LATEST MANAGEMENT OF FEBRILE SEIZURE

dr. Nelly Amalia Risan, SpA Neuropediatric Subdivision Department of Child Health FK UNPAD/RSHS

Febrile Seizure

The most common form of seizure in children 4-5% children at least had 1 episode of febrile seizure ( Nelson Ellenberg, 1976 ) Worry parents, labeled vulnerable Hows the out come ?

Definition

ILAE, 1980 : Seizure in children, mostly in age 6 months 5 years, which happen during fever (rectal temperature > 38 C ) and not caused by CNS infection or others. (Consensus
Development Panel, 1980 )

Continued

A child who has an episode of afebrile seizure and then had an episode of febrile seizure is not clasified into Febrile Seizure. GEFS+ syndrome (Generalized Epilepsy with Febrile Seizure plus ), Febrile seizure that continues after >6 years old and followed by epilepsy in youth. Etiology is a defect in sodium channel (autosomal dominant).

Classification 1. Simple Febrile Seizure 2. Complex Febrile Seizure

ILAE, Commission on Epidemiology and Prognosis, 1993

Complex Febrile Seizure is (meet one of the following criteria ) :

1. seizure more than 15 minutes 2. focal/partial seizure 3. repeated seizure in 24 hours

Epidemiology 70 80% simple febrile seizure 20 - 30% complex febrile seizure - 4% focal - 8% lasted more than 15 minutes - 16% repeated in 24 hours

Etiology

Interaction of 3 factors : 1. Brain immaturity and termoregulator 2. Fever ----> increase O2 demand 3. Genetic predisposition > 7 chromosome locus (poligenic, autosomal dominant)

Continued Fever caused by: URTI 38% Otitis media 23% Pneumonia 15% Gastroenteritis 7% Post vaccination ( DTwP, Measles ) 25 in every 100 000 children receiving vaccination

Diagnosis

Anamnesis Physical examination and neurologic examination, if the level of consciousness is intact with etiology of fever is well defined no need for other lab exam

Other Examination

Laboratory Complete blood count peripheral blood smear performed to investigate the fever source Electrolyte, glucose exam were performed if indicated (vomitting, or diarrhea)

Lumbal Puncture Indication: if there is suspicion of meningitis. Not performed routinely in febrile seizure patient. Only if there is suspicion of meningitis.

Continues

Infant less than 12 months needs special attention as meningitis symptoms mostly not clear. Recommendation for Lumbal puncture: 1. Infant < 12 mo: strongly recommended 2. Infant 12 18 mo: recommended 3. Infant > 18 mo: not performed routinely
AAP, the neurodiagnostic evaluation of the child with first simple febrile seizures. Pediatrics, 1996

Electroencephalografy/ EEG

EEG cannot predict incidence of epilepsi or repeated Febrile seizure. Not recommended for Febrile seizure patient.

Prognosis and Complication

2 risk: 1. Repeated febrile seizure 30 40% in first years 2. Epilepsy ( 2 4% )

Predictor of repeated febrile seizure: 1. Age less than 1 years old 2. Family histiry of febrile seizure 3. The temperature is not high and short duration of fever when the seizure happen

Predictor for epilepsy : 1. Neurologic defect or delayed development 2. Family history of epilepsy 3. Complex febrile seizure

Treatment

Mostly short seizure, and stops before arriving at medical facility If the seizure persist: give diazepam per rectal 0,5 mg / kg, or Body weight < 10 kg : 5 mg Body weight > 10 kg : 10 mg maximum 2 times

Other medication

Antipyretic Recommended although there is no evidence can prevent febrile seizure.

Camfiel et al,1980 ; Uhari et al, 1995

Anticonvulsant

Oral diazepam 0,3 mg/kg TID, effective decreasing incidence of febrile seizure. Side Effect: somnolen adn ataxia. Phenobarbital, phenytoin or carbamazepin is not effective to prevent Febrile Seizure.

Maintenance anticonvulsant

Phenobarbital 4 5 mg /kg BB dived in 2 dose, maximum 200 mg/day, or Valproic Acid 20-40 mg/kg/day effektive for decreasing the risk of repeated Febrile Seizure. Side effect of phenobarbital: behaviour disorder /hiperactivity and decreasing IQ untolerable

Side effect

Valproic Acid in young children can cause liver disfunction.

Prophylaxis Recommendation

Considering Febrile Seizure is a benign condition and there is side effects of medication prophylaxis given in short term, except for selective case that requires long term prophylaxis

AAP. Cpmmittee on drugs. Behavioural & cognitive effect of anticonvulsant therapy. AAP. Practice parameter: longterm treatment of the child with simple febrile seizure.

Indication for maintenance medication

Prolong seizure There is evident neurological defects before of after the seizure Focal or partial seizure

Prognosis
2 risk 1. Repeated Febrile Seizure (50% in 1st years) 2. Epilepsy (2-4%)
Predictor for repeated seizure: 1. Age <12 mo 2. Family history of Febrile Seizure 3. Temperature is not high and the fever duration is short when the seizure happen

Predictor for Epilepsy 1. Neurological defect or delayed development 2. Family Histiry of epilepsy 3. Complex Febrile Seizure