Febrile Seizures

Febrile seizures are seizures without a definite cause that are associated with fever. Febrile seizures, by definition, do not include seizures occurring in patients with an intra-cranial infection, such as meningitis or encephalitis, toxic encephalopathy, or any other neurologic illness. The definition also excludes seizures associated with fever that occur in patients who have a history of a previous nonfebrile seizure. Febrile seizures usually occur in children between the ages of 3 months and 5 years and represent the most common convulsive disorder of young children, affecting 2% to 5% of U.S. children. The most common age of onset is in the second year of life, and boys are affected slightly more often than girls (Freeman and Vining, 1995; Hirtz, 1997).

Risk factors for a first febrile seizure include a family history of febrile seizures, developmental delays, very high fever, and child care attendance. Approximately one third of children who experience a first febrile seizure will experience at least one more. The younger the child when the first febrile seizure occurs, the more likely the child is to have another febrile seizure. Most recurrences occur within 1 year. A family history of febrile seizures also increases the likelihood of recurrence. Fortunately, less than 5% of children who experience a febrile seizure develop epilepsy.

Febrile seizures can be of any type, but are most often tonic-clonic. Febrile seizures are usually shorter than 6 minutes, and fewer than 8% last longer than 15 minutes. Most children therefore do not come to the attention of the family physician until after the seizure is over. Although it is commonly believed that the rate of fever increase is an important factor in the development of febrile seizures, no data support this as being more important than fever severity.

Box 42-7 Seizure Classification

Partial Seizures

Simple (consciousness is preserved) Complex (consciousness is impaired) Secondarily generalized

Simple partial seizures evolving to generalized tonic-clonic Complex partial seizures evolving to generalized tonic-clonic Simple partial seizures evolving to complex partial, then to generalized tonic-clonic

Generalized Seizures

Tonic-clonic

Absence

Atypical absence

Myoclonic

Tonic

Atonic

The evaluation of a child who has had a febrile seizure should begin with a careful history and physical examination. The history should include symptoms of infection, medication use, toxic ingestions, developmental and health problems, prenatal/birth and family history, and detailed description of the seizure by witnesses. The physical examination should pay particular attention to signs of severe illness, including petechiae, meningismus, tense or bulging fontanelle, Kernig's and Brudzinski's signs, and signs of neurologic abnormality, including decreased alertness or cognition and deficits of motor strength or tone. Even in children with a previous history of febrile seizures, a seizure associated with fever may be a sign of an intracranial infection. If intracranial infection is suspected, a lumbar puncture (LP) should be performed. Otherwise, LP is not necessary. Children older than 18 months who have meningitis or encephalitis usually demonstrate typical clinical signs and symptoms. Many of these children lack histories, symptoms, or signs suggesting meningitis and thus do not require LP. However, children younger than 12 to 18 months may lack the typical clinical signs and symptoms of intracranial infection and are more likely to require LP. If a child is already taking antibiotics and experiences a seizure associated with fever, partially treated meningitis should be considered. The presence of a source of infection, such as otitis media, does not exclude the possibility of meningitis. Other features in the history that should also raise suspicion of meningitis in children with seizures and fever include evaluation for illness by a physician within the past 48 hours, a seizure that occurs in the office or emergency department (ED), or a focal seizure.

Most children with febrile seizures do not require routine laboratory testing. The only laboratory studies needed are those that will assist in evaluating the source of the child's fever. Radiography of the skull, neuroimaging studies such as CT and MRI, and EEG are not usually indicated. Children who are diagnosed with a febrile seizure should be observed in the ED or physician's office for several hours. These children may then be sent home, provided (1) they demonstrate satisfactory clinical improvement and are alert, (2) their fever has been appropriately evaluated and treated, and (3) close outpatient follow-up is possible. If there is any question about intracranial infection, if a child does not demonstrate expected clinical improvement during observation, or if follow-up cannot be ensured, hospital admission is recommended.

One of the most important components of outpatient management of children with febrile seizures is education of the parents. Seizures are frightening events for most parents. They should be reassured that febrile seizures do not result in brain damage and that the risk of epilepsy is very low. Slightly more than one in six children, however, experience another seizure within 24 hours, and about one in three experiences another febrile seizure at some point. If another seizure occurs, parents should be advised to place the child on his or her side or face down on the abdomen. Contrary to common belief, they should not attempt to place anything between the child's teeth during a seizure. The parents should carefully observe the child, and if the seizure does not spontaneously resolve after 10 minutes, they should call 9-1-1. Parents may have concerns about routine vaccinations for children with a history of febrile seizures. The diphtheria and tetanus toxoids and pertussis (DTP) and measles, mumps, and rubella (MMR) vaccinations are most likely to produce fever associated with seizure. If a febrile seizure is going to occur after vaccination, it is most likely to occur within 48 hours of the DTP vaccination or within 10 days of the MMR vaccination.

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