Febrile seizures (FS) are most common seizures of childhood, occurring in two – five percent of children six months to five year of age. FS is also associated with many risk factors of seizures that have been identified. Initially it is important to identify whether the features of FS are simple or complex and also its is important to identify the cause of fever. FS can be extremely frightening for parents, even if they are harmless to children, making it important to address the parent’s anxiety in the most sensitive manner.
The diagnosis of FS is clinical and it is important to exclude intracranial infections, in particular after a complex FS. After an initial FS, physicians should reassure parents about the low risk of long-term effects including neurological sequelae, epilepsy and death. This risk is increased in patients younger than eighteen months and also continuous or intermittent antiepileptic or antipyretic medication is not recommended for the prevention of recurrent of FS.
Management of FS consists of symptoms control and treating the cause of fever. Parents are often distressed and need to be appropriately informed and guided for the management of their child’s fever by health care professionals. Due to inappropriate use of diagnostic tests and treatments it is extremely important to improve the knowledge of pediatricians and neurologists on FS management and to standardize the diagnostic and therapeutic work-up.
Febrile seizures (FS) also known as convulsion are most common type of seizure that are mostly seen in children from five/six month to five/six year of age and is triggered by fever.
Their prevalence is approximately 3%-4% in white children, 6%-9% in Japanese children and 5%-10% in Indian children. FS can be extremely frightening for parents, even if FS is generally harmless to children, making it important to address parental anxiety in the most sensitive manner.
The exact cause of FS is still unknown, although some studies show a possible association with environmental factors and genetic factors. However, fever is normal response to infection but release of high level of cytokines during a fever may lead to alteration in brain activities, triggering seizure. According to some studies it is also indicated that FS are generally found to be occurring in male gender rather than female gender. Causes of FS may include a family history of FS, an elevated peak body temperature, certain underlying causes of fever, parental and natal complications, low serum calcium, sodium or blood sugar level, microcytic hypochromic anemia, iron and zinc deficiencies etc.
It is also found that FS are also associated with phylogenetic inheritance, even if autosomal dominant inheritance of a defined ‘febrile seizure susceptibility trait’ has been identified in some families. Mutation in genes that encode for sodium channel may play a key role in development of FS. The most frequent infections associated with FS in children are chickenpox, in?uenza, middle ear infections, upper and lower airway infections (such as tonsillitis, pneumonia, bronchitis and sinusitis), tooth infections and gastroenteritis (especially those caused by rotavirus).
According to some past studies it has been found that FS has prevalence of 2%-5% in children in Western Europe and United States and the peak age of onset is 18 months. It is also found that children aged 12-30 months represents 50% of all children with FS while the proportion of children who faces FS at the age of four year is low i.e. 6%-15%. Children of all ethnic group may present with FS but there is some high prevalence in some ethnic groups particularly in Guamanians (14%), Japanese (6%-9%) and Indians (5%-10%).
FS usually occur to those children having temperature more than 38?. Although children may face seizure at any point during a febrile disease and may only develop fever after their seizure. Typical symptoms and sign of FS may include loss of consciousness, dif?culty breathing, pallor or turning blue, foaming at the mouth, eyes rolling to the back of the head, a ?xed gaze, generalized or focal twitching, and jerking of the arms and legs. After the first episode of seizure, children may be irritable, confused or drowsy but a child can completely get recover after approximately 30 minutes.
Fig1: figure representing tonic-clonic phase of febrile seizure
FS is further classified into two categories:
SFS is the most common convulsion or seizure that is found in children and is a frequent cause of visit to the emergency department (ED). Also make up 70% of all FS and generally have no long-term neuro-developmental consequences. Historically it was assumed by many emergency medicine providers that children who experience SFS were more ‘ill’ than equally febrile children without seizure and evaluated them with SFS more rigorously. However later it was hypothesized that children with first time FS were not at high risk of serious bacterial illness (SBI).
CFS is a type of seizure with focal onset, one that occurs more than once during a febrile illness or one that last for more than 10 to 15 minutes and generally requires the administration of anticonvulsants to interrupt it.
Table 1: clinical characteristics of simple febrile seizure (SFS) and complex febrile seizure (CFS)
A major concern in any febrile child with a seizure is the possibility of central nervous system infection. When central nervous system infection is excluded, the clinician should consider other causes of fever. Although it has been shown that many febrile seizures are more likely to occur with respiratory illness, any febrile illness may be the cause for example; viral, upper respiratory infection, otitis media, pneumonia and gastroenteritis are all common. If such symptoms are not visible patient should go for urine analysis or urine culture.
Fig 2: sign and symptoms of a febrile seizure
Since many febrile seizures occur early in illness and may be presenting features but other occurring during or after the onset of fever may reflect difficulties in both taking and accurately recording the temperature of young children. There is no data to support the rate of temperature rise as being more important than the peak temperature achieved. It also unclear whether there may be a lower limit of fever under which it would be difficult to make diagnosis of febrile seizure. It is also possible that the peak of fever may be related to recurrence of febrile seizure. A child suffering from febrile seizure usually shakes all over and loses consciousness. Sometime child may get very stiff or twitch in just one area of the body.
Other than fever, infection may be the cause of febrile seizure as the fever that triggers febrile seizure are usually caused by viral infection and less commonly by bacterial infections. Influenza and the virus that causes roseola, which often are accompanied by high fevers, appear to be most frequently associated with febrile seizures. The risk of febrile seizure may increase after childhood vaccinations. A child can develop a low-grade fever after a vaccination. The fever, not the vaccination, causes the seizure.
The genetics of febrile seizure (FS) is extensive, continually expanding and is complicated reflecting the complexity of the disorder. The risk of developing febrile seizure is higher than some families than in others. A positive family history of febrile seizure can be elicited in 25%-40% of patients with febrile seizure and reported frequency in sibling of children with febrile seizure has ranged from 9% to 22%. It has been reported that children having both parents affected from febrile seizure than only one parent are on high risk of developing febrile seizure. Although there is clear evidence for genetic basis of febrile seizure but the mode of inheritance is unclear.
Most convincing evidence has emerged from linkage studies. Linkage on various chromosomes like 2q48, 5q49, 5p50, 8q51, 19p52 and 19q53. strongest linkage on chromosome 2q and specifically linkage to the gene responsible for sodium channel receptors and specifically mutation in the alpha subunit of the first neuronal sodium channel gene. The linkage on chromosomes 2q and 19q associated with the phenotype of febrile seizures, generalized epilepsy (tonic-clonic, absence, and myoclonic), and a continuation of febrile seizures (.5 years of age) (GEFS+),44 54 shows evidence of sodium channel involvement. There is currently no evidence that any of these loci have any role in the more common, ”simple” FS, with the possible exception of the chromosome 5 locus reported in the Japanese population.
Most children with febrile seizure do not experience further febrile seizure, but one third will. More than half of the risk is realized during the first year after the initial febrile seizure and over 90% recur within two years. A family history of febrile seizure in a first degree relative is associated with an increased risk of recurrence.
Recurrence appear to occur in those children whose initial febrile seizure occurred with relatively low fever. Multiple initial seizures occurring during the same febrile episode also appear to be associated with an increased risk of recurrence. Recurrent febrile seizure tends to be prolonged if the initial febrile seizure was prolonged. There are some risk factors that are associated with risk of recurrence, some of them are listed below:
Children with all mentioned risk factors have up to 80% of having further episodes and children having none of the above-mentioned risk factors have 4%chance of having further febrile seizure.
When a child is identified or diagnosed with febrile seizure it is important to collect all the details and accurate history in order to perform complete clinical evaluation, including neurologic examination to rule out secondary causes of convulsion. The differential diagnosis of febrile seizure includes rigors, febrile delirium, febrile syncope, breathe holding attack, reflex anoxic seizures, evolving epilepsy syndrome and central nervous system infection. The clinical evaluation focuses on identifying the infection causing fever. If still problem occur same, the child needs emergency stabilization using ABCDE approach (airways, breathing, circulating, disability and exposure/examination, plus blood glucose check) and the seizure should be stopped with antiepileptic drugs as soon as possible. After stabilization, vital signs should be recorded: temperature, heart and respiratory rate, capillary re?ll time, and blood glucose. Furthermore, it is necessary to differentiate between a ?rst FS and the ?rst episode of a febrile or epileptic convulsion, and a clear history of fever, either before or soon after FS, should be identi?ed. Some test like computed tomography (CT), MRI, electroencephalography (EEG), or a combination of these may be considered in children with a history of complex or recurrent FS or who present with neurological abnormalities to rule out the presence of neurologic conditions. After a FS in a healthy child with a clear source of infection, an EEG is not recommended.
Fig 3: figure representing brain with normal tissue and abnormal tissue after febrile seizure
A child with a simple febrile seizure doesn’t need to be hospitalized if he or she is in good clinical condition and if the source of infection is clear. Most febrile seizure episodes are short- lived and self-terminating and also do not require long-term treatment with antiepileptic drugs. In the evaluation of a child with FS, it is important to recognize red ags, which are useful in deciding if further management is required or not.
Table 1: Red ag signs and symptoms in a child presenting with febrile seizures (FS)
Hospitalization for observation is necessary when a child presents with red flag sign and symptoms. In acute phase treatment is directed at identifying the underlying cause of the fever and its symptomatic managements. At the same time, it is important to ensure adequate hydration by encouraging child to drink and paracetamol can be administered to relieve discomfort caused by infection. Several trials have demonstrated that antipyretic drugs do not reduce the risk of febrile seizure recurrence and therefore attempting to reduce patient’s temperature is not all recommended. Parents and caretaker should be made aware that the rationale for the administration of antipyretic drugs is to relieve the discomfort caused by the infection, not to reduce the risk of febrile seizure. Below mentioned table provide with some advices for parents on initial management of febrile seizures at home:
Table 2: advice for parents on initial management of febrile seizure at homes. no Initial management of FS
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