FEBRILE SEIZURE-UG DISCUSSION

• 11/2 yrs old previously healthy child is admitted with h/o fever followed by seizure which lasted for less than 15 minutes . there was no h/o trauma . she had runny nose 2 yrs prior to seizure. She had two episodes of seizures previousl at 6 months and 8 months of age . she recovered from seizure after about half an hour and continues to be playful active as ever eventhough her fever has not settled.

Symptom analysis:

• 11/2 yr old presents with fever and seizure with recovery after a short interval. She has normal sensorium now . she had past history febrile seizures, so this is most likely to be simple febrile seizure,which is the most common cause of fever and seizure in children

h/o previous illness

• she had febrile seizures previously
• no episode of seizures with out fever

ante natal history

• no h/o fever with rash- intrauterine infection-toxoplasmosis, cmv,runbella can have significant cns involvement
• no h/o antenatal usg detected anomalies- significant cns and other system aniomalies can co exist
• no h/o bleeding uti,meconium,brady cardia demanding emergency interventions
• delivery and transion normal( perinatal events causing prolonged resuscitation can cause significant damage to brain – asphyxia accounts only 10 % of it,rest could infectious,metabolic,vascular,genetic,developmental anomalies)
• neonatal period- hypoglycemia -50 % of children develop developmental anomalies
• neonatal jaundice – levels demanding exchange may damage basal ganglia – can cause neurological problems later

developmental history

• is there a delay?
• Delay is defined as development quotient less than 70. Calculate for four domains and average it (e.g.11/2 yr old may be just standing not walking hand held . 10- 11 months /18 months =<70
• 11/2 yr old running using spoon with spilling = normal development)
• Developmental delay increases chance of recurrence and epilepsy in future

Dietary history

• Breast fed,complimentary feeds and now on family diet

Immunization history

• National schedule
• No optional vaccine
• Ppv taken

Family history

• Family history of febrile seizure mother,uncle

Social and environmental

• Middle income group with pucca house and sanitary latrine

History analysis

• 11/2 yr old presents with simple febrile 3 rd episode with a previous history of febrile seizures and positive family history. sHe has normal sensorium , normal development . there is history auri prior to this episode . so this is most likely to be a simple febrile seizure

GENERAL EXAMINATION

• Well child active ,playful running around
• No pallor,icterus, cyanosis ,clubbing,lne,or edema

VITALS

• Rr,hr,bp normal( bp cuff width 40% of mid arm circumference length % 80 of mid arm circumference)
• Temp normal

HEAD TO FOOT

• Look for neurocutaneous markers( café au lait-brown colored, ash leaf macule-white leaf shaped, neurofibroma, axillary freckling,shagreen patch, lumar tuft of hair,lumbar sinus,lipoma ,telangiectasiaare a few)
• Head-gross macro microcephaly
• Af- sitting postion –bulging of not
• Face- dysmorphism
• Eyes –squint, cataract
• Ear – low set
• Mouth – enanthem,pharyngeal congestion
• Palate – midline defects
• Neck
• Limbs
• Chest abdomen
• Genitalia
• Lower limbs
• Skin exanthems

ANTHROPOMETRY

• Hc: < 3 sd= microcephaly ,>2 sd macrocephaly
• Wt
• Length
• Mid arm circumference

NEUROLOGICAL EXAMINATION

• Hf
• Cn-
• Ms
• Ss
• Gait
• Signs of meningeal irritation( are les reliable in a child of less than 1 yr)

DEVELOPMENTAL EXAMINATION

• Test in each domain

Discussion

• 11/2 yr old child presents with febrile seizure , maintain normal sensorium after seizures, with a h/o previous febrile seizure, positive family history and ,normal development
• She is a well child , with no neurocutaneous markers, normal anthropometry, normal vital signs.
• Her neurologic assessment and development assessment is normal
• She is most probably having simple febrile seizure ,with recurrence. Family history points to a genetic aetiology
• Since it is simple febrile seizure , you need to give only symptomatic measures
• There is no role for anti convulsants
• Parents who are anxious may be given prophylaxis with clobazem at the time of fever

Communication

POINTS TO REMEMBER

History:

• h/o fever ,grade of fever, timing seizure and onset of fever
• associated symptoms like nasal discharge,sorethroat,rash,dysuria ,frequency,earache
• type of seizure,duration, post ictal state, sensorium normal after post ictal period
• recurrence and timing of febrile seizure
• any afebrile seizure/myoclonic seizure
• family history- may have many with febrile seizure
• development normal or not
• immunization – hib,pneumococcal

Physical examination

• Well child ,sensorium normal or not
• Any posturing
• Pallor- iron def increases feb seizure
• neurocutaneous markers(nf-1,ts,sws,)
• exanthems/enanthems(measles)
• mouth –pharyngitis,ulcers
• palate- petechaie(strp throat) ,erythematous macule(viral)
• neck –nodes
• fac- dysmorphism
• chest
• abdomen
• genitalia
• limbs
• spine-tuft of hair,assymmetry of gluteal fold
• hc –micro/macrocephaly
• wt ,ht mac,bmi
• development-
• nervous system
• rs- auri/pharynx,tonsil
• abd-hsm
• cvs-

What is fever?

• Rectal temperature above 100.4f/38 c is considered as fever(nelson 20 th ed)

What are the common cause of fever?

• Infections
• Malignancy( all.aml,nl)
• Autoimmune disorder(sojia)
• Drugs
• injections

How do you recognize seizure?

• Episodic movements with altered consciousness suggest seizure activity when any of the following features are present: (1) no response to tactile stimulation (touch of the face or body), (2) unusual eye movements (rapid eye fluttering or fixed eye deviation), (3) unusual head movements (forced head version), (4) unusual mouth movements (chewing or lip smacking), (5) unusual facial movements (twitching of the face), (6) stereotyped hand movements (repetitive reaching), (7) unusual posturing of a limb (freezing of an arm or leg), or (8) unexpected incontinence.

What are seizure mimics?

• Pseudoseizures should be suspected when the events are triggered by emotional disturbance or by suggestion, when the abnormal movements are not compatible with a typical seizure (pelvic thrusting, side-to-side head movement, forced eye closure), when the events occur most frequently during the daytime in the presence of other people, and when there is no postictal state. Tics are stereotyped, recurrent paroxysmal events that can be differentiated from seizures by the patient’s ability to suppress them consciously
• Syncope,breath holding spells,tics, chorea,day dreaming are a few

What are the common cause sof seizure in children?

• Febrile seizure
• Infection(meningitis encephalitis,brain absces cerebral malriaintrauterine infection)
• Developmental abnormality of brain (lissencephaly)
• Hypoglycemia
• Electrolyte abnormalities( hypocalecemia,hyponatremia)
• neurodegenerative
• Intracranial hemorrhage
• Demyelinating disorder

What is febrile seizure?

• 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.
• Febrile seizures often occur in the context of otitis media, roseola and human herpesvirus (HHV) 6 infection, shigella, or similar infections, making the evaluation more demanding. In patients with febrile status, HHV-6B (more frequently) and HHV-7 infections were found to account for one-third of the cases

What is complex febrile seizure?

• complex febrile seizure is more prolonged (>15 min), is focal, and/or reoccurs within 24 hr. Febrile status epilepticus is a febrile seizure lasting longer than 30 min. Some use the term simple febrile seizure plus for those with recurrent febrile seizures within 24 hr.

What is the chance of recurrence of seizure?

Risk factors

MAJOR

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

MINOR

• Family history of febrile seizures
• Family history of epilepsy
• Complex febrile seizure
• Daycare
• Male gender
• Lower serum sodium at time of presentation

Having no risk factors carries a recurrence risk of approximately 12%; 1 risk factor, 25-50%; 2 risk factors, 50-59%; 3 or more risk factors, 73-100%.

What should I do if a child has seizure?

What is the chance of epilepsy after seizure?

• Simple febrile seizure -1%
• Recurrent febrile seizures – 4%
• Complex febrile seizures (more than 15 min duration or recurrent within 24 hr) -6%
• Fever <1 hr before febrile seizure – 11%
• Family history of epilepsy -18%
• Complex febrile seizures (focal) – 29%
• Neurodevelopmental abnormalities -33%

• There are no long-term adverse effects of having 1 or more simple febrile seizures. Simple febrile seizures do not have an increased risk of mortality even though they are, understandably, concerning to the parents when they first witness them

What is the genetics of febrile seizure?

• 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.Identified single genes include FEB 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 genes on chromosomes 8q13-q21, 19p13.3, 2q24, 5q14-q15, 6q22-24, 18p11.2, 21q22, 5q34, 3p24.2-p23, and 3q26.2-q26.33. Only the function of FEB 2 is known: it is a sodium channel gene, SCN1A.

What is febrile seizure plus?

• GEFS+ is an autosomal dominant syndrome with a highly variable phenotype. Onset is usually in early childhood and remission is usually in mid-childhood. It is characterized by multiple febrile seizures and by several subsequent types of afebrile generalized seizures, including generalized tonic–clonic, absence, myoclonic, atonic, or myoclonic astatic seizures with variable degrees of severity. A focal febrile seizures plus epilepsy variant, in which the seizures are focal rather than generalized, has also been described

What are neurocutaneous markers?

• six or more café-au-lait macules larger than 5 mm in greatest diameter in prepubertal individuals and larger than 15 mm in greatest diameter in postpubertal individuals
• Axillary or inguinal freckling consisting of multiple hyperpigmented areas 2-3 mm in diameter. Skinfold freckling usually appears between 3 and 5 yr of age.
• Two or more neurofibromas or 1 plexiform neurofibroma
• Two or more iris Lisch nodules
• Facial angiofibroma or forehead plaque
• Ungual or periungual fibroma (non-traumatic)
• Hypomelanotic macules (>3) ash leaf
• Shagreen patch
• capillary malformation may also be evident over the lower face, trunk,and in the mucosa of the mouth and pharynx
• Linear Nevus
• macular whorls, reticulated patches, flecks,
• and linear streaks that follow Blaschko lines
• telagiectsia
• tuft of hair ,sinus,lipoma at lumbar region

What is the management of febrile seizure?

• Any child with seizure take care of airway( head tilt chin lift) breathing (suctioning and bagging if necessary) and circulation( bp,crt,i/v line ,then give lorazepam .1 mg/kg stat Children who are seizing at home after 5 mts can be given buccal midazolam every10 kg /4 puff or rectal diazepam .5 mg/kg per dose
• If the parents are very anxious concerning their child’s seizures, intermittent oral diazepam (0.33 mg/kg every 8 hr during fever) or intermittent rectal diazepam (0.5 mg/kg administered as a rectal suppository every 8 hr), can be given during febrile illnesses. Intermittent oral nitrazepam, clobazam, and clonazepam (0.1 mg/kg/day) have also been used.
• Antipyretics can decrease the discomfort of the child but do not reduce the risk of having a recurrent febrile seizure, probably because the seizure often occurs as the temperature is rising or falling
• 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 role of rbs and electrolytes?

• Blood studies (serum electrolytes, calcium, phosphorus, magnesium, and complete blood count) are not routinely recommended in the work-up of a child with a first simple febrile seizure. Blood glucose should be determined in children with prolonged postictal obtundation or with poor oral intake (prolonged fasting). Serum electrolyte values may be abnormal in children after a febrile seizure, but this should be suggested by precipitating or predisposing conditions elicited in the history and reflected in abnormalities of the physical examination

What is the role of lumbar puncture?

• Meningitis should be considered in the differential diagnosis, and lumbar puncture should be performed for all infants younger than 6 mo of age who present with fever and seizure, or if the child is illappearing 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 immunization status is unknown.A lumbar puncture is an option in children who have been pretreated with antibiotics

Do we need to do EEG in febrile seizure?

• If the child is presenting with the first simple febrile seizure and is otherwise neurologically healthy, an EEG need not normally be performed as part of the evaluation. An EEG would not redict the future
• recurrence of febrile seizures or epilepsy even if the result is abnormal.Spikes during rowsiness are often seen in children with febrile seizures,particularly those older than age 4 yr, and these do not predictlater epilepsy. EEGs performed within 2 wk of a febrile seizure often have nonspecific slowing, usually posteriorly. Thus, in many cases, ifan EEG is indicated, it is delayed until or repeated after more than 2 wk have passed.
• An EEG should, therefore, generally be restricted to special cases in which epilepsy is highly suspected, and, generally, it should be used to delineate the type of epilepsy rather than to predict its occurrence.

Do we need to do CT or MRI after febrile seizure?

• A CT or MRI is not recommended in evaluating the child after a first simple febrile seizure. The work-up of children with complex febrile seizures needs to be individualized. This can include an EEG and neuroimaging, particularly if the child is neurologically abnormal