Continuing Education Activity

Febrile seizures are seizures that are caused by a sudden spike in body temperature with fevers greater than 38C or 100.4F, with no other underlying seizure-provoking causes or diseases such as central nervous system (CNS) infections, electrolyte abnormalities, drug withdrawal, trauma, genetic predisposition or known epilepsy. This activity reviews the pathophysiology of febrile seizures and highlights the role of the interprofessional team in its management.

Objectives:

• Recall the etiology of febrile seizures.
• Describe the investigation of a child with febrile seizures.
• Summarize the treatment option for febrile seizures.
• Explore modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by febrile seizures.

Introduction

Febrile seizures are seizures that are caused by a sudden spike in body temperature with fevers greater than 38C or 100.4F, with no other underlying seizure-provoking causes or diseases such as the central nervous system (CNS) infections, electrolyte abnormalities, drug withdrawal, trauma, genetic predisposition or known epilepsy. Febrile seizures categorize as either simple febrile seizures or complex febrile seizures. Differentiation between simple and complex febrile seizures is important as the approach and workup for each is different.[1][2][3]

Etiology

Febrile seizures occur with a fever higher than 38 C or 100.4 F and no other seizure-provoking etiologies such as described above. The highest fever necessary to cause febrile seizures is specific to the individual as each child's threshold convulsive temperature varies. While the degree of fever is ultimately the most significant factor in febrile seizures, these seizures often occur as the patient's temperature is rising. In fact, a febrile seizure may be the first sign that a child is ill, with the presence of fever greater than 38 degrees discovered shortly after that. There is no specific cause of fever that is more likely to cause febrile seizures, however, viral rather than bacterial infections are most commonly associated with febrile seizures. A particular virus, HHV-6, is most commonly associated with febrile seizures in the United States and European countries. In Asian countries, influenza A virus has been frequently associated with febrile seizures. Any fever of adequate height may cause a febrile seizure.[3][4]

Epidemiology

The exact age constituting a febrile seizure varies slightly throughout medical literature with 6 months to 60 months (5 years) being a common working definition. Febrile seizures are extremely common, occurring in up to 4% of children in this age group. Some children have a single febrile seizure event, and others have multiple events over early childhood.

Pathophysiology

The exact pathophysiology of febrile seizures is not understood. There is a recognized genetic predisposition with 10% to 20% of first-degree relatives of patients with febrile seizures also experiencing febrile seizures. No specific mode of inheritance is known.[5]

History and Physical

A detailed description of the seizure event is essential for the evaluation of a possible febrile seizure patient. Historical information regarding the exact appearance and length of the event is vital. Information regarding the symptoms of a central nervous system (CNS) infection, underlying structural abnormalities, personal history of neurologic problems, personal immunization history, and personal or family history of prior seizure is essential in deciding whether an event of concern constitutes a febrile seizure or rather constitutes a more severe illness presenting with a seizure.

Once a seizure is qualified as a febrile seizure, the examiner should seek additional information to differentiate whether it is simple or complex.

Simple febrile seizures occur more commonly than complex febrile seizures and are characterized by a seizure that is generalized, lasts less than 15 minutes, and does not recur within 24 hours.

Complex febrile seizures are characterized by the presence of at least one of the following features: focality, duration of longer than 15 minutes, and recurrence within a 24-hour period. In either instance, a general physical exam and neurologic exam are necessary. Post-ictal drowsiness is not abnormal in febrile seizures but typically resolves within a few minutes. A patient recovering from a febrile seizure will rapidly return to baseline and towards a normal neurologic exam. If a patient does not return to baseline, remains completely unresponsive to noxious stimuli after the seizure, or has other symptoms of acute neurologic dysfunction before the seizure (such as acute headaches, alteration of mental status, or concern for weakness), other complicating etiologies should be a consideration.

Evaluation

A patient with a normal general and neurologic exam, whose history is consistent with a simple febrile seizure, does not need a further laboratory, imaging, or neurophysiologic evaluation. If a patient's history is consistent with a complex febrile seizure, an electroencephalogram (EEG) is obtained to look for underlying abnormalities that may predispose the patient to seizures. If this initial EEG is abnormal, imaging is the next step. In a complex febrile seizure returning to baseline, often these are outpatient studies.[4][6]

A lumbar puncture may be a consideration in the setting of fever and seizures. For a patient with the appropriate history of a febrile seizure and a rapid return to baseline, no lumbar puncture is necessary. Lumbar puncture is a recommendation when there are signs or symptoms that cause concern of a CNS infection; further, the lumbar puncture should be considered in infants aged 6 months to 12 months without appropriate immunization against Streptococcus pneumoniae or Haemophilus influenza type B and in patients taking antibiotics in which partial treatment may mask meningitis or other CNS infection.

Imaging studies are not indicated for simple febrile seizures.

Treatment / Management

There is no specific treatment for simple or complex febrile seizures other than appropriate treatment for underlying etiologies driving the ongoing febrile illness.  Antipyretics have not been shown to prevent a recurrence of febrile seizures.  In patients who have a frequent recurrence of febrile seizures such as seizures with a majority of febrile illnesses, studies have examined treatment with benzodiazepines as a bridging measure for a few days during subsequent febrile events.[7][8][9]

Febrile status epilepticus can occur in less than 10% of children during the first febrile seizure. Rectal diazepam is used to abort this disorder if it lasts more than 5 minutes. There are also recommendations for intranasal midazolam. Patients with febrile status epilepticus are at risk for future episodes of the same event.

Differential Diagnosis

The differential diagnosis of febrile seizures include:

• Aseptic meningitis
• Bacterial meningitis
• Encephalitis
• Tonic-clonic seizures

Prognosis

About 30% of children with a previous febrile seizure remain at an increased risk of recurrent febrile seizures.

Children less than 12 months at the time of the first febrile seizure have a 50% chance of having a second seizure within the first year. This risk drops to 30% the following year. Other than young age during the first febrile seizure, a family history of febrile seizure, low degree of fever during the seizure, and a shorter interval between fever and the seizure may indicate a higher probability of recurrent febrile seizures. However, features associated with complex febrile seizures do not necessarily increase the risk of recurrence of febrile seizures.

About 1-2% of children with simple febrile seizures - only slightly higher risk than the general population- develop subsequent epilepsy. However, children with complex febrile seizures, abnormal neurodevelopment, or with a family history of epilepsy have a higher risk of epilepsy(approximately 5-10%). 

There is no evidence that febrile seizures are linked to learning disabilities or lower intelligence.

Consultations

• Pediatrician
• Neurologist

Pearls and Other Issues

Most patients with a febrile seizure event do not require hospitalization or intensive medical interventions. Occasionally a patient with a prolonged complex febrile seizure of a focal nature may develop focal weakness, commonly known as Todd's paralysis. Typically this resolves within a few hours, but it may take up to a few days for complete resolution. Even though febrile seizures are often considered relatively benign, studies have shown that patients with a febrile seizure status have an increased risk of developing mesial temporal sclerosis which can increase future chances of focal epilepsy. Febrile seizure status is defined as a seizure lasting longer than 30 minutes. Therefore, prompt treatment of prolonged seizures of a febrile nature is as necessary as prompt treatment of prolonged seizures arising from other etiologies.

Additionally, as above, it is vital to quickly expand the differential diagnosis considerations if a patient is not awakening and steadily improving toward the baseline, or if a patient has unexpected abnormalities on the neurologic exam. A patient who will not respond to noxious stimuli after a seizure or who appears to be waxing and waning in mental status needs evaluation for possible ongoing seizure activity. The standard procedure for this evaluation is typically by a prolonged EEG study. Other considerations in a patient not recovering as expected include intracranial abnormalities such as a tumor, hemorrhage, hydrocephalus, stroke, or another significant metabolic abnormality.

Enhancing Healthcare Team Outcomes

Febrile seizures are not uncommon in the pediatric population. They only occur when there is a rise in body temperature. These seizures are benign and generally have no long-term complications in most children. The diagnosis and management of these children should be done in a systemic fashion in collaboration with an interprofessional team that consists of the pediatrician and neurologist.

The key is patient education. The nurse and clinician should educate the family that even though dramatic in appearance, these seizures do not lead to neurological disease or dysfunction. The more parents are aware of this disorder, the less likely it is that they will rush to the emergency room or seek alternative unproven remedies. However, the parents should also be educated on when to bring the child with a seizure to the emergency department because in some cases the cause may be a virus or a bacterial infection of the brain. The pharmacist should educate the family on managing the fever with acetaminophen and not aspirin. However, the family should also be educated that antipyretics do not prevent future febrile seizures.[10][11] (Level III)

Finally, patients need to be told that a febrile seizure does not lead to any adverse neurological or psychological problems. An interprofessional team approach to the care of febrile seizures will lead to the best outcomes. [Level 5]

Outcomes

The prognosis for most children with a febrile seizure is excellent. About 30% of children who have one febrile seizure will experience another seizure later on. The risk of epilepsy in the future is slightly increased compared to the general population. However, a simple febrile seizure does not affect cognition, intellect or induce neurological dysfunction.[12][13](Level V)