FEBRILE SEIZURE

IN CHILDREN

Dewi Sutriani Mahalini

Neuropediatric Division
Department of Child Health
Medical Faculty of Udayana University/Sanglah Hospital
Email: dewi_sutriani@yahoo.com
 Definition of Seizure
Definition:
a sudden temporary change in brain function
caused by an abnormal rhytmic electrical
discharge.
Clinical manifestation 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
Mechanisme of Seizure

Partial secondary
generalized

Focal seizure General seizure

mechanisme

3
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

5
 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 second-
degree 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
FS 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

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
plasma membrane states & synaptic
transmission
Carney PR. Pediatric Practice Neurology, 2010
 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

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 DIAGNOSIS
The diagnosis of FS is not always
easy

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

21
 Differences Between
FS & Seizures due to Febrile Brain Diseases.
Febrile seizure Seizure and fever in
(FS) brain disease
Genetic predisposed to May be strong Mostly minor or insignificant
seizure
Type of seizure Tonic-Clonic Focal or focal -generalized
Duration of seizure Mostly 1-3 min1 Often prolonged, 10 min to
seldom prolonged hours (status like)
Clinical setting which seizure in at the onset of a febrile In a variety of CNS infections
occure
Type of underlying cerebral None Various types of inflammatory
pathology vascular changes and edema
Postictal neurologic Very uncommon Common
(Todds paralysis Conscious
EEG Rapidly normalizes after Abnormal throughout febrile
convulsion episode

Niedermeyer E. Epilepsy Guide: Diagnosis and Treatment of Epileptic Seizure Disorders , 1985
Work up child with FS
1. Hospitalization (rarely
nescessary except complex FS)
2. Evaluation cause of fever
3. Laboratory test :
if necessary / by indication
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)
Strongly consider: infant < 12 months
Should be consider: children between
12-18 mo
Not routinely : beyond 18 mo
5. EEG : not necessary since non
predictive of recurrence / epilepsy
later
RCP / BPA, 1991. AAP, 1999. Fukuyama Y, 1996. Baumer
J.2004.
MANAGEMENT OF FS

1. Prevention of prolonged
seizure
2. Intermittent prophylaxis
3. Continuous prophylaxis

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 SEIZURE

MEDICAL EMERGENCY

Have to be managed quickly

& appropriately
 % cease
spontaneousl
y

Seizure
duratio
10 n
minutes

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
 Post Seizure Medication
FEVER find and solve the etiology of fever
R/ Antipyretic
Strongly recommended although its not
proven can reduce the risk of seizure
(Level I, recommendation E)
Acetaminophen 10 15 mg/kg, 3- 4 times/day
Ibuprofen 5-10 mg/Kg, 3-4 times/day
R/ Prescribe antibiotic when theres indication

Prevent the recurrence of seizure : Very Important!

32
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. 33
CONTINOUS PROPHYLAXIS
Meta analysis of 47 controlled trials found:
phenobarbitone risk of recurrence FS
Phenobarbitone and valproate had significantly
lower risk of recurrence than those on plasebo.
Recurrence rate :
12.8% with valproate
13% with phenobarbital
34% in untreated controls

Wallace and Aldridge-smith 1981, Rantala et al, 1997.

Temkin 2001.
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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
Considerdaily continuous
anticonvulsant
Multiple febrile seizure ( 2 or more within 24
hours)
Seizure occur under
NIH, 1980. the
Ismael S, age
1983.of 12 months
Fukuyama Y, 1996
Frequent seizures (4 or more times in 12 mo) 35
PROGNOSIS
Normal children most children
Epilepsy : 2-4%
4-6 times higher than the incidence of
epilepsy in the general child
population
Learning & behaviour disorder
(uncommon)
Diskinesia &
Incoordination(uncommon)
Mental Retardation (rarely)
Risk of developing epilepsy after FS
based on asscociated factors

Positive
family history Abnormal
5.3% 10 Developme
% nt 3.3%

23
%
13 18%
%

Complex
febrile seizure
4.1%

Nelson KB, Ellenberg JH: Prognosis in children with febrile

seizures.
 y o u
an k
Th
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)
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