Febrile Convulsions

Prepared by: Dr. Basem Abu-Rahmeh

Directed by: Dr. Afaf Al-Arini

Definition

• Seizure in children occurring between 6 months and 6 years precipitated by fever from infection/inflammation/metabolic disorders outside CNS in children who are otherwise neurologically normal .

• It is not a form of epilepsy because brain is normal.

How Common

• Prevalence is 2-4% of children less than 6 years.• 4% of febrile convulsion occur at age less than 6

months.• 6% occur after the age of 6 years• 90% occur between 6 months and 6 years.• Vaccination is rarely followed by febrile

convulsion and mainly after:• DTP after one day of vaccination in 6-9/100000• MMR after 8-14 day of vaccine in 25-35/100000

Etiology and Pathogenesis

• The exact etiology of febrile convulsion is unknown.

• A strong genetic influences is applied because of increase frequency among family members to have febrile convulsions.

Clinical Picture• In most cases it is generalized tonic clonic

convulsion.• Febrile convulsion is divided into three main

groups based on symptoms of the seizure:• Simple febrile convulsion (convulsion occur in

majority of the cases ~ 75%, lasting less than 15 minutes and 80% less than 6 minutes and 50% less than 3 minutes, not having focal features, single in 24 hours).

• Complex febrile convulsion: represent 25% of the cases, lasting more than 15 min, with focal features, multiple in 24 hours.

• Febrile status epilepticus.

Diagnosis

• History:• Age

• Fever (duration, peak and rate of increase).

• History of trauma.

• History of vaccination (pertussis).

• Other sites of infection.

• Family history.

• Metabolic disorders.

• GI symptoms.

Recurrence

• If recurred it will be within 1st year of the first attack and recurrence most likely will be if :– If first convulsion occur under age of 15 month (50%

recurrence rate)– Complex febrile convulsion.– First febrile convulsion with low grade fever.– Positive family history of febrile convulsion or epilepsy.

– If first degree relative (one person) recurrence will be in 30%.– If first degree relative (2 persons) recurrence will be in 50%.– If first degree relative 3 persons recurrence will reach 100%.– If no family history recurrence will be 10%.

When to refer and admit

• Strongly admit for LP or treatment if any of the following factors present:– Age under 18 months (may have meningitis with no signs).– If signs of meningitis present.– Child is toxic (irritable or drowsy).– Current treatment with antibiotics because may mask

meningeal signs– Complex convulsion– First simple attack of febrile convulsion.– The course of fever requires hospital management in its own

right.– Parents wish (anxious)

Examination

• Look for focal signs of infection.– 50% was having otitis media in one study– Reseola Infantum detected in increased fequency.– Most causes of fever are simple infection rather than

complex infection (Otitis Media, Pharyngitis versus pneumonia).

• Usually CNS examination in simple Febrile convulsion in normal but in Complex type you can find Focal neurological deficit.

• Skin rash • Others

Investigations

• LAB.: Mainly concentrated to look for the source of infection or fever.

• Imaging Studies as CT, MRI not indicated

• EEG not indicated because most have normal EEG.

Differential Diagnosis

• CNS infection.

• Metabolic Disorder as hypogylcemia and Hyponatremia.

• Poisoning.

• Shigella toxins

• Post vaccination.

• Epilepsy.

Complications and Prognosis

• Wrong diagnosis lead to delay diagnosis of meningitis.• Recurrence.• Status epilepticus represent 25% of status epilepticus

in children.• Epilepsy increase (1% compared with normal

populations which is about 0.5%with the following factors:

• Neurologically abnormal or developmentally delayed before onset of febrile convulsion.

• If atypical seizure • Family history of epilepsy

Management

• Control fever by antipyretics (paracetamole or ibubrufen) + cold compressors.

• Rectal diazepam rarely need to abort febrile convulsion because convulsion most of the time is short in duration but prolonged give it.

• If children have risk factor for recurrence give diazepam in early fever.

Prophylactic Treatment

• Phenobarbitol / valproic acid daily oral dose are effective in preventing febrile convulsion but benefits of prophylaxis rarely outweighs the risk of adverse effects

• Vaccination is not contraindicated• No treatment is effective in decreasing risk of

future epilepsy **so in general drug rational that included in febrile

convulsion are brufen , revanin, rectal dizepam.

Counseling of the Parents

• Parents should be in formed about the benign nature of febrile convulsion and that it may recure.

• Parents should be taught to manage the convulsion by placing the child in recovery position (lying In his or her side to prevent aspiration and control fever).