Fever (greater than 38.0 Celsius) is a common presentation in many children. Fever in addition to seizures can be very scary to parents. 3% of healthy children between the ages of 5 months to 5 years experience seizures that are triggered by fever. This fever is often caused by viral respiratory illnesses but can also be more serious such as infection from UTI, meningitis, or acute otitis media. The seizures almost always last for only a couple of minutes, however about 1% of the seizures develop into status epilepticus. It is important to pay special attention to patients who have developmental delays as febrile seizures in these patients can be the first sign of epilepsy and as such appropriate workup and referral to neurology should be made for these patients. Patients who do not have a fever at the time, or shortly after a seizure episode are also not considered to have febrile seizures and require appropriate workup and referral.
Diagram 1. EEG for the workup of a seizure by neurologists. Done to rule out neurological causes of seizures.
The treatment of this condition starts by cooling down the febrile child to prevent further seizures. Undressing them and using a wet sponge on their skin and the use of antipyretics such as Ibuprofen and Tylenol can reduce the short term likelihood of experiencing another seizure. Further, workup should be targeted into finding out the source of the fever and treating that (urinalysis, respiratory illness symptoms, etc). If there are no clear sources of a fever in a child with fever and seizures, and lumbar puncture may be required to rule out meningitis.
Diagram 1. Lumbar puncture (LP) might be needed to rule out meningitis as a cause of fever causing seizures.
During a seizure, placing patients in the recovery position (Diagram 2) and maintaining an open airway are the most important factors. Any seizure lasting more than 10 minutes should be treated with benzodiazepines (rectal diazepam in pediatric patients). Some seizures persist even after rectal diazepam and may require IV lorazepam to prevent the development into status epilepticus. Checking the blood glucose level can identify hypoglycemia, which is a trigger of seizures in some patients. There is often a post-ictal state associated with most seizures and parents should expect this as part of the normal recovery.
Diagram 2. Recovery position for patients experiencing a seizure episode
The definition of this condition includes a seizure lasting longer than 5 minutes or multiple seizures without full recovery within 5 minutes. Delay in treatment can be life-threatening. Patients should be placed in recovery position (similar to other types of seizures), have a supported airway, be given oxygen, get their blood sugar checked and IV lorazepam in addition to rectal diazepam should be started. Sometimes benzodiazepines fail to stop the convulsions and this may require the administration of anesthetics to stop the seizure.
Recurrence of seizures in these patients is quite high at 30-35% during the subsequent febrile episodes. Parents must be educated on managing their kids with fever in the future and provide first aid during seizures. The overall risk of developing epilepsy (2 or more unprovoked seizures) after an uncomplicated febrile seizure episode is very low at 2-3% in this patient population and most are not at increased risk for epilepsy compared to other children with no history of febrile seizures. Most children with this disorder do not require anticonvulsant medication unless the number of episodes is frequent and the duration is prolonged.
What are complicated febrile seizures?
A febrile seizure is considered complicated or complex if one or more of these applies:
- The seizure lasts more than 15 mins
- There is more than 1 episode within 24 hours
- There is evidence for focal seizure separate from other parts of the body
Conversely, uncomplicated or simple febrile seizures involve one or all of these:
- A seizure lasting less than 15 minutes
- One episode within 24 hours or less frequent
- Generalized seizure
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