1. Febrile seizure: can be prevented?

3. The Aim
To improve the pediatric practitioner's understanding of the natural history of febrile convulsion
To provide reasonable guidelines for the management of simple febrile convulsion based on current scientific evidence

4. Topics Definitions Risks and Prognosis Emergency Management Pathway:
Acute management
Hospital admission
Investigations
Prevention of Recurrences
Parent Education

5. Definitions
“an epileptic seizure ... occurring in childhood after age one month, associated with a febrile illness not caused by an infection of the CNS, without previous neonatal seizures or a previous unprovoked seizure, and not meeting criteria for other acute symptomatic seizures”.
Commission on Epidemiology and Prognosis, International League Against Epilepsy (1993) Guidelines for epidemiologic studies on epilepsy. Epilepsia 1993; 34,

6. Simple Febrile Seizures
A short generalized seizure, of a duration of <15 min, not recurring within 24 h, occurring during a febrile episode not caused by an acute disease of the nervous system, in a child aged 6 months to 5 years, with no neurologic deficits (i.e., with no pre-, peri-, or postnatal brain damage, with normal psychomotor development, and with no previous afebrile seizures) (American Academy of Pediatrics 1996, 1999; Fukuyama et al., 1996).
Fever may not be detected before the seizure, but it must be present at least in the immediate post acute period and be the symptom of a pediatric disease

7. Complex Febrile Seizures
focal, or generalized and prolonged seizure, of a duration of greater than 15 min, recurring more than once in 24 h, and/or associated with postictal neurologic abnormalities, more frequently a postictal palsy (Todd’s palsy), or with previous neurologic deficits (NELSON, K.B. and ELLENBERG, J.H. 1976, American Academy of Pediatrics 1996; Berg & Shinnar, 1996; Knudsen, 2000).

8. Febrile Status
"Febrile Status" is a febrile convulsion lasting 30 minutes or more , either one long lasting convulsion or a series of shorter convulsions, without regaining consciousness inter-ictally.

9. Special Considerations
N.B. 1 Febrile Convulsion should be distinguished from "convulsion with fever“ which includes any convulsion in any child with fever of any cause. Thus, children with meningitis, encephalitis, or cerebral malaria do not have febrile convulsions but have convulsions with fever. The same is true for children with severe neurologic disorders and/ or severe mental retardation.
N.B.2 The number of so-called "reflex anoxic convulsions“ presenting as febrile convulsions is unknown. It seems to be a syncopal type of anoxic convulsion resulting from vagal induced bradycardia or asystole with reduced cerebra blood flow. The provoking factor may be fever, thus mimicking a febrile convulsion.

10. Febrile Recurrences
‘Recurrence’ in this context means more than one episode of febrile convulsions, as opposed to ‘multiple’ which means more than one convulsion during an episode of fever. The overall risk of a recurrence was 34.3%. (Level IIa)
Predictors of recurrence are:
Young age at onset (one year or less),
family history of febrile seizures
Focal, prolonged and multiple convulsions.
Most recurrences occur within three years of the first.
(Berg et al, 1990)

11. (Am Fam Physician. 2012;85(2):149-153.

12. Predisposing factors for later afebrile seizures (epilepsy)
Family history of epilepsy
Age of onset of febrile seizures
Abnormal neurological or developmental status
Characteristics of febrile convulsions
Recurrent episodes of febrile convulsions
Most children with febrile convulsions do not develop epilepsy. (Level IIa)

13. Neurological impairment
No child in the population-based National Collaborative Perinatal Project (NCPP) developed persisting hemiplegia or other motor deficit during or immediately after an asymptomatic febrile convulsion. (Nelson and Ellenberg, 1976)
In a cohort of 398 children who had febrile convulsions, a total of 19 (4.8%) had lengthy febrile convulsions (>30 minutes): in this group there was no evidence of neurological sequelae in those who had been normal before the lengthy attacks . (Verity et al., 1985)
Maytal and Shinnar, 1990 in their study of ‘febrile status epilepticus’ (febrile convulsions lasting longer than 30 minutes), reported that no child died or developed new neurological deficits following the episodes of status.

14. Intellectual outcome
Ellenberg and Nelson, 1976 identified 431 sibling pairs that were discordant for febrile convulsions in the population-based NCPP and found that at seven years of age children who were normal before any febrile convulsion did not differ in IQ from their normal seizure-free siblings. Neither recurrent seizures nor those lasting longer than 30 minutes were associated with IQ deficit. Risk of Intellectual Deficit (Level IIa) in (those with pre-existing neurological or developmental abnormality or those who develop subsequent afebrile convulsions)
However specific cognitive difficulties have been described – Martinos et al reported that recognition memory is impaired in children after prolonged febrile seizures. When followed up after about a year the children were still showing deficiencies in recognizing a face after a five minute delay; this was associated with relatively small hippocampal volumes in those children56.

16. Initial Management
First the convulsion should be stopped if it is continuing. Then the temperature should be measured to confirm that the child is febrile
It is important to determine whether or not the fever preceded the convulsion. The parents/carers may report a febrile illness and they may have measured the child’s temperature before the seizure started.

17. Acute Management of Febrile Convulsion:
Maintain a clear airway.
Protect the child from injury.
Place the child in a semi-prone position.
Loosen clothing or remove excess clothing.
Give oxygen if available.
Apply suction for nasal or oral secretions if facility available
Treat fever by sponging with tepid water and antipyretics (e.g. acetaminophen).
(Level Ib)

18. Acute Management of Febrile Convulsion:
The home use of rectal diazepam to abort seizures in children with convulsive disorders has been shown to be effective.
There is now evidence that buccal midazolam is as safe and effective in controlling febrile seizures as rectal diazepam McINTYRE, et al (2005)

19. Acute Management of Febrile Convulsion:
Monitor vital signs.
If facilities and medications are available – administer rectal diazepam mg/kg/dose if convulsion lasts for more than 5 minutes.
(Level IV)
Administer intravenous anticonvulsant if the child is still convulsing for >15 minutes (diazepam, lorazepam or phenobarbital), (preferably in the listed order), and depending on the availability of anticonvulsant.

20. Acute Management of Febrile Convulsion:
a. Intravenous diazepam, mg/kg/dose (maximum rate: 1-2 mg/minute) to a maximum dose of 2-4 mg in an infant or 5-10 mg in the older child. The same dose can be repeated every 10 to 30 minutes to a total of 3 doses, if necessary. b. Intravenous lorazepam, mg/kg/dose (maximum rate: 1 mg/minute) to a maximum dose of 4 mg can be given; with an additional 0.05 mg/kg 10 minutes later if needed. c. Intravenous phenobarbital in a dose of mg/kg (rate: 30 to 100 mg/minute); with half of the initial dose repeated in an hour if necessary. (Level IV)

21. Hospital Admission Is individualized.
depends on the experience of the practitioner
After a first convulsion, the following factors favor admission (Level IV) (RCP/BPA Joint Working Group, 1991):
1. complex convulsion:
- lasting longer than 15 minutes or
- with focal features or
- repeated in 24 hours of first convulsion or
- with incomplete recovery after 1 hour;
2. the pediatrician is suspicious of possibility of meningitis and encephalitis;
3. a child aged <18 months;
4. anxious parents or inadequate home care.

22. investigations
‘No investigations are routinely necessary in all children after a febrile convulsion’, according to the RCP/BPA Joint Working Group, 1991.
In addition to drawing a blood specimen for glucose in a child who is drowsy, one should obtain toxicology screen, electrolytes and urea esp. in some children with continuing convulsions (Level IV)

23. Role of Lumbar Puncture
When to do Lumbar Puncture (LP) ?
In every child with complex first febrile convulsion
In every child <1 year of age with a febrile convulsion (clinical signs and symptoms of meningitis may be minimal or absent)
Between months, LP should be considered because the clinical signs and symptoms of meningitis may be subtle.
In a child >18 months, LP should be done in the presence of meningeal signs and symptoms or whenever the history or examination suggests the presence of an intracranial infection.
In infants and children with febrile convulsions who have received antibiotic treatment, LP should be strongly considered, since such treatment can mask evidence of meningitis.
(Level IV) (RCP/BPA Joint Working Group, 1991)
LP needs to be considered in every child who has a febrile convulsion in whom there is even a small possibility of acute bacterial meningitis. However, most febrile convulsions associated with meningitis are complex.
(Level IV) .
A convulsing child who is comatosed should receive neuroimaging before LP.
(Level IV)

24. investigations
EEG:
EEG is rarely indicated in the management of a simple febrile convulsion. It does not predict which children progress to a seizure disorder. EEG may have a limited role in the diagnosis of acute encephalopathic disorders if the child remains encephalopathic for longer than normal following a febrile seizure. (Level IV)

25. investigations Neuroimaging:
Neuroimaging is not necessary in most cases, but there are exceptions, e.g. in a child with:
papilledema,
cranial nerve palsies (e.g. 6th nerve palsy),
other persisting focal neurological signs (e.g. hemiparesis) or
marked depression in mental status, then neuroimaging probably appropriate. (Level IV)

26. Prevention of Recurrences: Management of Fever
There is no evidence that antipyretic treatment prevents the recurrence of febrile convulsions.
Fever should be treated in order to promote the comfort of the child and to prevent dehydration.
Use of antipyretic drug is effective and paracetamol or ibuprofen is advised.
An adequate fluid intake is advisable.
(Level Ib)

27. Therapeutic Intervention for Recurrent Febrile Convulsions
intermittent Therapy with Diazepam During an Acute Attack:
If given in sufficient doses, it is likely to be effective in preventing febrile convulsion recurrence. (Level Ib) when used in an early stage of febrile episode (at the time of up-going fever over 38.5°C).

28. Therapeutic Intervention for Recurrent Febrile Convulsions
Intermittent diazepam prophylaxis seems to be effective in reducing the recurrence rate provided: (Level Ib):
suggested doses for prophylaxis = 0.5 mg/kg administered orally, or rectally every 12 hr whenever the rectal temperature is >38.5°C, with a maximum of 4 consecutive doses to avoid accumulation of the drug.

29. Therapeutic Intervention for Recurrent Febrile Convulsions
Long-term Anticonvulsant Prophylaxis:
No definitive evidence that prophylactic treatment of febrile convulsions with anticonvulsants can prevent later epilepsy.
There is no prospective study that looked into this important question.
There had been traditional advocate of using long-term anticonvulsant prophylaxis (phenobarbitone in 1970 or sodium valproate in early 1980s). However, this is currently not advised due to side effects. Other anticonvulsants (carbamazepine, phenytoin) are not useful. (Level Ia)

30. As such, the committee concluded that, on the basis of the risks and benefits of the effective therapies, neither continuous nor intermittent anticonvulsant therapy is recommended for children with 1 or more simple febrile seizures.
Pediatrics 2008;121:1281–1286

31. Immunization
None of the current standard vaccinations are contraindicated (Level IV)
DTP
Diphtheria, tetanus, pertussis, and poliomyelitis immunization have already been given to children at 2-4 months. Thus this should be before the usual onset of febrile convulsions. If a child has febrile convulsion before immunization against diphtheria, pertussis, and tetanus due to delay in immunization, the child could be immunized provided the parents have been instructed about the management of fever and the use of rectal diazepam. (Level IV)
MMR
There is no contraindication to Measles, Mumps and Rubella (MMR) vaccination for children with history of febrile convulsion. Parents should be advised about the management of fever after giving MMR vaccination. Keep the child under close observation. Rectal diazepam is recommended to be given in case convulsion lasting >5 minutes occurs. (Level IV)

32. Parental Education
Studies have shown that many parents witnessing a child's first convulsion thinks that their child is dying or is already dead. Try to decrease parental anxiety by counseling. Reassurance and education is thus very important. Instructions on the future management of possible recurrences should be given with emphasis on practical issues of how to manage a child with febrile convulsion at the scene. (Level IV)

34. Recommended Checklist for Pediatricians/Family Physicians
An accurate description of the convulsion, including its duration
Information about the nature of the episode
A record about the family history with regard to febrile and non-febrile convulsions
The age at first convulsion
The temperature on admission
Whether signs of meningitis are present or absent
An assessment of the cause of the fever
The child's neurodevelopmental state when recovered
The blood glucose concentration, if the child was seen during a convulsion
Other serum chemistries as indicated (electrolytes, calcium)
An estimate of the likely prognosis, advice to the parents about what to do if further convulsions occur, and advice about future immunization
What the parents were told at admission and before discharge

35. KEY messages
Febrile seizures (simple and complex) are almost always benign and generally are not associated with neurological consequences.
The mainstay of investigation and treatment is to rule out bacterial infection.
There are limited indications for investigations including blood work, neuroimaging or electroencephalography (EEG).
Clear explanation to and reassurance of caregivers is key in the management of the child