Author:
John P.Santamaria
StefaniAshby
Description
- Occurs between 6 mo and 5 yr of age associated with fever:
- No evidence of intracranial infection or other defined CNS primary cause
- Average age of onset is 18-22 mo
- Children with previous nonfebrile seizures excluded
- Most common pediatric convulsive disorder:
- Affects 2-4% of young children in the U.S.
- Occurs in normal children with a systemic viral illness
- High-risk children:
- History of febrile seizure in immediate family members
- Delayed neurologic development
- Males
- Subgroups:
- Simple febrile seizures:
- Brief, self-limited, lasting <10-15 min, resolve spontaneously
- Generalized without any focal features
- Complex febrile seizures:
- Duration >15 min
- Focal features
- >1 seizure within a 24-hr period
- Risk of recurrence:
- One-third of cases
- Early age of onset, history of febrile or afebrile seizures in first-degree relatives, and temperature <40°C during initial seizure increase the likelihood of recurrence
- Risk of subsequent epilepsy:
- Greatest for those with prior abnormal neurologic development, a complex (>15 min) first febrile seizure, a focal seizure, or a family history of afebrile seizures
- Only slightly greater than the general population if first febrile seizure is simple and neurologic development normal
- Not affected by the use of prophylactic medications
ALERT |
| Because this is usually self-limited, intervention must be individualized in relation to airway, breathing, and seizure management |
Etiology
Common childhood infections:
- Upper respiratory illnesses
- Otitis media
- Roseola
- GI infections
- Shigellagastroenteritis
Signs and Symptoms
- Fever
- Seizure may occur concurrent with recognition of the febrile illness
- Seizure
- Generalized tonic-clonic seizure most common:
- Tonic phase:
- Muscular rigidity
- Apnea and incontinence
- Self-limited and last only a few minutes
- Other seizure types:
- Staring with stiffness
- Limpness
- Jerking movements without prior stiffening
History
- Careful history and physical exam help confirm diagnosis and rule out other etiologies
- Symptoms/evidence of infectious illness
- Duration and pattern of fever
- Medication exposure/toxin
- Recent immunizations
- Trauma/occult trauma
- Growth pattern and developmental level
- Family history of seizures
- Complete description of seizure
Physical Exam
- Reducing temperature may be useful in evaluation; give antipyretics early
- Evidence of infectious illness - rash, ear infection, respiratory infection, diarrhea, etc.
- Careful neurologic exam including mental status
- Presence of meningismus, bulging fontanelle, nuchal rigidity, etc.
- Evidence of focal deficit or increased ICP
Diagnostic Tests & Interpretation
Lab
- Routine lab studies not indicated
- Evaluate for a source of fever if serious bacterial infection is suspected:
- WBC
- UA
- Blood and urine cultures
- Lumbar puncture:
- Not routinely indicated although threshold for performing LP should be lower in children <12 mo, who have any evidence of signs or symptoms suggestive of CNS infection
- Indications for LP in children 12-18 mo of age:
- History or irritability, decreased feeding, lethargy
- Consider if deficient in Haemophilus influenzae type b or Streptococcus pneumoniae immunizations
- Physical signs of meningitis/HSV meningoencephalitis and /or history consistent with meningitis/encephalitis
- Complex seizure
- Prolonged postictal state
- Prior antibiotics, potentially altering presentation
- Abnormal mentation after at least partial resolution of postictal state
- Indications for LP in children >18 mo old:
- Signs/symptoms of CNS infection present
- Electrolytes and bedside glucose in infants and children with vomiting or diarrhea
- EEG:
- Not helpful in the initial evaluation of febrile seizures
- May be indicated if developmental delay, underlying neurologic abnormality, or focal seizure
- Does not help predict recurrences or risk for later epilepsy
- Anticonvulsant levels, if on anticonvulsants
- Toxicology studies of blood and urine if history and physical exam suggestive
Imaging
- CXR in patients with significant respiratory symptoms, pertinent findings on physical exam, or significant febrile illness
- Head CT:
- Indicated with traumatic injuries, focal neurologic findings, or inability to exclude elevated intracranial pressure
Differential Diagnosis
- Febrile delirium
- Febrile shivering with pallor and perioral cyanosis
- Breath-holding spell during febrile event
- Acute life-threatening event
- Other causes of seizure:
- Afebrile seizure occurring during febrile event
- Sudden discontinuance of anticonvulsants
- Infection:
- Meningitis/encephalitis
- Acute gastroenteritis, often with dehydration
- Head trauma
- Toxicologic:
- Anticholinergics
- Sympathomimetics
- Other
- Hypoxia
- Metabolic disease
- Intracranial masses
- CNS vascular lesions
Prehospital
- Protect the airway
- Oxygen
- Support breathing, as needed
- Antipyretics and fever control
- Cautions:
- Keep child from incurring injury while actively convulsing
- Respiratory insufficiency and apnea occur secondary to overaggressive treatment with benzodiazepines
- Simple febrile seizures are self-limited and generally require no anticonvulsant therapy or ventilatory support
Initial Stabilization/Therapy
- Support the airway and breathing
- Benzodiazepines rarely needed:
- Prolonged seizures or compromised patients
- Lorazepam, diazepam, or midazolam
- Rectal diazepam, nasal midazolam, or nasal lorazepam may be easily administered with good efficacy
ED Treatment/Procedures
- Rarely is pharmacologic intervention required; usually self-limited
- Seizures refractory to benzodiazepines:
- Appropriate antibiotic treatment for specific bacterial disease if identified
- Fever control
- Reassurance and education of parents is essential
Medication
- Acetaminophen: 10-15 mg/kg/dose PO, PR; do not exceed 5 doses/24 hr or 4 g/24 hr
- Diazepam: 0.2 mg/kg IV (max 8 mg); 0.5 mg/kg PR (max 20 mg)
- Fosphenytoin: 20 mg/kg IV over 20 min
- Ibuprofen: 10 mg/kg PO
- Levetiracetam: 20-60 mg/kg IV (max 2.5 g) over 15 min
- Lorazepam: 0.1 mg/kg IV (max 4 mg)
- Midazolam: 0.15 mg/kg IV; 0.2 mg/kg buccal/IM (max 10 mg); 0.3 mg/kg IN (max 10 mg)
- Phenobarbital: 20 mg/kg IV (max 1 g) over 15-30 min; monitor for respiratory depression
- Phenytoin: 20 mg/kg IV over 30-45 min
Disposition
Admission Criteria
- Recurrent or prolonged seizures
- Fever from source not appropriately treated as outpatient
Discharge Criteria
- Simple febrile seizures:
- Normal neurologic exam
- Source of fever is appropriately treated as outpatient
- Reassurance to parents
Follow-up Recommendations
Schedule follow-up with primary care physician
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