Febrile seizure
Background
- Occur in 2-5% of American children before age 5[1]
- 50% of patients never have temperature >39
- Febrile seizures do not increase the risk of serious bacterial illness
Prognosis
- 2-3% chance of developing epilepsy (1% for general population)
- 50% of patients <12 mo will have another simple febrile seizure
- 30% of patients >12 mo will have another simple febrile seizure
Clinical Features
- Seizure + fever
Simple Febrile Seizure
- Age 6mo-5yr, with majority occurring between 12mo-18mo
- Single seizure in 24hr
- Duration <15min
- Generalized with no focal features
- Returns to neurologic baseline and has normal neuro exam after brief post-ictal period
Complex Febrile Seizure
- Any exception to above
- May indicate more serious disease process
Differential Diagnosis
Pediatric seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with or "outgrowing" AEDs
- Non-epileptic seizure
- Meningitis
- Encephalitis
- CNS abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia
- Pyridoxine responsive seizure[2]
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Seizure with VP shunt
- Toxic ingestion
- Psychogenic nonepileptic seizure (pseudoseizure)
- Hydrocephalus
- Intracranial mass
- Syncope
- Breath-holding spell
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
- Infatile Spasms/West Syndrome
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
Evaluation
- The key is to distinguish between simple febrile seizure secondary to minor illness vs. seizure from serious central nervous system infection, which may also present with fever and seizure.
- Glucose in all patients
Simple febrile seizure
- Neither labs nor neuroimaging are absolutely necessary
- Normal pediatric fever workup
Complex febrile seizure
- Consider CBC, blood culture, UA, urine culture, CSF studies
- Consider CT if:
- Persistently abnormal neuro exam (especially with focality)
- Signs/symptoms of increased ICP
- Patient has VP shunt
- Consider ECG if:
- Family history of long QT, Brugada, sudden death
- Routine EEG not indicated
- Consider only if developmental delay or for focal symptoms
- Causes amenable to specific treatment
- Hypoglycemia
- Hyponatremia (water intoxication, dilution of formula)
- Hypocalcemia
- Hypomagnesemia
- INH ingestion
Algorithm for the differentiation between simple and complex febrile seizures. Guidelines for evaluation of each.
Management
Ongoing Seizure
See Seizure (peds)
Seizure Stopped
- Treat underlying infection if indicated
Disposition
Discharge
- Simple febrile seizure if patient at baseline
- Follow-up in 1-2d
- Around-the-clock acetaminophen may prevent seizure recurrence in the same febrile episode[3]
- Complex febrile seizure if patient well-appearing, work-up normal
- Follow-up in 24hr
Admit
- Ill-appearing
- Lethargy beyond postictal period
See Also
- Seizure
- Fever (Peds)
References
- https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/febrile-seizures-fact-sheet
- Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
- Murata et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. November 2018, VOLUME 142 / ISSUE 5
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