FEBRILE SEIZURE

Dewi Sutriani Mahalini

Neuropediatric Division
Department of Child Health
Medical Faculty of Udayana University/Sanglah Hospital

Seizure
Definition:
a sudden temporary change in brain function
caused by an abnormal rhytmic electrical
discharge
due to the releasing of excessive electric
load from deteriorated neurons cells in the
brain
Can caused by disturbance of:
Physiological
Anatomical
Biochemical
Combination of the above component

 medical emergency
Have to be managed quickly &
appropriately

Seizure

Mechanisme of Seizure
Partial secondary
generalized

Focal seizure
mechanisme

General seizure

Definition
Defined by The International League
Against Epilepsy (ILAE)
Febrile seizure:
a seizure occurring in childhood after one
month of age, associated with a febrile illness
not caused by an infection of the central
nervous system, without previous neonatal
seizures or a previous unprovoked seizure, and
not meeting criteria for other acute
symptomatic seizures
Jones T, Jacobsen SJ. Childhood Febrile Seizures: Overview
and Implications. Int. J. Med. Sci. 2007, 4 (2):110-14

Definition
Febrile Seizure is a seizure in childhood,
usually occurring associated with fever (>380C
rectal) but without evidence of intracranial
infection or define cause.
Seizure with fever in children who have
suffered a previous non-febrile seizure are
excluded.
Ismael S, KPPIK XI, 1983;
Soetomenggolo TS. Buku Ajar Neurologi Anak 1999

Natural history
Most febrile seizures occur
between 6 months and 36
months of age peaking at 18
months
The occurrence of a childs first
(initial) febrile seizures has been
associated with: first or seconddegree relative with history of
febrile and afebrile seizures

PATHOPHYISIOLOGY
Remain

unknown
It is possible that 3 feature
interact resulting in a febrile
seizure:
1. Immature brain
2. Fever
3. Genetic predisposition
Carney PR. Pediatric Practice Neurology, 2010

Immature brain
rarely occur before 1-3 mo
certain degree of myelination/
network maturation is required
for clinical expression of FS
FS rarely occur after 5-6 years
Enhanced neuronal excitability
during normal brain maturation
FS

Carney PR. Pediatric Practice Neurology, 2010

FEVER
Fever

associated with cytokine

release
Activation of cytokine release
may increase the susceptibility to
FS
IL-1( a pyrogenic proinflamatory
cytokine) involved in generation
of FS
Temperature changes affect
Carney PR. Pediatric Practice Neurology, 2010
plasma membrane states &

FEVER....
Responsible for occurrence of fever in febrile
convulsion:
respiratory tract infection
gastro enteritis
urinary tract infection
roseola infantum
post immunizations

The degree of temperature:

75% of children had temperature >38oc
25% of children had temperature > 40oc

Genetic factors
Genetic

factors play an essensial role

in the genesis of FS.
Although there is clear evidence for a
genetic basis of FS, the mode of
inheritance is unclear
The risk of developing FS is higher in
some families than in others (25-40 %)
Genetic loci for FS
Chromosome 2q, 19q SCN1A, SCN1B,
SCN2A gene
Carney PR. Pediatric Practice Neurology, 2010

TYPE OF FEBRILE
SEIZURE

SIMPLE FEBRILE SEIZURES

COMPLEX FEBRILE SEIZURE
FEBRILE SEIZURE PLUS

ILAE, Commission on epidemiology & prognosis.

Epilepsia 1993

CLASSIFICATION...

Simple febrile seizures: consist of

A brief (lasting <15 minutes)
Generalized seizure tonic-clonic )
or there are no focal features and
it resolves spontaneously
Which occurs only once within a
24 hour period.

American Academy of Pediatrics Practice.

Pediatric Neurology Working Groups

CLASSIFICATION...

Complex febrile seizures

Prolonged ( Duration > 15 minutes),
Focal
Occuring in a cluster of 2 or more
convulsions within 24 hours
(recurrent within the same febrile
illness over a 24-hour period).

American Academy of Pediatrics Practice.

Pediatric Neurology Working Groups

Febrile Seizure Plus (Fs+)

FS

continous until >6 years old

FS > 13 times/ years
History : seizure without fever
previously

Scheffer IE, et al. Brain 1997;120:479-90.

Baulac S, et al. Lancet Neurol. 2004;3:421-30.
Panayiotopoulos CP.The epilepsies.2005. h128-30.

INCIDENCE.....
National Collaberative Perinatal Project
Study:
74%

of initial febrile seizure were simple

26% of the initial febrile seizure were
complex

4% focal
8% prolonged greater than 15 minutes
16% with recurrence within 24 hours
0.4% with Todd paresis
Carney PR. Pediatric Pratice Neurology.2010

RISK FACTORS FOR FIRST FS

The risk of a 1st FS is about 30% if

have >2 risk factor below:
A first or second degree relative
with FS
Delayed neonatal discharged of
greater than 28 days of age
Parental report of slow
development

Predictors of recurrent febrile

seizures
A

history of focal, prolonged, and

multiple Seizures
Family history of febrile seizures
onset of febrile seizure <12 months of
age
temperature <40C at time of seizure
a history of complex, initial febrile
seizures
Jones T, Jacobsen SJ. Childhood Febrile Seizures: Overview
and Implications. Int. J. Med. Sci. 2007, 4 (2):110-14

Chung et al. Febrile seizures in Chinese children. j. pediatrneurol.

2005.08.007

Diagnosis
Anamnesis :

Confirm : Seizure or non seizure

Type, duration and frequency of seizure

Find the cause of fever
Find the risk factor
Physical examination:
- Post ictal consciousness very important
- Neurological examination is in normal range
= todds paresis when long duration seizure
- Find the intracranial infection sign

21

DIAGNOSIS
The

diagnosis of FS is not always

easy

Diferential Diagnosis
encephalopathy, encephalitis and
meningitis
Febrile shivering (peribuccal
cyanosis)
22

Differences Between
FS & Seizures due to Febrile Brain Diseases.
Febrile seizure
(FS)

Seizure and fever in

brain disease

Genetic predisposed to
seizure

May be strong

Mostly minor or insignificant

Type of seizure

Tonic-Clonic

Focal or focal -generalized

Duration of seizure

Mostly 1-3 min1

seldom prolonged

Often prolonged, 10 min to

hours (status like)

Clinical setting which seizure

occure

in at the onset of a febrile

In a variety of CNS infections

Type of underlying cerebral

pathology

None

Various types of inflammatory

vascular changes and edema

Postictal neurologic
(Todds paralysis

Very uncommon
Conscious

Common

EEG

Rapidly normalizes after

convulsion

Abnormal throughout febrile

episode

Niedermeyer E. Epilepsy Guide: Diagnosis and Treatment of Epileptic Seizure Disorders , 1985

Work up child with FS

Hospitalization (rarely
nescessary except complex FS)
2. Evaluation cause of fever
3. Laboratory test :
if necessary / by indication
1.

CBC
Electrolyte
Blood sugar
RCP / BPA, 1991. AAP, 1999. Fukuyama Y, 1996. Baumer
J.2004.

Work up child with FS

4.

Lumbar puncture exclude

intracranial infection
(meningitis)

5.

Strongly consider: infant < 12 months

Should be consider: children between
12-18 mo
Not routinely : beyond 18 mo

EEG : not necessary since non

predictive of recurrence / epilepsy
later
RCP / BPA, 1991. AAP, 1999. Fukuyama Y, 1996. Baumer
J.2004.

MANAGEMENT OF FS
Prevention of prolonged
seizure
2. Intermittent prophylaxis
3. Continuous prophylaxis
1.

26

% cease
spontaneousl
y

10
minutes

Seizure
duratio
n

Probability of a seizure ceasing spontaneously

decreases rapidly after 10 minutes

DRUG DOSES

Table.

DRUGS USED TO TERMINATE STATUS EPILEPTICUS

Drug

Onset of

Duration of

Maximal Rate

Action

action

Diazepam

1-3 minute

5-15 minute

< 2 mg/min

Midazolam

2-5 minute

30-60 minute

< 2 mg/min

Phenytoin

10-30 minute 12-24 hours

< 1 mg/kg/min
< 50 mg/min

Phenobarbit

10-20 minute 1-3 days

< 1 mg/kg/min

al
< 100 mg/min
Freedman SB. Clin Pediatric Emergency Medicine,2003

Emergency Drugs

INTERMITTENT PROPHYLAXIS
Rectal or oral diazepam

Intermittent diazepam prophylaxis

seems to be effective in reducing the
recurrency rate.

Doses for prophylaxis whenever

temperatur
> 38,50 C : 0,3 mg/kg
orally, or 0,5 mg/kg rectally every 8
hours

Parents should be advised not to give

rectal diazepam if the seizure has
stopped.

32

CONTINOUS PROPHYLAXIS
Meta

analysis of 47 controlled
trials found that phenobarbitone
the risk of recurrence of FS
Phenobarbitone and valproate had
significantly lower risk of
recurrence than those on plasebo.
Recurrence rate of 12.8% with
valproate, 13% with phenobarbital,
and 34% in untreated controls
Wallace and Aldridge-smith 1981, Rantala et al, 1997.
Temkin 2001.

33

CONCENSUS 2005
Daily

continuous anticonvulsant
(one or more)
The presence of an abnormal neurologic (CP,
MR, Microcephaly)
History of prolonged febrile seizure (>15
min)
History of focal seizure

Consider

daily continuous
anticonvulsant
Multiple febrile seizure ( 2 or more within 24
hours)
NIH, 1980.
Ismael
S, age
1983.of
Fukuyama
Y, 1996
Seizure occur
under
the
12 months
Frequent seizures (4 or more times in 12 mo)

34

PROGNOSIS
children most children
Epilepsy : 2-4%, (3% on average)
4-6 times higher than the
incidence of epilepsy in the
general child population
Learning & behaviour disorder
(uncommon)
Diskinesia &
Incoordination(uncommon)
Mental Retardation (rarely)
Normal

Risk of developing epilepsy after FS

based on asscociated factors

Positive
family history
5.3%

Abnormal
Developme
nt 3.3%

10
%
23
%

13
%

18%

Complex
febrile seizure
4.1%
Nelson KB, Ellenberg JH: Prognosis in children with febrile
seizures.

Epilepsy following FS
The risk of later epilepsy is higher
when :
The child had been developmentally
abnormal prior to first seizure
The first seizure was long, lateralized, or
repeated during a single febrile episode.
Complex FS
A first - degree relative with epilepsy

Aicardi, 1994

The

risk of initial febrile seizures

has also been studied after
receipt of pediatric vaccinations
DTP and Measles, MMR
2-4% of children who experience
at least one febrile seizure event
go on to develop recurrent
afebrile seizures (epilepsy)

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