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).