Clinical Notes : Paediatrics
144. Fever Seizure
Definition
A febrile seizures is a seizure occurring in febrile children between the ages of 6 and 60 months who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures.(1)
The first occurrence is usually before 3 years of age, but is infrequent in children younger than 6 months.
Febrile seizures have a peak incidence at 18 months of age and are most common between 6 months and 5 years.
Most febrile seizures are simple with approximately 20% to 30% being complex.(2)
Pathophysiology
Viral infections triggering fever are most common, with bacteraemia as an infrequent cause (3)
Febrile seizures are dependent upon a threshold temperature and this seems to vary from one individual to another.(4)
Age plays an important role in the susceptibility of febrile seizures.
the risk of recurrence of seizure declines with growing older (5)
Febrile seizures recur in approximately 30% of children during subsequent febrile illnesses.(6)
Most recurrences occur within 2 years
The most consistently identified risk factor for febrile seizure is the presence of a close family history (within first-degree relatives) of febrile seizure. The more relatives affected, the greater the risk. (7)
Classification
A simple febrile seizure is characterised by generalised tonic-clonic activity without focal features, for less than 10 minutes, without a recurrence in the subsequent 24 hours and resolving spontaneously.(8)
Complex febrile seizures are defined by one or more of the following features: (9)
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a focal onset or focal features during the seizure
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prolonged duration (greater than 10 to 15 minutes)
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recurrent within 24 hours or within same febrile illness
Between 9% and 35% of all first febrile seizures are complex
Physical signs consistent with diagnosis
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extracranial infection and fever (e.g., upper respiratory infection, otitis media, gastroenteritis)
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rapid recovery of consciousness after seizure (within 30 minutes)
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absence of nuchal rigidity and focal neurological abnormalities
Management
During a witnessed seizure, the patient should be protected from physical injury.
Additionally, airway, breathing, and circulatory assessment and support are vital.
A simple febrile seizure will stop spontaneously within a few minutes, and anticonvulsant therapy is not needed.
Body temperature should be reduced to relieve discomfort.
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ibuprofen
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children 6 months-12 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day
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paracetamol
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10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day
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For a complex febrile seizure buccal administration of midazolam may be given in preference to rectal diazepam.
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midazolam
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children 1-2 months of age: 300 micrograms/kg (maximum 2.5 mg/dose) buccally as a single dose
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repeat after 10 minutes if required;
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children 3-11 months of age: 2.5 mg buccally as a single dose
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repeat after 10 minutes if required;
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children 1-4 years of age: 5 mg buccally as a single dose
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repeat after 10 minutes if required
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children 5-9 years of age: 7.5 mg buccally as a single dose
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repeat after 10 minutes if required;
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children 10-17 years of age: 10 mg buccally as a single dose
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repeat after 10 minutes if required
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diazepam
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children <2 years of age: consult specialist for guidance on dose
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children 2-5 years of age: 0.5 mg/kg rectally as a single dose
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may repeat in 4-12 hours if required;
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children 6-11 years of age: 0.3 mg/kg rectally as a single dose
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may repeat in 4-12 hours if required
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Refer all cases to A+E for evaluation by a pediatrician.
Re-examination of a child with apparent recovery from a febrile seizure is mandatory within 24 hours.
Parent instructions
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A first febrile seizure in a child is a frightening experience. Parents' concerns may continue long after the seizure abates.
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Child should be protected from injury during the seizure.
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Some children have a susceptibility to febrile seizures that resolves before the age of 6.
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The risk of non-febrile seizures and epilepsy is small.
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Recurrence is likely, usually within the year, but some preventive measures can be successful.
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If a seizure develops and lasts longer than 3 to 5 minutes, child should be taken to the nearest hospital emergency department.
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Parents should receive CPR training.
Prognosis
the vast majority of children with febrile seizures have a normal long-term outcome (10)
The risk of non-febrile seizures and epilepsy developing after simple febrile seizures is 5% or less.
However, after complex febrile seizures, the risk of developing epilepsy is 10% to 20% (11)
Febrile seizures are not associated with sudden unexpected death (12)
1. Capovilla G, Mastrangelo M, Romeo A, et al.
Recommendations for the management of "febrile seizures":
Ad Hoc Task Force of LICE Guidelines Commission.
Lega Italiana Contro l'Epilepsia
Epilepsia. 2009 Jan;50(suppl 1):S2-6
2. Shinnar S, Glauser TA.
Febrile seizures.
J Child Neurol. 2002 Jan;17(suppl 1):S44-52
3. Millichap JG, Millichap JJ.
Role of viral infections in the etiology of febrile seizures.
Pediatr Neurol. 2006 Sep;35(3):165-72.
4. Berg AT, Shinnar S, Shapiro ED, et al.
Risk factors for a first febrile seizure: a matched case-control study.
Epilepsia. 1995 Apr;36(4):334-41.
5. van Stuijvenberg M, Steyerberg EW, Derksen-Lubsen G, et al.
Temperature, age, and recurrence of febrile seizure.
Arch Pediatr Adolesc Med. 1998 Dec;152(12):1170-5
6. Sadleir LG, Scheffer IE.
Febrile seizures.
BMJ. 2007 Feb 10;334(7588):307-11.
7. Saghazadeh A, Mastrangelo M, Rezaei N.
Genetic background of febrile seizures.
Rev Neurosci. 2014;25(1):129-61
8. Mewasingh LD.
Febrile seizures.
BMJ Clin Evid. 2014 Jan 31;2014
9. Waruiru C, Appleton R.
Febrile seizures: an update.
Arch Dis Child. 2004 Aug;89(8):751-6
10. Knudsen FU.
Febrile seizures: treatment and prognosis.
Epilepsia. 2000 Jan;41(1):2-9.
11. Chungath M, Shorvon S.
The mortality and morbidity of febrile seizures.
Nat Clin Pract Neurol. 2008 Nov;4(11):610-21
12. Holm IA, Poduri A, Crandall L, et al.
Inheritance of febrile seizures in sudden unexplained death in toddlers.
Pediatr Neurol. 2012 Apr;46(4):235-9
Summary of recommendations for the management of infantile seizures
Task force report for the ILAE Commission of Pediatrics
International League Against Epilepsy
2015
Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure
American Academy of Pediatrics
2011
Treatment of the child with a first unprovoked seizure
American Academy of Neurology; Child Neurology Society
Last published: 2003 (reaffirmed 2018)
BMJ Best Practice
Jan 2019
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