August 26, 2019

Episode 169.0 – Febrile Seizures

9 minutes

A look at the most common type of seizures in the young pediatric population.

Hosts:

Brian Gilberti, MD

Audrey Bree Tse, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Febrile_Seizures.mp3

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Tags: Pediatrics

Show Notes

Background

The most common type of seizure in children under 5 years of age

Occur in 2-5% of children

In children with a fever, aged 6 months to 5 years of age, and without a CNS infection

Risk Factors

4 times more likely to have a febrile seizure if parent had one

Also increase in risk if siblings or nieces / nephews had one

Common associated infections

Human Herpesvirus 6

Human Herpesvirus 7

Influenza A & B

Simple Febrile Seizure

Generalized tonic-clonic activity lasting less than 15 minutes in a child 6 months to 5 years of age

Complex Febrile Seizure

Lasts longer than 15 minutes, occurs in a child outside of this age range, are focal, or that recur within a 24-hour period.

Diagnostics / Workup

Gather thorough history and perform thorough physical exam

Most cases will not require labs, imaging or EEG

If e/o meningitis, perform LP

AAP suggests considering LP in:

Children 6-12 months who are not immunized for H flu type B or strep pneumo

Children who had been on antibiotics

For complex seizures, clinician may have a lower threshold for obtaining labs

Hyponatremia is more common in this group than in the general population.

LPs are more commonly done by providers, but these are low yield with one study showing bacterial meningitis being diagnosed in just 0.9% (Kimia 2010), all of whom did not have a normal exam or negative cultures.

Neuroimaging is also exceedingly low yield if the patient returns to baseline (Teng 2006)

One study that showed that the duration of complex febrile seizure, being greater than 30 minutes, was associated with a higher incidence of bacterial meningitis. (Chin 2005)

Of they have history and exam concerning for meningitis, they should get an LP

If they look dehydrated or edematous, you would have more of a reason to get a chemistry

Treatment

Benzodiazepine if seizure lasted for >5 minutes, either IV or IN

Supportive care

Tylenol or motrin if febrile

Fluids if signs of dehydration

Antipyretics “around the clock”

A majority of data show no benefit in preventing recurrence of seizure

One study (Murata 2018) found that giving tylenol q6h at 10 mg/kg for the first 24 hours following the initial seizure decreased the rate of recurrence when compared to children who did not receive antipyretics.

NNT here was 7

Questionable whether we can generalize these findings from a single ED in Japan.

No role for antiepileptics

Prognosis

High rate of recurrence (~1/3) within 1 year of initial seizure

Risk increases for

Younger age at which they had initial seizure

Lower temperature at which they had seizure

If initial febrile seizure was prolonged, more likely that the next will be prolonged

1-2% develop epilepsy for simple febrile seizure, slightly above risk of general population

5-10% develop epilepsy for complex febrile seizure

Follow up with PMD

Generally, peds neuro follow up is not necessary

References

Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005;90(1):66-9.

Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010;126(1):62-9.

Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. 2018;142(5).

Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:h4240.

Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013;54(12):2101-7.

Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide, 8th Edition. New York: McGraw-Hill Education.

Subcommittee on Febrile S, American Academy of P. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-94.

Teng D, Dayan P, Tyler S, Hauser WA, Chan S, Leary L, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-8.

Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-22.

A special thanks to our editors:

Michael A. Mojica, MD

Director, Pediatric Emergency Medicine Fellowship

Bellevue Hospital Center

Christie M. Gutierrez, MD

Pediatric Emergency Medicine Fellow

Columbia University Medical Center

Morgan Stanley Children’s Hospital

New York Presbyterian

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