Background

Febrile fits occur in infants ranging from six months up to five years old and are identified by a temperature of 100.4°F or higher. Neurological impairment, viral infections, family history of seizures, delayed development, reduced serum zinc or iron levels, as well as maternal smoking and stress during pregnancy are among the risk factors. Most cases resolve spontaneously and without complications; however, there may be an increased risk for epilepsy or other seizure disorders among some patients. These can be classified as simple if they are single (last less than 15 minutes) or complex where there are multiple seizures within 24 hours with focal neurological signs present. Health care providers need better skills in managing febrile convulsions to improve outcomes for their clients. 

Epidemiology

Most often, kids who are 6 months up to 5 years old experience febrile seizures. It is the most common type of convulsion during childhood presenting with a slight male predominance ratio of 1.6:1. Affecting 2%–5% of children in the US and Europe, it is baselined at between 12 and 18 months of age. More cases occur in winter afternoons for Japan, Finland, and America, showing some association seasonality as well as time-bound factors like daytime vs night hours. 30% of children will have more than one febrile episode but some may only ever show signs once. 

Anatomy

Pathophysiology

The pathophysiology of febrile seizures remains elusive, but we do know that it involves a complex genetic predisposition as well as immaturity and vulnerability of the central nervous system with various environmental factors playing a role too. This means the brain is more prone to seizures during infancy itself because of fever-induced excitation among neurons due to different risk agents hence will be a major cause for the high frequency witnessed among children who are under 3 years old. 

Etiology

Febrile seizures are generalized seizures in infants aged 6 months to 5 years which are characterized by fever more than 100.4°F. The factors that increase the likelihood of these attacks are neurologic impairments, viral infections, family history of seizure disorders, delayed development, low serum levels of zinc and iron as well as maternal smoking habits or stress conditions during pregnancy. There could be genetic predisposition such as autosomal dominant inheritance mode or polygenic/multifactorial inheritance pattern exhibited among sufferers too. More so, babies at their first few months after birth experience an increased risk for this condition particularly if they had been administered postnatal corticosteroids while those under one year old generally have lower convulsion thresholds even though some drugs can alter it alongside imbalance of water or electrolytes in body. Additionally vaccines like DTaP-IPV-Hib, MMRV, conjugated pneumococcal vaccine and certain forms of inactive flu shots may lead to a temporary rise in occurrence of febrile seizures. 

Genetics

Prognostic Factors

Febrile seizures generally are not harmful and do not cause long-term neurological or cognitive difficulties. However, 30% of kids who have had febrile seizures before are more likely to have them again. One should also consider some factors like young age, family history, low fever temperature, and short period between fever start and convulsions if they want to know whether recurrent febrile attacks might occur in their child or not. While simple febrile seizures may later develop epilepsy in 1-2% cases among children but this number goes up by 2-10% with complex ones which happen early during infancy stage last longer than 15 minutes abnormal neurodevelopment due genetic predisposition toward having such conditions being present within relatives. 

Clinical History

For assessment, it’s important to have a detailed past medical history as well as a description of the suspected febrile seizure. A parent or guardian should give details about vaccination records, family history with immunization status, recent illnesses among other things like exposure to toxins or personal health record. While simple febrile episodes last only a few minutes (usually less than 15), complex forms may last longer than 15 minutes and are accompanied by focal weakness after the attack. 

Clinical examination 

A thorough neurological examination should be conducted on the patients who experience seizure activity. Differential diagnosis can be taken into account if the symptoms persist.  

Physical Examination

This includes evaluation of vital signs, nature and causes of fever, dermatological signs, and neurological findings. A fundus examination for evaluating intacranial pressure should be done. Further, dermatological symptoms may lead to the presence of any underlying conditions.  

Age group

Associated comorbidity

1. Subsequent epilepsy 
2. Autism spectrum disorder 
3. Tourette syndrome 
4. Asthma 
5. Allergic rhinitis 
6. Encephalopathy 
7. Intellectual disability 
8. ADHD (attention deficit hyperactivity disorder) 
9. Unexpected death 

Associated activity

Acuity of presentation

Simple febrile seizures do not require more tests, however if the patient has had complex seizures in the past, then a thorough check up should be carried out. This should involve looking for anything that may be causing them such as infections or abnormalities in the brain structure; an EEG and some other tests can also be done at this point. Hospital admission is necessary for more studies in the case of complicated scenarios. On the other hand, lumbar punctures are not justified during such periods but rather advocated for children aged less than 12 months who are yet to be vaccinated against anything plus those who may have recently taken antibiotics. 

Imaging studies such as CT (computed tomography) or MRI (magnetic resonance imaging) studies can be considered if presence of any of the following condition is observed: 

1. Speculated structural abnormality in brain 
2. Severe trauma of head 
3. An increase in intracranial pressure 
4. Enlarged head 
5. Focal neurologic abnormality 

Differential Diagnoses

1. Seizures due to drugs 
2. Breath-holding spells 
3. Infections of CNS such as bacterial or viral meningitis, aseptic meningitis, encephalitis 
4. Febrile mycoclonus 
5. Febrile delirium 
6. Rigours or shaky chills 
7. Tonic-clonic seizures 
8. GEFS+ (generalised epilepsy with febrile seizures plus) 
9. Simple febrile seizures 
10. Hyponatremia 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

During a febrile seizure: To ensure the safety of the child who has febrile seizures, the first step is laying the child on a flat, soft surface, which can prevent choking on other fluids, including saliva, and protect from any risk during the seizure. Also, it is essential not to keep any sharp or other objects nearer that can harm the child. 

Protect the Airway: To keep the airway clear for the child and make them not choke, place, or lay the child on their side by placing their head in which face should be downward. Not to insert anything, including medications, in their mouth during the seizure as it is harmful where there are chances that the child can bite their tongue. 

Monitoring and observing the seizure duration: When a child experiences a seizure, it is recommended to note the time and duration from the occurrence of the seizure, any unusual behaviours, and type of movements. If the seizure lasts for more than five minutes, then it should be considered as a complex seizure as febrile seizure lasts less than five minutes. 

After the Seizure: The focus should be on reducing the fever of the child, which will prevent another seizure from reoccurring. Tepid sponging could also help in reducing the temperature of the body, but cold water needs to be avoided. Medications to reduce the increased body temperature may be given. 

Preventive Measures:  These include reducing the temperature of the body using antipyretic medications, keeping the child hydrated, and wearing a lightweight dress is recommended. Monitoring of underlying diseases or infections that can cause fever should also be done. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modification-for-febrile-seizures

Management of Fever: It is recommended for the family or parents to monitor their child’s health, especially their body temperature, during any time when child falls sick. To make sure that their fever is under control, administration of antipyretic agents to reduce the temperature, making sure that the child is hydrated in case of fever to prevent dehydration, which is associated with worsening of seizures. 

Infection control: There are high chances that many febrile seizures are known to occur and be triggered by an infection. It is mandatory to take steps to prevent and control infections, and it is recommended to follow and practice hygiene, like washing hands and avoiding children from being infected or affected by any sick individuals whenever possible. Vaccinations and immunization of the child are essential to take care of against diseases. 

Regular Sleep Cycle: Children need to get adequate sleep to maintain their sleep cycle, which could avoid stress and prevent seizures from reoccurring. 

Managing acute signs of febrile seizures: In children with a known history of febrile seizures, which are prolonged or frequent, antipyretic medications are recommended to use when the first sign is fever, which is only a preventive measure that is followed when a doctor is giving instructions. 

Communication and Education: Community education on febrile seizures is essential, which can help individuals know do’s and do not’s during an event of a febrile seizure and how to manage and control fever.  

Consultation: Follow-up should be regular to keep the child’s health on track and receive guidance on how to manage febrile seizures if at all occur, in which healthcare experts provide appropriate preventive measures or medical help. 

Use of Antipyretic Medications in febrile seizures

Acetaminophen: Also known as paracetamol, it is a non-opioid analgesic with antipyretic properties used in the management of pain and fever. It is safe and used against febrile seizures in children, only to relieve fever by reducing the temperature that is associated with febrile seizures. 

Ibuprofen: It is an NSAID with antipyretic properties, which is used to treat pain and fever. In the management of febrile seizures, it effectively lowers body temperature or fever in children. 

Use of Anticonvulsants in febrile seizures

midazolam: midazolam is a benzodiazepine that is short-acting and has rapid onset of action following an injection. It is used to produce sedation or drowsiness and is used in the emergency management of seizures, especially febrile seizures with a duration of more than five minutes. 

diazepam: it is a benzodiazepine that is used in the management of specific types of seizures, such as febrile seizures. Oral diazepam is used in intermittent prophylaxis, but rectal diazepam is used in children with prolonged febrile seizures. 

phenobarbital: The barbiturate class included phenobarbital, which is used in the management of seizures and is particularly effective for febrile seizures. It is the drug of choice in young children with uncomplicated febrile seizures, which are recurrent. 

phenytoin: it is a hydantoin derivative included as a first-generation anticonvulsant drug in the management of recurrent febrile seizures. 

levetiracetam: It is a novel antiepileptic drug that is effective in the prevention of recurrent febrile seizures and given orally. 

propofol: it is an intravenous anesthetic compound used in monitored anesthesia care or used as an induction agent for general anesthesia. It does have anticonvulsant properties, which inhibit epileptic discharges in EEG and prevent seizures in clinical settings. 

primidone: it is an antiepileptic drug and first-generation barbiturate, which is used in the prevention of febrile seizures, which are recurrent by reducing abnormal brain electrical activity. 

clobazam: It is a benzodiazepine that is used as an adjunctive in the prevention of recurrent febrile seizures. 

sodium valproate: It is an antiepileptic medication used daily in the effective management of febrile seizures, which are recurrent in children. 

phases-of-management

Pre-seizure phase 

Management of temperature of child is essential when there is a history of febrile seizures. Monitor the temperature and administer required antipyretic medications to lower the temperature. Factors that trigger febrile seizures should be identified and child’s exposure to such things should be prevented. 

During the seizure 

Safety: During a febrile seizure, the first thing to do is to keep the child safe by laying the child on their side with the head facing down on a flat, soft surface to prevent choking on fluids, including saliva, and minimize the harm. 

Do Not Restrain. Trying to restrain from movements or holding the child down is not a recommended way of stopping the seizures as it may cause harm to the child. 

Seizure Duration: It is instructed to observe and note the time in which the seizure started and the duration from how long it took place. Febrile seizures generally terminate on their own,in complex cases when seizures last for more than five minutes, medical intervention is needed where anticonvulsants are prescribed for controlling febrile seizures. 

Post-seizure care 

Post-seizure care needs to be taken for the child by reassuring and focussing on comforting the child. Administration of antipyretic agents to reduce the body temperature or to check fever as prescribed by the doctor. Preventive measures that are necessary for the management of febrile seizures need to be understood. 

Medication

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References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210946/