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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 4
| Issue : 1 | Page : 4-9 |
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Management of febrile seizure and differentiating it from epilepsy: A short review
Kali Prasanna Swain1, Shubhankar Mishra2
1 Assistant Professor, Department of Neurology, SCB Medical College, Cuttack, India
2 Post-Doctoral Senior Resident, Department of Neurology, SCB Medical College, Cuttack, India
| Date of Submission | 23-Apr-2018 |
| Date of Acceptance | 25-May-2018 |
| Date of Web Publication | 1-Feb-2019 |
Correspondence Address:
Shubhankar Mishra
Post-Doctoral Senior Resident, Department of Neurology, SCB Medical College, Cuttack
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2395-2113.251347
Febrile seizure is the most common seizures seen in infancy and pre-school era. They are mostly benign in nature. There are two categories of febrile seizures, simple and complex. Both the International League against Epilepsy and the American academy of paediatrics have published definitions on the classification of febrile seizures. Simple febrile seizures are mostly benign, but a prolonged (complex) febrile seizure can have long term consequences. Most children who have a febrile seizure have normal health and development after the event, but recent evidence suggests a small subset of children presenting with seizures and fever may have recurrent seizure or develop epilepsy. Diagnosis is solely clinical. But other causes of fever and seizure must be ruled out. Electroencephalogram, lumbar puncture and neuroimaging, all are to be used for specific indications but not routinely. Treatment consists of acute management and prophylaxis for further attack. This review will give an overview of the definition of febrile seizures, epidemiology, evaluation, treatment, outcomes and recent research.
Keywords: febrile seizure, clobazam, prophylaxis, epilepsy
How to cite this article:
Swain KP, Mishra S. Management of febrile seizure and differentiating it from epilepsy: A short review. Indian J Community Fam Med 2018;4:4-9 |
How to cite this URL:
Swain KP, Mishra S. Management of febrile seizure and differentiating it from epilepsy: A short review. Indian J Community Fam Med [serial online] 2018 [cited 2023 May 28];4:4-9. Available from: https://www.ijcfm.org/text.asp?2018/4/1/4/251347 |
| Introduction | |  |
Febrile seizure is defined as seizures that occur between the age of 6 and 60 months with a temperature of 38°C (100.4°F) or higher, which are not the result of central nervous system infection or any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures[1] (American academy of paediatrics definition). Febrile seizures (FS) are the single most common seizure type and occur in 2 to 5% of children younger than age 5 years with a peak incidence in the second year of life.[2] FS are considered benign, but a small subset of children presenting with seizures and fever may have recurrent FS or develop epilepsy. The incidence and prevalence of FS is similar across the world with some geographic variations such as higher prevalence in Japan and Guam.[3] According to some Indian studies, febrile seizures occur in 3-4% of children under the age of 5 years. Usually, they do not occur beyond the age of 5 years implying a specific vulnerability of young children to fever as a precipitant. The median age of occurrence is 18-22 months.[4] FS are not considered a form of epilepsy, but a FS can be the first presentation of subsequent epilepsy. Febrile seizure is a very common disease in under 5 children. Largely it can be managed in primary care settings. This article will help primary care physicians in diagnosing febrile seizure at the earliest and better management of the disease which will prevent unnecessary admission and referral. It will help in better counseling to decrease severe stress in parents.
Spectrum of febrile seizures
Febrile seizure can present in different forms starting from simple seizure with fever to generalised epilepsy form. The details of the spectrum are described in Box No-1.
Diagnosis approach
A child in FS age group having fever followed by seizure (one or multiple episode) can be diagnosed as febrile seizure after ruling out other clinical features like altered sensorium, toxic look, severe irritability, features of increased cranial pressure, meningeal signs etc.
Largely FS is a benign disease. But in future it can land up in epilepsy. Syndromic febrile seizure like Dravet syndrome has maximum chance of conversion into epilepsy in future.
Any patient of suspected febrile seizure should be evaluated with proper history and risk factors. Approach guidelines are given in the following algorithm. (Box 3)
| Investigations | | |
Blood analysis: The American Academy of Paediatrics (AAP) has guidelines for evaluation of first simple febrile seizure, and state that clinicians should work to identify the source of the fever when a child presents within 12 hours of a simple febrile seizure[15] Each child who presents with a febrile seizure requires a detailed history and a thorough general and neurologic examination. Febrile seizures often occur in the context of otitis media, roseola and human herpesvirus (HHV) 6 infection, shigella, or similar infections, making the evaluation more demanding. In patients with febrile status, HHV-6B (more frequently) and HHV-7 infections were found to account for one-third of the cases.[1],[16],[17],[18] Several laboratory studies need to be considered in evaluating the patient with febrile seizures. It is not recommended to perform routine serum investigations when a child has a simple febrile seizure.[16] The investigations that are performed should be based on the clinical presentation of the febrile illness.
Lumbar puncture: The AAP guidelines strongly recommend a lumbar puncture in any child who presents with a seizure, a fever and has meningeal signs and symptoms. It is also recommended in any child whose history or examination suggests the presence of meningitis or intracranial infection.[15] Meningitis should be considered in the differential diagnosis, and lumbar puncture should be performed for all infants younger than 6 months of age who present with fever and seizure, or if the child is ill appearing or at any age if there are clinical signs or symptoms of concern. A lumbar puncture is an option in a child 6-12 month of age who is deficient in Haemophilus influenzae  pe b and Streptococcus pneumonia immunizations or for whom immunization status is unknown. In patients presenting with febrile status epilepticus in the absence of a central nervous system infection, a nontraumatic lumbar puncture rarely shows cerebrospinal fluid (CSF) pleocytosis (96% have <3 nucleated cells in the CSF) and the CSF protein and glucose are usually normal.[1]
Neuroimaging: Neuroimaging is not recommended after a simple febrile seizure.[16] If a patient presents with focal complex FS and/or FSE, one should consider performing brain MRI to evaluate for a structural abnormality as an explanation for the seizure.[18] When MRI is unavailable computed tomography can be performed. According to consequence of prolonged febrile seizure (FEBSTAT study), imaging showed that developmental abnormalities of the hippocampus were more common in the febrile status epilepticus (FSE) group than in controls, with hippocampal malrotation being the most common.[17] This study has demonstrated that children with FSE are at risk for acute hippocampal injury and that a substantial number also have abnormalities in hippocampal development.
Electroencephalography (EEG): The AAP recommends that an EEG should not be performed in the evaluation of neurologically healthy children with a simple febrile seizure,[1],[19] but EEG may be useful for evaluating patients with complex or atypical features or with other risk factors for the development of epilepsy.[20] An EEG would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal.[1] Spikes during drowsiness are often seen in children with febrile seizures, particularly those older than age 4 year, and these do not predict later epilepsy. EEGs performed within 2 weeks of a febrile seizure often have nonspecific slowing, usually posteriorly. Thus, in many cases, if an EEG is indicated, it is delayed until or repeated after more than 2 weeks have passed.[1]
| Treatment | | |
Treatment of ongoing seizures
Acute1,:
Rectal diazepam (0.2-0.5mg/kg) is often prescribed to be given at the time of reoccurrence of a febrile seizure lasting longer than 5 min. Alternatively, buccal or intranasal midazolam(0.15mg/kg) may be used and is often preferred by parents.[1] Prolonged seizures are accompanied by an increased risk of complications, and treatment should be initiated before it reaches >5 minutes in duration. Prolonged FS should be treated acutely using the same algorithm as prolonged seizures caused by other aetiologies. A prolonged FS if continued then a full SE protocol should be initiated.[23] FSE is a neurological emergency and the most common cause of SE in children younger than two years of age.[22] Most children should be observed until they are awake and alert. Children, especially those with a first febrile seizure, should be hospitalized if any of the following are present: (i) Lethargy beyond postictal state; (ii) Unstable clinical status; (iii) Age <18 months; (iv) Complex features; (v) Uncertain home situation; (vi) Unclear follow up. Any child with the slightest suspicion of meningitis should be admitted and investigated[4].
Chronic: Using round-the-clock prophylactic administration of antipyretics has not been shown to affect the incidence of recurrence of FS and is not recommended. It is not recommended to treat children with FS using daily anti-epileptic medications because of high likelihood of adverse effects.[23]
Recurrence: The risk of recurrence is influenced by both the age of the child and the type of FS. About one-third of children with a first FS will have a recurrence. If there is no risk factors a recurrence risk of approximately 12%; 1 risk factor, 25-50% (mild risk); 2 risk factors, 50-59% (intermediate risk); 3 or more risk factors, 73-100% (high risk) (box-1).
Long Term Management
The primary goal of long-term management of febrile seizure is to prevent recurrences. Treatment options include:
- Prolonged daily prophylaxis with phenobarbitone(3-5mg/kg) or valproate (15-60mg/kg)
- Intermittent prophylaxis with diazepam or other benzo-diazepines like clobazam (0.3-1mg/kg maximum 10 mg).
Continuous Prophylaxis
Phenobarbital is effective in preventing the recurrence of simple febrile seizures.[24],[25] Long-term phenobarbital treatment appears to influence cognition and behaviour, a large price for prevention of benign condition.[4] Valproate is as effective as phenobarbitone in preventing recurrent, simple febrile seizures. In randomized controlled studies, only 4% of children taking valproate as opposed to 35% of control subjects had a subsequent febrile seizure.[26]
Drawbacks to therapy with valproate include its rare association with fatal hepatotoxicity, thrombocytopenia, weight loss and gain, gastrointestinal disturbances and pancreatitis. Continuous prophylaxis may be considered for children with a high risk for later epilepsy.
Intermittent Benzodiazepine Prophylaxis
Diazepam administered intermittently either rectally as suppositories, or solution or orally at the onset of fever has been shown to be effective in preventing recurrence of febrile seizures.[4] By either route, generally a dose of 0.3 to 0.5 mg/kg (max 10 mg) is used. A maximum of 4-5 doses are given per illness.[27] Intermittent clobazam (0.3-1mg/ kg/day) given orally for 2 days has also been found to be useful in preventing febrile seizure recur-rences.[28] Adverse effects of oral diazepam include lethargy, drowsiness and ataxia. The sedation associated with this therapy could mask evolving signs of meningitis. Some children show signs of irritability and restlessness due to clobazam. According to a study, risks of recurrent febrile seizure in the Diazepam group was 2.6 times greater compared to those in the clobazam group. The result indicates that Clobazam is safe, efficacious, requires less frequent dosing and has less adverse effects such as drowsiness, sedation, ataxia and irritability as compared to Diazepam.[29] It must however be remembered that this therapy does not decrease the incidence of later epilepsy in children with febrile seizures.[30]
| Patient Education | | |
It is the most important aspect of management of febrile seizures.[1],[4] As seizures in their child can be very frightening for the parents they should be counselled properly with particular emphasis on:
- The benign nature of the febrile seizures.
- That febrile seizures do not lead to neurological problems or develop-mental delay.
- What they should do immediately if their child has another seizure.
- A doctor should be consulted if the seizure lasts for more than 5 min.
| Difference from epilepsy | | |
Epilepsy is a disease of the brain defined by any of the following conditions.[31]
- At least two unprovoked (or reflex) seizures occurring >24 h apart
- One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
- Diagnosis of an epilepsy syndrome
Epilepsy is considered to be resolved for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age or those who have remained seizure- free for the last 10 years, with no seizure medicines for the last 5 years.
Febrile seizure is primarily a provoked seizure. But in the long run it can progress to epilepsy. There is difference in incidence of epilepsy in different type of febrile seizures [Table-1].
| Conclusion | | |
Febrile Seizures are generally benign events and do not cause lasting intellectual or neurologic damage. EEG and neuroimaging are not indicated in the usual evaluation of simple febrile seizure. Acute treatments are indicated when seizure is prolonged. Anti-epileptic therapy either intermittent or continuous can prevent recurrences of febrile seizure but does not prevent subsequent epilepsy. Most children with febrile seizures do not require anti- epileptic therapy; in cases of severe parental anxiety and/or multiple recurrences, intermittent therapy may be advised. Early diagnosis and better management of the febrile seizure at the primary health care setting will prevent unnecessary admission and referral. Primary physicians should emphasize on parent counselling & education because this plays pivotal role in management of the febrile seizure.
Funding
Nil
Conflict of interest
Nil
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[Table 1]
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