Febrile seizure

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Febrile seizure
Other namesFever fit, febrile convulsion
Clinical thermometer 38.7.JPG
An analog medical thermometer showing a temperature of 38.8 °C or 101.8 °F
Specialty Emergency medicine, neurology
Symptoms Tonic-clonic seizure [1]
Usual onsetAges of 6 months to 5 years [1]
DurationTypically less than 5 minutes [1]
TypesSimple, complex [1]
CausesHigh body temperature [1]
Risk factors Family history [1]
Differential diagnosis Meningitis, metabolic disorders [1]
Treatment Supportive care [1]
Medication Benzodiazepines (rarely needed) [1]
Prognosis Good [1]
Frequency~5% of children [2]

A febrile seizure, also known as a fever fit or febrile convulsion, is a seizure associated with a high body temperature but without any serious underlying health issue. [1] They most commonly occur in children between the ages of 6 months and 5 years. [1] [3] Most seizures are less than five minutes in duration, and the child is completely back to normal within an hour of the event. [1] [4] There are two types: simple febrile seizures and complex febrile seizures. [1] Simple febrile seizures involve an otherwise healthy child who has at most one tonic-clonic seizure lasting less than 15 minutes in a 24-hour period. [1] Complex febrile seizures have focal symptoms, last longer than 15 minutes, or occur more than once within 24 hours. [5] About 80% are classified as simple febrile seizures. [6]

Contents

Febrile seizures are triggered by fever, typically due to a viral infection. [6] They may run in families. [1] The underlying mechanism is not fully known, but it is thought to involve genetics, environmental factors, brain immaturity, and inflammatory mediators. [7] [8] [6] The diagnosis involves verifying that there is not an infection of the brain, there are no metabolic problems, and there have not been prior seizures that have occurred without a fever. [1] [6] Blood testing, imaging of the brain, or an electroencephalogram (EEG) is typically not needed. [1] Examination to determine the source of the fever is recommended. [1] [6] In otherwise healthy-looking children a lumbar puncture is not necessarily required. [1]

Neither anti-seizure medication nor anti-fever medication are recommended in an effort to prevent further simple febrile seizures. [1] [9] In the few cases that last greater than 5 minutes, a benzodiazepine such as lorazepam or midazolam may be used. [1] [10] Efforts to rapidly cool during a seizure is not recommended. [11]

Febrile seizures affect 2–10% of children. [2] They are more common in boys than girls. [12] After a single febrile seizure there is an approximately 35% chance of having another one during childhood. [6] Outcomes are generally excellent with similar academic achievements to other children and no change in the risk of death for those with simple seizures. [1] There is tentative evidence that affected children have a slightly increased risk of epilepsy at 2% compared to the general population. [1]

Signs and symptoms

Signs and symptoms depend on if the febrile seizure is simple versus complex. In general, the child's temperature is greater than 38 °C (100.4 °F), [4] although most have a fever of 39 °C (102.2 °F) or higher. [6] Most febrile seizures will occur during the first 24 hours of developing a fever. [6] Signs of typical seizure activity include loss of consciousness, opened eyes which may be deviated or appear to be looking towards one direction, irregular breathing, increased secretions or foaming at the mouth, and the child may look pale or blue (cyanotic). [4] [6] They may become incontinent (wet or soil themselves) and may also vomit. [4]

Types

There are two types of febrile seizures: simple and complex. [5] Febrile status epilepticus is a subtype of complex febrile seizures that lasts for longer than 30 minutes. [7] It can occur in up to 5% of febrile seizure cases. [13]

Types [6] [14] [7]
SimpleComplex
Characteristics Generalized tonic clonic movements (stiffening and shaking of arms and legs) Focal movements (usually affecting a single limb or side of the body)
Duration<15 minutes (with most lasting <5 minutes)>15 minutes
Postictal state None or short period of drowsinessLonger period of drowsiness; may experience Todd's paralysis
RecurrenceNo recurrence in the first 24 hoursMay recur in the first 24 hours

Causes

Genetic associations [15]
Type OMIM Gene
FEB3A 604403 SCN1A
FEB3B 604403 SCN9A
FEB4 604352 GPR98
FEB8 611277 GABRG2

Febrile seizures are due to fevers, [12] usually those greater than 38 °C (100.4 °F). [16] The cause of the fevers is often a viral illness. [1] The likelihood of a febrile seizure is related to how high the temperature reaches. [1] [6] Some feel that the rate of increase is not important [1] while others feel the rate of increase is a risk factor. [17] This latter position has not been proven. [17]

In children, illnesses that often cause a fever include middle ear infections and viral upper respiratory infections. [5] Other infections associated with febrile seizures include Shigellosis, Salmonellosis, and Roseola. [5] Although the exact mechanism is unknown, it is speculated that these infections may affect the brain directly or via a neurotoxin leading to seizures. [5]

There is a small chance of a febrile seizure after certain vaccines. [18] The risk is only slightly increased for a few days after receiving one of the implicated vaccines during the time when the child is likely to develop a fever as a natural immune response. [6] Implicated vaccines include: [18] [6]

It was previously thought that febrile seizures were more likely to occur with the combined MMRV vaccine, but recent studies have found there to be no significant increase. [19] Overall, febrile seizures triggered by vaccines are uncommon. [19] Children who have a genetic predisposition towards febrile seizures are more likely to have one after vaccination. [19]

The seizures occur, by definition, without an intracranial infection or metabolic problems. [1] They run in families with reported family history in approximately 33% of people. [1] [6] Several genetic associations have been identified, [15] including GEFS+ and Dravet Syndrome. [7] Possible modes of inheritance for genetic predisposition to febrile seizures include autosomal dominance with reduced penetrance and polygenic multifactorial inheritance. [20] [6] An association with iron deficiency has also been reported, particularly in the developing world. [21] [22]

Mechanism

The exact underlying mechanism of febrile seizures is still unknown, but it is thought to be multi-factorial involving genetic and environmental factors. [6] [7] Speculation includes immaturity of the central nervous system at younger ages, making the brain more vulnerable to the effects of fever. [6] [20] The increased activity of neurons during rapid brain development, may help explain why children, particularly younger than age 3, are prone to febrile seizures, with occurrences decreasing after age 5. [6] Other proposed mechanisms include the interactions of inflammatory mediators, particularly cytokines, which are released during a fever, causing elevated temperatures in the brain, which may somehow lead to a seizure. [7] [8] Specific cytokines implicated include elevated CSF IL-1β and serum IL-6. [8]

Diagnosis

The diagnosis is made by eliminating more serious causes of seizure and fever: in particular, meningitis and encephalitis. [14] However, in children who are immunized against pneumococcal and Haemophilus influenzae , the risk of bacterial meningitis is low. [7] If a child has recovered and is acting normally, bacterial meningitis is very unlikely, making further procedures such as a lumbar puncture unnecessary. [6]

Diagnosis involves gathering a detailed history including the value of highest temperature recorded, timing of seizure and fever, seizure characteristics, time to return to baseline, vaccination history, illness exposures, family history, etc.; and performing a physical exam that looks for signs of infection including meningitis and neurological status. [6] Blood tests, imaging of the brain and an electroencephalogram are generally not needed. [1] [14] However, for complex febrile seizures, EEG and imaging with an MRI of the brain may be helpful. [20] [23]

Lumbar puncture is recommended if there are obvious signs and symptoms of meningitis or if there is high clinical suspicion. [14] However, lumbar puncture is an option that may be considered in children younger than 12 months of age since signs and symptoms of meningitis may be atypical, if the child does not return to baseline, or if the child lacks immunization against Haemophilus influenzae and pneumococcal or vaccination status is unknown. [14] [5] [6]

Differential diagnosis includes other causes of seizures such as CNS infections (i.e. meningitis, encephalitis), metabolic disturbances (i.e. electrolyte imbalances), CNS trauma, drug use and/or withdrawal, genetic conditions (i.e. GEFS+), FIRES, shivering, febrile delirium, febrile myoclonus, breath holding spells, and convulsive syncope. [6] However, febrile seizures are still the most likely cause of convulsions in children under the age of 5 years old. [14]

Prevention

There is no benefit from the use of phenytoin, valproate, ibuprofen, diclofenac, acetaminophen, pyridoxine, or zinc sulfate. [9] There is no evidence to support administering fever reducing medications such as acetaminophen at the time of a febrile seizure or to prevent the rate of recurrence. [24] Rapid cooling methods such as an ice bath or a cold bath should be avoided as a method to lower the child's temperature, especially during a febrile seizure. [11]

There is a decrease of recurrent febrile seizures with intermittent diazepam and phenobarbital but there is a high rate of adverse effects. [9] They are thus not recommended as an effort to prevent further seizures. [1]

Treatment

Side positioning for person having a seizure Seizure Recovery Position.pdf
Side positioning for person having a seizure

If a child is having a febrile seizure, the following recommendations are made for caregivers: [25]

In those with a single seizure lasting greater than 5 minutes or two consecutive seizures lasting greater than 5 minutes in which the person has not returned to their baseline mental status, defined as status epilepticus, intravenous lorazepam, rectal diazepam, or intranasal midazolam is recommended. [1] [3] Anti-seizure medication are used in status epilepticus in an effort to prevent complications such as injury to the hippocampus or temporal lobe epilepsy. [26]

Secondary causes of a seizure should be addressed if present. Questions that may be asked of the caregivers who witnessed the seizure include the length of the seizure, the timing of the day, loss of consciousness, loss of bowel or urinary continence, a period of altered level of consciousness or confusion once the seizure stopped, movement of the eyes to a specific side, recent infections, recent medication usage including antibiotics or fever reducer medications, family history of febrile and afebrile seizures, vaccination and travel history.[ citation needed ]

Vital signs should be monitored in the emergency department along with observation for 6 hours. Evaluation for the cause of fever should be performed including signs of an infection such as a bulging tympanic membrane (otitis media), red pharynx, enlarged tonsils, enlarged cervical lymph nodes (streptococcal pharyngitis or infectious mononucleosis), and a widespread rash. [6] CNS infections such as meningitis, encephalitis and brain abscesses should be ruled out, along with electrolyte abnormalities.[ citation needed ]

Prognosis

Long term outcomes are generally good with little risk of neurological problems or epilepsy. [1] Those who have one febrile seizure have an approximately 30- 40% chance of having another one in the next two years, with the risk being greater in those who are younger. [1] [6]

Simple febrile seizures do not tend to recur frequently (children tend to outgrow them) and do not make the development of adult epilepsy significantly more likely (about 3–5%) compared with the general public (1%). [27] Children with febrile convulsions are more likely to have a febrile seizure in the future if they were young at their first seizure (less than 18 months old), have a family history of a febrile convulsions in first-degree relatives (a parent or sibling), have a short time between the onset of fever and the seizure, had a low degree of fever before their seizure, or have a seizure history of abnormal neurological signs or developmental delay. Similarly, the prognosis after a complex febrile seizure is excellent, although an increased risk of death has been shown for complex febrile seizures, partly related to underlying conditions. [28]

Epidemiology

Febrile seizures happen between the ages of 6 months and 5 years. [1] [3] [29] The peak age for a febrile seizure is 18 months, with the most common age range being 12–30 months of age. [30] They affect between 2-5% of children. [1] [3] [29] They are more common in boys than girls. [12] [6] Febrile seizures can occur in any ethnic group, although there have been higher rates in Guamanians (14%), Japanese (6-9%) and Indians (5-10%). [31]

Related Research Articles

<span class="mw-page-title-main">Epilepsy</span> Group of neurological disorders causing seizures

Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal, excessive, and synchronized electrical discharge in the brain cells called neurons. The occurrence of two or more unprovoked seizures defines epilepsy. The occurrence of just one seizure may warrant the definition in a more clinical usage where recurrence may be able to be prejudged. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly such as broken bones or through causing accidents. In epilepsy, seizures tend to recur and may have no detectable underlying cause. Isolated seizures that are provoked by a specific cause such as poisoning are not deemed to represent epilepsy. People with epilepsy may be treated differently in various areas of the world and experience varying degrees of social stigma due to the alarming nature of their symptoms.

<span class="mw-page-title-main">Seizure</span> Period of symptoms due to excessive or synchronous neuronal brain activity

An epileptic seizure, informally known as a seizure, is a period of symptoms due to abnormally excessive or synchronous neuronal activity in the brain. Outward effects vary from uncontrolled shaking movements involving much of the body with loss of consciousness, to shaking movements involving only part of the body with variable levels of consciousness, to a subtle momentary loss of awareness. These episodes usually last less than two minutes and it takes some time to return to normal. Loss of bladder control may occur.

<span class="mw-page-title-main">Encephalitis</span> Inflammation of the brain

Encephalitis is inflammation of the brain. The severity can be variable with symptoms including reduction or alteration in consciousness, headache, fever, confusion, a stiff neck, and vomiting. Complications may include seizures, hallucinations, trouble speaking, memory problems, and problems with hearing.

A convulsion is a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking. Because epileptic seizures typically include convulsions, the term convulsion is often used as a synonym for seizure. However, not all epileptic seizures result in convulsions, and not all convulsions are caused by epileptic seizures. Non-epileptic convulsions have no relation with epilepsy, and are caused by non-epileptic seizures.

<span class="mw-page-title-main">Status epilepticus</span> Medical condition

Status epilepticus (SE), or status seizure, is a medical condition consisting of a single seizure lasting more than 5 minutes, or 2 or more seizures within a 5-minute period without the person returning to normal between them. Previous definitions used a 30-minute time limit. The seizures can be of the tonic–clonic type, with a regular pattern of contraction and extension of the arms and legs, or of types that do not involve contractions, such as absence seizures or complex partial seizures. Status epilepticus is a life-threatening medical emergency, particularly if treatment is delayed.

<span class="mw-page-title-main">Temporal lobe epilepsy</span> Chronic focal seizure disorder

In the field of neurology, temporal lobe epilepsy is an enduring brain disorder that causes unprovoked seizures from the temporal lobe. Temporal lobe epilepsy is the most common type of focal onset epilepsy among adults. Seizure symptoms and behavior distinguish seizures arising from the medial temporal lobe from seizures arising from the lateral (neocortical) temporal lobe. Memory and psychiatric comorbidities may occur. Diagnosis relies on electroencephalographic (EEG) and neuroimaging studies. Anticonvulsant medications, epilepsy surgery and dietary treatments may improve seizure control.

<span class="mw-page-title-main">Meningococcal disease</span> Often life-threatening bacterial infection

Meningococcal disease describes infections caused by the bacterium Neisseria meningitidis. It has a high mortality rate if untreated but is vaccine-preventable. While best known as a cause of meningitis, it can also result in sepsis, which is an even more damaging and dangerous condition. Meningitis and meningococcemia are major causes of illness, death, and disability in both developed and under-developed countries.

In the field of neurology, seizure types are categories of seizures defined by seizure behavior, symptoms, and diagnostic tests. The International League Against Epilepsy (ILAE) 2017 classification of seizures is the internationally recognized standard for identifying seizure types. The ILAE 2017 classification of seizures is a revision of the prior ILAE 1981 classification of seizures. Distinguishing between seizure types is important since different types of seizures may have different causes, outcomes, and treatments.

Dravet syndrome (DS), previously known as severe myoclonic epilepsy of infancy (SMEI), is an autosomal dominant genetic disorder which causes a catastrophic form of epilepsy, with prolonged seizures that are often triggered by hot temperatures or fever. It is very difficult to treat with anticonvulsant medications. It often begins before one year of age, with six months being the age that seizures, char­ac­ter­ized by prolonged convulsions and triggered by fever, usually begin.

<span class="mw-page-title-main">Rolandic epilepsy</span> Most common epilepsy syndrome in childhood, usually subsiding with age

Benign Rolandic epilepsy or self-limited epilepsy with centrotemporal spikes is the most common epilepsy syndrome in childhood. Most children will outgrow the syndrome, hence the label benign. The seizures, sometimes referred to as sylvian seizures, start around the central sulcus of the brain.

The central nervous system (CNS) controls most of the functions of the body and mind. It comprises the brain, spinal cord and the nerve fibers that branch off to all parts of the body. The CNS viral diseases are caused by viruses that attack the CNS. Existing and emerging viral CNS infections are major sources of human morbidity and mortality.

Panayiotopoulos syndrome is a common idiopathic childhood-related seizure disorder that occurs exclusively in otherwise normal children and manifests mainly with autonomic epileptic seizures and autonomic status epilepticus. An expert consensus has defined Panayiotopoulos syndrome as "a benign age-related focal seizure disorder occurring in early and mid-childhood. It is characterized by seizures, often prolonged, with predominantly autonomic symptoms, and by an EEG [electroencephalogram] that shows shifting and/or multiple foci, often with occipital predominance."

<span class="mw-page-title-main">Meningitis</span> Inflammation of the membranes around the brain and spinal cord

Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, intense headache, vomiting and neck stiffness and occasionally photophobia.

Haemophilus meningitis is a form of bacterial meningitis caused by the Haemophilus influenzae bacteria. It is usually associated with Haemophilus influenzae type b. Meningitis involves the inflammation of the protective membranes that cover the brain and spinal cord. Haemophilus meningitis is characterized by symptoms including fever, nausea, sensitivity to light, headaches, stiff neck, anorexia, and seizures. Haemophilus meningitis can be deadly, but antibiotics are effective in treating the infection, especially when cases are caught early enough that the inflammation has not done a great deal of damage. Before the introduction of the Hib vaccine in 1985, Haemophilus meningitis was the leading cause of bacterial meningitis in children under the age of five. However, since the creation of the Hib vaccine, only two in every 100,000 children contract this type of meningitis. Five to ten percent of cases can be fatal, although the average mortality rate in developing nations is seventeen percent, mostly due to lack of access to vaccination as well as lack of access to medical care needed to combat the meningitis.

Generally, seizures are observed in patients who do not have epilepsy. There are many causes of seizures. Organ failure, medication and medication withdrawal, cancer, imbalance of electrolytes, hypertensive encephalopathy, may be some of its potential causes. The factors that lead to a seizure are often complex and it may not be possible to determine what causes a particular seizure, what causes it to happen at a particular time, or how often seizures occur.

<span class="mw-page-title-main">Epilepsy in children</span>

Epilepsy is a neurological condition of recurrent episodes of unprovoked epileptic seizures. A seizure is an abnormal neuronal brain activity that can cause intellectual, emotional, and social consequences. Epilepsy affects children and adults of all ages and races, it is one of the most common neurological disorders of the nervous system. As well as, this condition is more common among children than adults affecting about 6 out of 1000 US children that are between the age of 0 to 5 years old. The epileptic seizures can be of different types depending on the part of the brain that was affected, seizures are classified in 2 main types partial seizure or genralized seizure.

Epilepsy-intellectual disability in females also known as PCDH19 gene-related epilepsy or epileptic encephalopathy, early infantile, 9 (EIEE9), is a rare type of epilepsy that affects predominately females and is characterized by clusters of brief seizures, which start in infancy or early childhood, and is occasionally accompanied by varying degrees of cognitive impairment. The striking pattern of onset seizures at a young age, genetic testing and laboratory results, potential developmental delays or developmental regression and associated disorders, eases diagnosis.

Febrile infection-related epilepsy syndrome (FIRES), is onset of severe seizures following a febrile illness in someone who was previously healthy. The seizures may initially be focal; however, often become tonic-clonic. Complications often include intellectual disability, behavioral problems, and ongoing seizures.

People with epilepsy may be classified into different syndromes based on specific clinical features. These features include the age at which seizures begin, the seizure types, and EEG findings, among others. Identifying an epilepsy syndrome is useful as it helps determine the underlying causes as well as deciding what anti-seizure medication should be tried. Epilepsy syndromes are more commonly diagnosed in infants and children. Some examples of epilepsy syndromes include benign rolandic epilepsy, childhood absence epilepsy and juvenile myoclonic epilepsy. Severe syndromes with diffuse brain dysfunction caused, at least partly, by some aspect of epilepsy, are also referred to as epileptic encephalopathies. These are associated with frequent seizures that are resistant to treatment and severe cognitive dysfunction, for instance Lennox-Gastaut syndrome and West syndrome.

A neonatal seizure is a seizure in a baby younger than age 4-weeks that is identifiable by an electrical recording of the brain. It is an occurrence of abnormal, paroxysmal, and persistent ictal rhythm with an amplitude of 2 microvolts in the electroencephalogram,. These may be manifested in form of stiffening or jerking of limbs or trunk. Sometimes random eye movements, cycling movements of legs, tonic eyeball movements, and lip-smacking movements may be observed. Alteration in heart rate, blood pressure, respiration, salivation, pupillary dilation, and other associated paroxysmal changes in the autonomic nervous system of infants may be caused due to these seizures. Often these changes are observed along with the observance of other clinical symptoms. A neonatal seizure may or may not be epileptic. Some of them may be provoked. Most neonatal seizures are due to secondary causes. With hypoxic ischemic encephalopathy being the most common cause in full term infants and intraventricular hemorrhage as the most common cause in preterm infants.

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