S MILE …I T ’ S M ONDAY ! AM Report Monday, July 11, 2011

F EBRILE S EIZURES

D EFINITION AND E PIDEMOLOGY Seizure accompanied by fever >/= without central nervous system infection Does not pertain to children with previous neurologic insults, known CNS abnormalities, or h/o afebrile seizures Affects 2-5% of infants and children aged 6 to 60 mos (5yrs)

C LASSIFICATION Simple Febrile Seizure Primary generalized seizure (no focal component) Lasts less than 15 min Does not recur within 24 hours Complex Febrile Seizure Seizure with focal component(s) Prolonged (>15min) Recurrent within 24 hours

S IMPLE F EBRILE S EIZURES Neurodiagnostic Evaluation Long-term Management

L OVE T HOSE C LINICAL P RACTICE G UIDELINES !! Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child with Simple Febrile Seizure (February 2011-update to the 1996 CPG) Febrile Seizures: Clinical Practice Guideline for the Long-term Management of a Child with Simple Febrile Seizures (June 2008-update to the 1999 CPG)

W HAT DO YOU WANT TO DO TO EVALUATE A SIMPLE FEBRILE SEIZURE ? LP? EEG? Labs Which ones? Neuroimaging CT or MRI?

N EURODIAGNOSTIC E VALUATION Action Statement 1a A LP should be performed in any child who presents with a seizure and fever and has meningeal signs and symptoms (eg, neck stiffness, Kernig and/or Brudzinski signs) or in any child whose history or examination suggests the presence of meningitis or intracranial infection (Strong Recommendation) In ~25% of children with meningitis, seizure is the presenting sign of disease 30-35% of those children (primarily younger than 18 mos) lacked any meningeal signs

N EURODIAGNOSTIC E VALUATION Action Statement 1b In any infant between 6 and 12 months of age who presents with seizure and fever, a LP is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received the immunizations as recommended) or when immunization status cannot be determined, due to an increased risk of bacterial meningitis (Opinion) Action Statement 1c A LP is an option in a child who presents with seizure and fever and is pretreated with antibiotics, because antibiotic treatment can mask the signs and symptoms of meningitis (Opinion)

N EURODIAGNOSITIC E VALUATION Action Statement 2 An electroencephaolgram (EEG) should not be performed in the evaluation of a neurologically healthy child with simple febrile seizure (Strong recommendation) Action Statement 3 The following tests should not be performed routinely for the sole purpose of identifying the cause of a simple febrile seizure: measurement of serum electrolytes, calcium, phosphorous, magnesium, or blood glucose or complete blood count (Strong Recommendation)

N EURODIAGNOSTIC E VALUATION Action Statement 4 Neuroimaging should not be performed in the routine evaluation of a child with simple febrile seizure (Strong recommendation)

L ONG T ERM M ANAGEMENT Four adverse outcomes that theoretically may be altered by an effective therapeutic agent Decline in IQ Increased risk of epilepsy Risk of recurrent febrile seizures Death

L ONG T ERM M ANAGEMENT Decline in IQ No studies have shown that simple febrile seizures have caused an increased incidence of Decline in IQ, academic performance, or neurocognitive attention Behavioral abnormalities Increased risk of epilepsy Risk of developing epilepsy is only slightly higher than that of the general population (by age 7, it is the same) Exceptions Children with multiple simple febrile seizures FHx of epilepsy Pts <12mos at the time of the first febrile seizure

L ONG T ERM M ANAGEMENT Increased risk of epilepsy No study has demonstrated that successful treatment of simple febrile seizures can prevent later development of epilepsy Risk of recurrent febrile seizures High rate of recurrence, varies with age <12 mos at first event: 50% >12 mos at first event: 30% Of those that have a second SFS, 50% will go on to have a third Death Never has been reported

L ONG T ERN M ANAGEMENT Recommendation On the basis of risks and benefits of the effective therapies, neither continuous or intermittent anticonvulsant therapy is recommended for children with 1 or more febrile seizures (Recommendation) Antipyretics are ineffective in preventing febrile- seizure recurrence

C OMPLEX F EBRILE S EIZURES A Brief word…

N O C LINICAL P RACTICE G UIDELINES  LP should be considered for febrile status epilepticus Urgent CT in patients with abnormally large heads, persistently abnormal neurologic exam (particularly with focal features) or signs and symptoms of increased ICP EEG more likely to be abnormal when convulsions are of long duration or have focal features Cannot predict the likelihood of recurrent febrile seizures or the development of afebrile seizures