onset
- Febrile status epilepticus
3)25% children have temperature between 38-39c

11. Vedio

12. Differential Diagnosis
1)Involuntary movements
2)Shaking chills
- Fine rhythmic oscillatory movements about a joint.
- Rarely involve facial or respiratory muscles
- Involve both sides, no loss of consciousness
3)Metabolic disorder
- History and physical examination yield clues.
4)Meningitis and encephalitis.

13. Diagnostic evaluation
(AAP) recommend a CSF examination in
- Febrile seizures occurring after the second day of
illness
- Seizures with fever in infant <12ms
Routine measurement of serum electrolytes
Measured only with history of vomiting , diarrhea,
abnormal fluid intake, dehydration or edema.
C-T,MRI head
Considered only in children with
- abnormally large head
- abnormal neurological examination
- Focal features
- signs and symptoms of raised ICP
Routine EEG
No evidence exists that epileptiform discharges in
children with FS have any diagnostic or prognostic
implication .No rational for doing EEG in FS

14. Diagnostic evaluation
Routine EEG
 AAP has recently stated that based on the
published evidence ,EEG should not be apart of the
routine evaluation of neurologically healthy
children with a simple FS .
 The routine practice of obtaining an early EEG in
neurologically normal children with complex febrile
seizures is not justified
 Early postictal EEG has a role in those cases with
a) clinical suspicion of either acute or remote
cerebral pathology
b)developmental delay.
c) prolonged or focal seizures .
d) When it is followed by residual neurological
signs

15. Immediate management
 Febrile Seizures that continue for >5 minutes
should be treated.
 Short acting benzodiazepine
 Diazepam rectal gel may be used 0.5 mg/kg
 And buccal (0.4-0.5mg/kg) or intranasal
(0.2mg/kg) midazolam.
 Can be administrated at home
 Midazolam is superior to diazepam.
 Paracetamol and ibuprofen are useful in
relieving the discomfort of a febrile child
 If persistent fosphenytoin 15-20mg/kg I.V.

16. :Risk factors for recurrence
-30% of children have recurrent FS during
subsequent illnesses. when
1) Onset before 18 months .
2) Lower temperature close to 38
3)shorter duration of fever < 1 hour before
seizure .
4)Family history of FS.
- If all these risk factors are present 76%
will have a recurrence of FS .
- 4% recurrence without risk factors.

17. :
Risk factors for Epilepsy
-1)Complex febrile seizure
-2)Neurological abnormalities
-3)A family history of epilepsy .
-4)short duration of fever (< 1 hour )befor
seizure.
-Children with no risk factors have a 2-4% of
developing a febrile seizures by the age of
25 year compared with 1.4% for general
population.
- In the presence of the risk factors the
incidence range from 10% to 21% to 49% .

18. :
The relation of epilepsy with fever
A) The onset of epilepsy syndrome.
1) Severe myoclonic epilepsy of infancy
(Dravet syndrome) infant presents with
febrile status around age of 6m.then develop
later a febrile seizures.
2)Febrile seizures plus ( ‫كل‬‫مايسخن‬‫يتشنخ‬ )
seizures with fever beyond the age of 5
year or a febrile seizures also occur.
B) The patient is already epileptic.
the child has previously had a febrile
seizure and then presents with seizures
triggered by fever.

19. :The relation of epilepsy with fever
-C)The patient develop epilepsy later.
A period of freedom from seizures follows
febrile seizures before the development of a
specific epilepsy syndrome such as child
hood absence epilepsy.

20. Benefits and risks of continuous
anticonvulsant
Phenobarbital
Phenobarbital is effective in preventing the
recurrence of FS from 25 per 100 subjects per
year to 5 per 100 subject per year.
-It must be given daily and maintained in
therapeutic range
-Adverse effect include
Hyperactivity, irritability ,lethargy sleep
disturbance and hypersensitivity reaction.
behavior adverse effects may occur in 20 to 40 %
of patient .

21. Benefits and risks of continues
anticonvulsant
Valporic acid
In randomized controlled studies, only 4% of
children taking valporic acid as opposed to 35%
of control subject ,had subsequent febrile seizure
-Valporic acid is as effective as phenobarbital in
preventing recurrent FS.
-Adverse effect include
.rare fatal hepatotpotoxicity thrombocytopenia,
weight loss and gain gastrointestinal disturbance
and pancreatitis.

22. Benefits and risks of continues
anticonvulsant
 Phenytoin – carbamazepine
Has been shown to be effective in preventing
the recurrence of FS.
 Primedone
primidone in doses of 15 to 20 mg/kh per day
has also been shown to reduce the recurrence
rate of febrile seizures .
 Adverse effect include
Include behavioral disturbances ,irritability and sleep disturbance.

23. Benefits and risks of intermittent anticonvulsant
Diazepam
-Administration of oral diazepam (given at time of fever)
could reduce recurrence of FS .
-Children with history of FS were given oral diazepam (
0.33mg/kg every 8 hours for 48 hours) the risk of
recurrence per person per year was decreased to 44%
with diazepam.
-There is also literature that demonstrate the feasibility
and safely of interrupting FS lasting less than 5
minutes with rectal diazepam and with both intranasal
and buccal midazolam.
- Adverse effects include lethargy drowsiness and ataxia
,respiratory depression is extremely rare, FS could occur
before a fever is notice .

24. Benefits and risks of intermittent antipyretic.
-No studies have demonstrated that antipyretics ,in the
absence of anticonvulsant ,reduce risk of recurrence of
FS.
- Whether antipyretics are given regularly (every 4 hours)
or sporadically (contingent on a specific body
temperature elevation) does not influence outcome .
-Acetaminophen are considered to be safe and effective
antipyretics for children ,however, hepatotoxicity with
acetaminophen and respiratory failure, metabolic
failure and coma with ibuprofen have been reported
after overdose .or in presence of risk factors.

25. Role of AED
Controversy has exist.
Based on the risk and benefits of effective therapies
neither continuous nor intermittent anticonvulsive therapy
is recommended for children with one or more simple
febrile seizures
After reviewing
Although anticonvulsive therapy with Phenobarbital or
valporic acid , primodine or and intermittent therapy with
oral diazepan is effective in decreasing recurrent febrile
seizures the risk and pontial side effects of these
medications outweigh the benefit.antipyretic s may
improve the comfort of the child they will not prevent FS.

26. Oral diazepam 0.33mg/kg every eight hours during
the first few days febrile illness was as effective as
was continuous administration of phenobarbital in
reducing episodes of recurrent febrile seizures in:
- Frequent and prolonged febrile seizures.
- Initial episodes are complex with family
history of non febrile seizures.

27. Children with febrile seizure are at increased
risk for developing afebrile seizures, but no
available data suggest that the prevention of
recurrent febrile seizures reduces the risk of
developing a febrile seizures.