PAEDIATRICS FEBRILE CONVULSION

CENTRAL NERVOUS SYSTEM

GO-508/I-451/ N-838

A. INTRO: a. Ghai: i. Seizure ii. During spikes of fever iii. In a child between 6 months to 5 years (Nelson: 6 months to 6 years), peak incidence at 18 months iv. In the absence of organic neurological disease National Institutes of Health: "An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or defined cause International League against Epilepsy (ILAE): "A seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures"

D. ETIOPATHOGENESIS: a. Risk Factors: (Ref: Emedicine) st i. Family history: 10% risk if 1 degree relative FAMILY HISTORY IS MORE SIGNIFICANT IN FEBRILE CONVULSION THAN EPILEPSY

ii. High temperature: Sudden rise, not slow rise iii. Developmental delay iv. Neonatal discharge after 28 days Perinatal illness requiring hospitalization v. Daycare attendance vi. Maternal alcohol intake and smoking during pregnancy: X 2 times vii. Presence of 2 of the above factors the risk of 1st episode to 30% b. Etio: Infections that can lead to febrile convulsion: (Ref: A to Z) i. Viral URTI: Commonest ii. LRTI: Pneumonia iii. ASOM iv. Measles v. Shigellosis vi. UTI c. Patho: (Ref: Emedicine) i. During dev, low threshold + frequent infec ii. Body responds with higher temp

B. INCIDENCE: a. Commonest cause of seizure in childhood b. Age: 3% between 6 months - 5 years c. Sex: M>F C. TYPES: Age Type Duration No. Simple/Benign 6m 5y GTC <10 min (Nelson: <15min) Single per febrile episode, within 24 hrs Absent Atypical/Complex <1 m or >5 y Focal >10 min (Nelson:>15 min) Multiple per febrile episode Altered sensorium Focal Neurologic deficits Present Present Abnormal 7% further atypical seizure 4 12%

iii. Release of IL 1 iv. Neuronal excitability v. Febrile seizure

Post Ictal phase

H/O neuro prob or dev prob F/H/O Epilepsy EEG Recurrence Risk of epilepsy

Absent Absent, but H/O febrile convulsion Normal within few days after seizure 10% further simple seizure 1-2% (same as other children)

©SASHMI MANANDHAR-KUSMS-5TH BATCH

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PAEDIATRICS E.

CENTRAL NERVOUS SYSTEM

GO-508/I-451/ N-838

DIAGNOSIS: (Ref: emedicine) a. History: i. Type of seizure (generalized or focal) and its duration (Refer types) ii. Fever and it s duration: Usually with sudden spikes of fever iii. Cause of fever (Refer Etio) iv. Recent antibiotic use: Partially Rx Meningitis v. History of seizures, neurologic problems, developmental delay, or other potential causes of seizure (eg, trauma, ingestion of toxic substances) b. Examination: i. Otitis media, pharyngitis, or a viral exanthema ii. Neurologic status iii. Meningeal signs iv. Signs of trauma or toxic ingestion

d. Procedure: Lumbar Puncture i. Indication: (Ref: emedicine) 1. Age < 12 18 months 2. Signs or circumstances suggestive of meningitis: a. A visit to a healthcare setting within the previous 48 hours b. Seizure activity at the time of arrival in the ED c. Focal seizure, suspicious physical examination findings (eg, rash, petechiae) cyanosis, hypotension, or grunting d. Abnormal neurologic examination

F.

D/D: (Ref: emedicine) a. Status Epilepticus b. Meningitis and encephalitis c. Epidural and subdural infections d. Sepsis

H. TREATMENT: a. At home: i. Lt lat position ii. Bring down the temp: 1. Tepid sponging of the whole body 2. Antipyretic: PCM, 15 mg/kg, repeated 8 hrly iii. Control the seizure: If lasting >5 min, Rectal Diazepam (if available) or iv. Hospital b. At Emergency: i. Reassurance to the parents ii. ABC iii. Antipyretic: 1. Acetaminophen, 10-15 mg/kg PO/PR q46h 2. Ibuprofen, 200-400 mg PO q4-6h while symptoms persist 3. Aspirin to be avoided as it can cause Reye s Syndrome iv. Anticonvulsants: 1. Diazepam a. 2-5 years: 0.5 mg/kg PR b. 6-11 years: 0.3 mg/kg c. May repeat rectal dose once after 412 h if needed 2. Midazolam, 0.2 mg/kg IV v. Antibiotics: If infec present vi. If seizure not controlled, RX in the line of status epilepticus

G. INVESTIGATIONS: Routinely not necessary a. Lab: i. Blood: CBC, Culture ii. Urine: R/E , Microscopy, Culture iii. Electrolyte assessment b. Imaging: i. CXR: Rule out LRTI ii. CT: If >4 episodes or clinically indicated c. Other: i. EEG: 1. Indi: a. Atypical febrile convulsion b. F/H/O Epilepsy 2. After 6 weeks of 1st attack 3. Normal in Simple seizure

©SASHMI MANANDHAR-KUSMS-5TH BATCH

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PAEDIATRICS I.

CENTRAL NERVOUS SYSTEM

GO-508/I-451/ N-838

COMPLICATIONS: a. Recurrence: i. Risk factors: 1. Young age at time of first febrile seizure 2. Female 3. Relatively low fever at time of first seizure 4. Family history of a febrile seizure in a first-degree relative 5. Brief duration between fever onset and initial seizure 6. Multiple initial febrile seizures during same episode ii. Prophyllaxis: 1. General measures: a. Temperature control during fever with tepid sponging b. Use of antipyretics 2. Specific: a. Oral Diazepam or Midazolam before the spike of fever (Intermitternt) b. If Atypical seizure or F/H/O Seizure (Continuous) i. Sod valproate, 10-20 mg/kg/day ii. Phenobarbitone, 3-5 mg/kg/day iii. For 1-2 yrs or age of 5 yrs, whichever comes earlier 3. Vaccine: Influenzae b. Temoral lobe epilepsy if progression to febrile status epilepticus

J.

PARENT COUNSELLING: a. Steps to be taken in case child has another seizure b. Call for assistance if the seizure lasts longer than 10 minutes or if the postictal period lasts longer than 30 minutes c. Benign nature of febrile seizures d. Reassured that simple febrile seizure does not lead to neurologic problems or developmental delay

©SASHMI MANANDHAR-KUSMS-5TH BATCH

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