Febrile Seizure


Article Author:
Kathryn Xixis


Article Editor:
Michael Keenaghan


Editors In Chief:
Temekis Hampton


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
1/22/2019 1:32:34 PM

Introduction

Febrile seizures are seizures that are caused by a sudden spike in body temperature with fevers greater than 38C or 100.4F, with no other underlying seizure-provoking causes or diseases such as central nervous system (CNS) infections, electrolyte abnormalities, drug withdrawal, trauma, genetic predisposition or known epilepsy. Febrile seizures categorize as either simple febrile seizures or complex febrile seizures. Differentiation between simple and complex febrile seizures is important as the approach and workup for each is different.[1][2][3]

Etiology

Febrile seizures occur with a fever higher than 38 C or 100.4 F and no other seizure-provoking etiologies such as described above. The highest fever necessary to cause febrile seizures is specific to the individual as each child's threshold convulsive temperature varies. While the degree of the fever is ultimately the most significant factor in febrile seizures, these seizures often occur as the patient's temperature is rising. In fact, a febrile seizure may be the first sign that a child is ill, with the presence of a fever greater than 38 degrees discovered shortly after that. There is no specific cause of fever that is more likely to cause febrile seizures. Any fever of adequate height may cause a febrile seizure.[3][4]

Epidemiology

The exact age constituting a febrile seizure varies slightly throughout medical literature with 6 months to 60 months (5 years) being a common working definition. Febrile seizures are extremely common, occurring in up to 4% of children in this age group. Some children have a single febrile seizure event, and others have multiple events over early childhood.

Pathophysiology

The exact pathophysiology of febrile seizures is not understood. There is a recognized genetic predisposition with 10% to 20% of first-degree relatives of patients with febrile seizures also experiencing febrile seizures. No specific mode of inheritance is known.[5]

History and Physical

A detailed description of the seizure event is essential for the evaluation of a possible febrile seizure patient. Historical information regarding the exact appearance and length of the event is vital. Information regarding the symptoms of a central nervous system (CNS) infection, underlying structural abnormalities, personal history of neurologic problems, personal immunization history, and personal or family history of prior seizure is essential in deciding whether an event of concern constitutes a febrile seizure or rather constitutes a more severe illness presenting with a seizure.

Once a seizure is qualified as a febrile seizure, the examiner should seek additional information to differentiate whether it is simple or complex. Simple febrile seizures occur more commonly than complex febrile seizures and are characterized by a seizure that is generalized, lasts less than 15 minutes, and does not recur within 24 hours. Complex febrile seizures are characterized by the presence of at least one of the following features: focality, duration of longer than 15 minutes, and recurrence within a 24-hour period. In either instance, a general physical exam and neurologic exam are necessary. Post-ictal drowsiness is not abnormal in febrile seizures but typically resolves within a few minutes. A patient recovering from a febrile seizure will rapidly return to baseline and towards a normal neurologic exam. If a patient does not return to baseline, remains completely unresponsive to noxious stimuli after the seizure, or has other symptoms of acute neurologic dysfunction before the seizure (such as acute headaches, alteration of mental status, or concern for weakness), other complicating etiologies should be a consideration.

Evaluation

A patient with a normal general and neurologic exam, whose history is consistent with a simple febrile seizure, does not need further laboratory, imaging, or neurophysiologic evaluation. If a patient's history is consistent with a complex febrile seizure, an electroencephalogram (EEG) is obtained to look for underlying abnormalities that may predispose the patient to seizures. If this initial EEG is abnormal, imaging is the next step. In a complex febrile seizure returning to baseline, often these are outpatient studies.[4][6]

A lumbar puncture may be a consideration in the setting of fever and seizures. For a patient with the appropriate history of a febrile seizure and a rapid return to baseline, no lumbar puncture is necessary. Lumbar puncture is a recommendation when there are signs or symptoms that cause concern of a CNS infection; further, the lumbar puncture should be considered in infants aged 6 months to 12 months without appropriate immunization against Streptococcus pneumoniae or Haemophilus influenza type B and in patients taking antibiotics in which partial treatment may mask meningitis or other CNS infection.

Treatment / Management

There is no specific treatment for simple or complex febrile seizures other than appropriate treatment for underlying etiologies driving the ongoing febrile illness.  Antipyretics are not shown to prevent a recurrence of febrile seizures.  In patients who have a frequent recurrence of febrile seizures such as seizures with a majority of febrile illnesses, studies have examined treatment with benzodiazepines as a bridging measure for a few days during subsequent febrile events.[7][8][9]

Differential Diagnosis

  • Aseptic meningitis
  • Tonic-clonic seizures
  • Bacterial meningitis
  • Encephalitis

Consultations

Pediatrician

Neurologist

Pearls and Other Issues

Most patients with a febrile seizure event do not require hospitalization or intensive medical interventions. Occasionally a patient with a prolonged complex febrile seizure of a focal nature may develop focal weakness, commonly known as Todd's paralysis. Typically this resolves within a few hours, but it may take up to a few days for complete resolution. Even though febrile seizures are often considered relatively benign, studies have shown that patients with a febrile seizure status have an increased risk of developing mesial temporal sclerosis which can increase future chances of focal epilepsy. Febrile seizure status is defined as a seizure lasting longer than 30 minutes. Therefore, prompt treatment of prolonged seizures of a febrile nature is as necessary as a prompt treatment of prolonged seizures arising from other etiologies.

Additionally, as above, it is vital to quickly expand the differential diagnosis considerations if a patient is not awakening and steadily improving toward baseline, or if a patient has unexpected abnormalities on neurologic exam. A patient who will not respond to noxious stimuli after a seizure or who appears to be waxing and waning in mental status needs evaluation for possible ongoing seizure activity. Standard procedure for this evaluation is typically by a prolonged EEG study. Other considerations in a patient not recovering as expected include intracranial abnormalities such as a tumor, hemorrhage, hydrocephalus, stroke, or another significant metabolic abnormality.

Enhancing Healthcare Team Outcomes

Febrile seizures are not uncommon in the pediatric population. They only occur when there is a rise in body temperature. These seizures are benign and generally have no long-term complications in most children. The diagnosis and management of these children should be done in a systemic fashion in collaboration with other specialists like the pediatrician and neurologist. The nurse should educate the family that even though dramatic in appearance, these seizures do not lead to neurological disease or dysfunction. The more parents are aware of this disorder, the less likely it is that they will rush to the emergency room. However, the parents should also be educated on when to bring the child with a seizure to the ER because in some cases the cause may be a virus or a bacterial infection of the brain. The pharmacist should educate the family on managing the fever with acetaminophen and not aspirin. However, the family should also be educated that antipyretics do not prevent febrile seizures.[10][11] (Level III)

Outcomes

The prognosis for most children with a febrile seizure is excellent. About 30% of children who have one febrile seizure will experience another seizure later on. The risk of epilepsy in the future is slightly increased compared to the general population. However, a simple febrile seizure does not affect cognition, intellect or induce neurological dysfunction.[12][13](Level V)


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Febrile Seizure - Questions

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Which statement is FALSE about anticonvulsants and febrile seizures?



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What is the most common cause of febrile seizures?



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Which of the following is most suggestive of a febrile seizure?



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An 11-month-old child presents with a clouded sensorium following a febrile seizure. Which of the following is most urgent?



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A 2-year-old is brought to the emergency department after a tonic-clonic seizure accompanied by a fever of 104 degrees F. The patient's eyes rolled back but there was no tongue biting or urinary incontinence. The event lasted 2 minutes and the child was sleepy afterwards. The child recognized her mother in the emergency department. The exam is normal except for right otitis media. Family medical history is significant for her father having a seizure disorder as a child which resolved before adulthood. What is the next best step?



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In a child less than 12 months of age with a fever, seizure, and clouded sensorium, which of the following tests must be a priority in the ER?



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Which of the following characteristics is suggestive of a simple febrile seizure?



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An 18 month old boy with Down syndrome has a generalized tonic-clonic seizure of 20 minutes duration. The child has a temperature of 38.9°C with normal neurologic exam. This was his first seizure. His older brother has had a febrile seizure. What is this patient's lifetime risk of developing epilepsy?



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A 2 year old girl has a 5 minute febrile seizure. Select the condition that would not increase her risk of developing epilepsy.



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What percentage of patients with a single febrile seizure in childhood will go on to develop epilepsy?



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How high should the body temperature be to define a seizure as a febrile seizure?



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Which of the following is the most common form of childhood seizures?



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Which of the following statements is true about febrile seizures?



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What is the most common type of seizure in childhood?



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What is the treatment of choice for febrile seizures?



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A 2-year-old is brought to the emergency department after a tonic-clonic seizure accompanied by a fever of 104 F. The patient's eyes rolled back but there was no tongue biting or urinary incontinence. The event lasted 2 minutes and the child was sleepy afterwards. The child recognized her mother in the emergency department. The exam is normal except for right otitis media. Family medical history is significant for her father having a seizure disorder as a child which resolved before adulthood. Which of the following is the next step?



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Which of the following treatments prevents febrile seizures?



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Which of the following is recommended with regard to the management of a single uncomplicated febrile seizure?



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A 3-year-old is brought to the emergency department after a seizure in which her eyes rolled back in her head, her arms and legs shook, and she experienced bladder incontinence. The patient was previously healthy, but her temperature is now 39.2 degrees Celsius. Select the additional information that would give the patient the best prognosis.



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A 3-year-old previously healthy boy is brought to the emergency department after a shaking episode. The mother states that she witnessed the entire event. She went to tuck the child in when she noticed that his entire body was shaking and she could not get him to stop. The episode lasted about 3 minutes and following that the patient was sweaty, irritable and hard to arouse. The mother called emergency medical services who stated that he had a temperature of 103.4 F and gave him rectal acetaminophen. By the time they got to the hospital, the boy was back to neurologic baseline. He does not remember the event and mom deny any recent trauma or stressors in the family. What is the likely diagnosis?



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Febrile Seizure - References

References

Leung AK,Hon KL,Leung TN, Febrile seizures: an overview. Drugs in context. 2018     [PubMed]
Batra P,Thakur N,Mahajan P,Patel R,Rai N,Trivedi N,Fassl B,Shah B,Saha A,Lozon M,Oteng RA,Shah D,Galwankar S, An evidence-based approach to evaluation and management of the febrile child in Indian emergency department. International journal of critical illness and injury science. 2018 Apr-Jun     [PubMed]
Pavone P,Corsello G,Ruggieri M,Marino S,Marino S,Falsaperla R, Benign and severe early-life seizures: a round in the first year of life. Italian journal of pediatrics. 2018 May 15     [PubMed]
Auvin S,Antonios M,Benoist G,Dommergues MA,Corrard F,Gajdos V,Gras Leguen C,Launay E,Salaün A,Titomanlio L,Vallée L,Milh M, [Evaluating a child after a febrile seizure: Insights on three important issues]. Archives de pediatrie : organe officiel de la Societe francaise de pediatrie. 2017 Nov     [PubMed]
Kwon A,Kwak BO,Kim K,Ha J,Kim SJ,Bae SH,Son JS,Kim SN,Lee R, Cytokine levels in febrile seizure patients: A systematic review and meta-analysis. Seizure. 2018 Jul     [PubMed]
Silverman EC,Sporer KA,Lemieux JM,Brown JF,Koenig KL,Gausche-Hill M,Rudnick EM,Salvucci AA,Gilbert GH, Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations. The western journal of emergency medicine. 2017 Apr     [PubMed]
Guedj R,Chappuy H,Titomanlio L,De Pontual L,Biscardi S,Nissack-Obiketeki G,Pellegrino B,Charara O,Angoulvant F,Denis J,Levy C,Cohen R,Loschi S,Leger PL,Carbajal R, Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Annals of emergency medicine. 2017 Jul     [PubMed]
Renda R,Yüksel D,Gürer YKY, Evaluation of Patients With Febrile Seizure: Risk Factors, Reccurence, Treatment and Prognosis. Pediatric emergency care. 2017 May 8     [PubMed]
Printz V,Hobbs AM,Teuten P,Paul SP, Clinical update: Assessment and management of febrile children. Community practitioner : the journal of the Community Practitioners'     [PubMed]
Rasmussen NH,Noiesen E, [Parents of children with febrile convulsions. Multidisciplinary quality development of information and documentation]. Ugeskrift for laeger. 2001 Feb 19     [PubMed]
Sperling MR,Bucurescu G,Kim B, Epilepsy management. Issues in medical and surgical treatment. Postgraduate medicine. 1997 Jul     [PubMed]
Lee J,DeLaroche AM,Janke AT,Kannikeswaran N,Levy PD, Complex Febrile Seizures, Lumbar Puncture, and Central Nervous System Infections: A National Perspective. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2018 Apr 27     [PubMed]
Offringa M,Newton R,Cozijnsen MA,Nevitt SJ, Prophylactic drug management for febrile seizures in children. The Cochrane database of systematic reviews. 2017 Feb 22     [PubMed]

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