FEBRILE SEIZURES UG

A 9 months old child develops fever of 103 degree with no focus since 3days.  Baby develops sudden stiffening of limbs followed by jerky movements of both upper and lower  limbs. Theee was frothing at moth with upward gaze.  The seizure lasted for 5 minutes. He recoverd in half an hours time and is active

He was in excellent general health according to mother. They took all vaccines so far from govt hospital.  He could stand holding a chair, picking up small objects from floor.  He will search for fallen toy and responds to call

 

Their family had a few cousins with similar problem in childhood

 

O/e

Head size 51 cm, cafe au lait spots on body 2numbers, no dysmorphism

No pallor, icterus, cyanosis clubbing or lymph adenopathy

Af open normal tension

Wt 9kg length 70cm

Cns nad

Development exam normal

 

Dx:

simple febrile seizure

Discussion

 

What is simple febrile seizure? 

 

A simple febrile seizure is a primary generalized, usually tonic-clonic, attack associated with fever, lasting for a maximum of 15 min, and not recurrent within a 24-hr period

 

What is complex febrile seizure? 

A complex febrile seizure is more prolonged (>15 min), and/or is focal, and/or recurs within 24 hr.

Will a child with simple or complex febrile seizure have increased risk for mortality or brain damage?

There are no long-term adverse effects of having one or more simple febrile seizures.

Compared with age-matched controls, patients with febrile seizures do not have any increase in the incidence of abnormalities of behavior, scholastic performance, neurocognitive function, or attention

There are no long-term adverse effects of having one or more simple febrile seizures. Compared with age-matched controls, patients with febrile seizures do not have any increase in the incidence of abnormalities of behavior, scholastic performance, neurocognitive function, or attention

What is the genetics of febrile seizure? 

The genetic contribution to the incidence of febrile seizures is manifested by a positive family history for febrile seizures in many patients.

In some families, the disorder is inherited as an autosomal dominant trait, and multiple single genes that cause the disorder have been identified in such families. However, in most cases the disorder appears to be polygenic, and many genes predisposing to it remain to be identified.

 

Genes associated with febrile seizures include SCN1A, SCN1B, SCN9A, and CPA6.

 

Name 2 epilepsy syndromes which start as febrile seizure

A few epilepsy syndromes typically start with febrile seizures; these are generalized epilepsy with febrile seizures plus (GEFS+), severe myoclonic epilepsy of infancy (SMEI or Dravet syndrome), and, in many patients, temporal lobe epilepsy secondary to mesial temporal sclerosis.

Should we do lumbar puncture in all cases? 

lumbar puncture should be performed for all infants younger than 6 mo of age who present with fever and seizure, if the child is ill-appearing, or at any age if there are clinical signs or symptoms of concern.

A lumbar puncture is an option in a child 6-12 mo of age who is deficient in Haemophilus influenzae type b and Streptococcus pneumoniae immunizations or for whom the immunization status is unknown.

A lumbar puncture is an option in children who have been pretreated with antibiotics

Should we do eeg in simple febrile seizure? 

If the child is presenting with the first simple febrile seizure and is otherwise neurologically healthy, an EEG need not be performed as part of the evaluation.

An EEG would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal.

What is febstat study? 

 

Children with prolonged febrile  seizures>20minutes is noted to have focal slowing on eeg and  changes in hippo ampus. After febrile status epilepticus, focal EEG slowing over the temporal lobe increases the chance that the patient may have medial temporal sclerosis on follow-up

What is the role of neuroimaging? 

A CT or MRI is not recommended in evaluating the child after a first simple febrile seizure.

The workup of children with complex febrile

Seizures needs to be individualized. This can include an EEG and neuroimaging, particularly if the child is neurologically abnormal.

Approximately 10% of children with febrile status epilepticus are reported to have unilateral or, less frequently, bilateral swelling of their hippocampus acutely; subsequent long-term hippocampal atrophy is evident in about 71% of those who had the acute finding

Should we treat all children? 

Acute at the time of seizure

Take care of airway, breathing circulation

Seizure persists for >5minute

Midazolam i/v (.1mg/kg)or midazolam spray can beused. 2mg/kg

 

In general, antiepileptic therapy, continuous or intermittent, is not recommended for children with one or more simple febrile seizures.

Parents should be counseled about the relative risks of recurrence of febrile seizures and recurrence of epilepsy, educated on how to handle a seizure acutely, and given emotional support

What is the role of antipyretics/iron/antiepileptics? 

Antipyretics can decrease the discomfort of the child but do not reduce the risk of having a recurrent febrile seizure.

Chronic antiepileptic therapy may be considered for children with a high risk for later epilepsy. T he possibility of future epilepsy does not change with or without antiepileptic therapy.

Iron deficiency is associated with an increased risk of febrile seizures, and thus screening for that problem and treating it appears appropriate.

What is the risk of recurrence?

MAJOR Age < 1 yr Duration of fever < 24 hr Fever 38-39°C (100.4-102.2°F)

Having no risk factors carries a recurrence risk of approximately 12%; one risk factor, 25–50%; two risk factors, 50–59%; three or more risk factors, 73–100%.

What is the risk of epilepsy? 

Complex febrile seizures (focal) 29%

Neurodevelopmental abnormalities (33%)

*Having more than one risk factor is at least in part additive.

About Dr. Jayaprakash

Asst. Prof. of Pediatrics, ICH. Institute of Child Health. Gov. Medical College Kottayam. Kerala, India.

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