CASE PRESENTATION

FEBRILE SEIZURES IN CHILDREN

Supervisor:
dr. Ulynar Marpaung, Sp. A

Written by:
Bening Irhamna
1102013057

DEPARTEMENT OF PEDIATRIC

FACULTY OF MEDICINE YARSI UNIVERSITY

RADEN SAID SUKANTO POLICE CENTRAL HOSPITAL

02 JULY 2018 – 08 SEPTEMBER 2018
 TABLE OF CONTENT

TITLE OF PAGE ...................................................................................... i

TABLE OF CONTENT ............................................................................ ii
PREFACE .................................................................................................. 1
SECTION I – CASE REPORT FEBRILE SEIZURES IN CHILDREN
1.1 Identity .................................................................................... 2
1.2 History Taking ........................................................................ 3
1.3 Physical Examination.............................................................. 5
1.4 Laboratory Findings ................................................................ 8
1.5 Working Diagnosis ................................................................. 9
1.6 Differential Diagnosis ............................................................. 9
1.7 Management ............................................................................ 9
1.8 Prognosis ................................................................................. 9
1.9 Follow Up ............................................................................... 10
SECTION II – LITERATURE OF REVIEW FEBRILE SEIZURES IN
CHIDREN
2.1 Definition ................................................................................ 18
2.2 Epidemiology .......................................................................... 18
2.3 Etiology ................................................................................... 19
2.4 Pathophysiology...................................................................... 20
2.5 Classification........................................................................... 21
2.6 Clinical Manifestation ............................................................. 21
2.7 Diagnostic Approach .............................................................. 22
2.8 Therapeutic Approach ............................................................. 25
2.9 Prevention Approach .............................................................. 27
2.10 Prognosis ............................................................................... 28
BIBLIOGRAPHY ..................................................................................... 29
CDC GROWTH CHART ......................................................................... 31

ii
 PREFACE
The immune system is responsible for knowing the difference between normal bodily
substances and foreign ones, as well as protecting the body from infections and foreign
substances. Different immune response can be perceived if an opportunistic microorganism is
introduced in the body. One common response of the body seen in children from infection is
fever. It is a physiologic response of the body that accompany childhood illnesses, especially
infections.
Febrile seizures are convulsions brought on by a fever in infants or small children. During
a febrile seizure, a child often loses consciousness and shakes, moving limbs on both sides of
the body. Less commonly, the child becomes rigid or has twitches in only a portion of the body,
such as an arm or a leg, or on the right or the left side only. Most febrile seizures last a minute
or two, although some can be as brief as a few seconds while others last for more than 15 minutes.
The latter is called complex febrile seizure.
Febrile seizures usually occur in children between the ages of five months and five years
and are particularly common in toddlers. Children rarely develop their first febrile seizure before
the age of six months or after three years of age. The older a child is when the first febrile seizure
occurs, the less likely that child is to have more.
Several factors can contribute to febrile convulsion. Before 5 years of age, the child has
not yet fully developed his/her hypothalamic control centre therefore temperature can easily
fluctuate. Family history of this particular seizure can also contribute in developing benign
febrile convulsion. Infection can be another causative factor in the occurrence of febrile seizure.

1
 SECTION 1 - CASE REPORT
FEBRILE SEIZURES IN CHILDREN

1.1 IDENTITY
Patient’s Identity
Name : Child Z
Birthdate : 29th August 2017
Age : 11 months
Gender : Male
Nationality : Indonesian
Race : Javanese
Religion : Islam
Address : Kampung Rambutan RT 011 RW 003, East Jakarta
Date of Admission : 29th July 2018
Date of Discharge : 1st August 2018

Parents’ Identity
Father Mother
Name Mr. A Mrs. Z
Age 23 years old 17 years old
Gender Male Female
Nationality Indonesian Indonesian
Religion Islam Islam
Occupation Employee Housewife
Last Education Primary School Primary School

Relationship with patient: Biological parents

2
1.2 PERSONAL HISTORY
The information was given by the patient’s mother on the 29th of July 2018.
 Chief Complaint: seizure in the last 1 hour prior to hospital admission
 Additional Complaint: fever, cough

Patient’ History of Present Illness:

A 11 months old male children was admitted to the emergency care unit with a chief
complaint of seizure in the last 1 hour prior to hospital admission. Complaints accompanied by
fever and cough.

1 day prior to hospital admission, the patient has a fever, sudden high fever, a fever that
occurs continuously. Fever ranges from 38C - 39C. The patient was only compressed by warm
water by his mother at home. Patient also have complaints of cough. Cough was not phlegm,
cough was rare and erratic. On the next day patient was taken to the primary health centre and
given paracetamol syrup to reduce fever.

Upon returning from the primary health centre, 1 hour prior to hospital admission, the
patient experienced a seizure. Seizures occur 1 time. The duration of seizure is around 5 minutes.
The patient clenched both hands when seizure occurred, both upper arms and lower limbs
trembled like shivering, the patient's eyes glared up. No foam comes out of the patient's mouth
and the tongue does not bite. The medicine given from primary health centre has not been used
by the patient. Then the patient is taken to the emergency room at the hospital. When in the
emergency room, the patient still had a fever but did not experience recurrent seizures.

Other complaints such as runny nose, stomach ache, nausea, vomiting, ear pain and fluid
coming out of the ear are denied. No complaints in defecation and urination.

Past Medical History: No past medical history to date. Mother denied any sickness, accidents
and injuries.

Allergy History: No known allergies were reported.

3
Birth History:
Mother’s Pregnancy History
The mother routinely checked her pregnancy to the midwife in the maternity clinic. She denied
any problem noted during her pregnancy. She took vitamins routinely given.
Child’s Birth History
 Labor : Maternity Clinic
 Birth attendants : Midwife
 Mode of delivery : Pervaginam
 Gestation : 38 weeks
 Infant state : Healthy
 Birth weight : 3300 grams
 Body length : 49 cm
There were no complications at delivery, APGAR score was unknown but the mother said Child
Z breathed spontaneously at birth and he did not require any respiratory support or phototherapy.

Developmental History

- Social Personality
 Smile : 3 months
 Reaching toys : 6 months
 Clapping hands : 6 months
- Psychomotor development
 Slant : 5 months
 Speech initiation : 6 months
 Sitting : 8 months
 Crawling : 8 months
 Standing : 9 months
- Language
 Screaming : 11 month
 Laughing : 6 months
 Turn one’s head : 3 months
Conclusion: developmental is within the normal limits and appropriate according to
the patient’s age.

4
Feeding History
- Breast milk : Exclusively 6 months
- Formula milk : None were given
- Baby biscuit : Milna and promina
- Fruit and vegetables : Banana and papaya

Immunization History:
Immunization Frequency Time
BCG 1 times 1 month old
Hepatitis B 4 times 0, 2, 3, 4 months old
DPT 3 times 2, 3, 4 months old
Polio 4 times 0, 2, 3, 4 months old
Measles 1 times 9 months

Family History
 Patient’s both parents were married when they were 16 years old and 23 years old, and
this is their first marriage
 There are not any congenital disease, significant illnesses or chronic illnesses in the
family declared
 No complaints are the same as patients when the patient's parents are still children
 Born died : ( - )
 Child dies : ( - )
 Miscarriage : ( - )

1.3 PHYSICAL EXAMINATION

General
 Patient is a well-developed with good nutrition. Appears to be well hydrated.
Vital Sign
 Body Temperature : 39,2oC
 Respiratory Rate : 25 breaths per minute
 Heart Rate : 120 beats per minute
Growth Parameter
 Weight : 9 kg
 Height : 73 cm
 Head Circumference : 45 cm
5
  CDC Growth Chart
 Weight for age : 9/10 x 100% = 90% (Gizi Baik)
 Height for age : 73/74 x 100% = 98,6% (Normal)
 Weight for height : 9/9,8 x 100% = 91,8% (Gizi Baik)

Head
 Normocephalic, atraumatic with thick hair.
Eyes
 Pupils equal, round and reactive to light. Extraocular muscle appeared intact. No
discharges, conjunctivitis or scleral icterus. No ptosis. Pallor were not detected for both
eyes.
Ears
 Clear external auditory canals. Pinnae shape and contour was normal. No pre-auricular
pits or skin tags. No erythema or bulging. No bleeding, secretion or serumen.
Nose
 Normal pink mucosa, no discharge or blood visible. Normal midline septum.
Mouth
 Moist mucous membrane. Tongue no dirty.
Pharynx
 Tonsil T1/T1, pharynx shows hyperemia.
Neck
 Grossly non-swollen. No tracheal deviation. No decrease in ROM. No lymphadenopathy,
goitre or masses detected.
Thorax
 Inspection : symmetric when breathing , retraction (-), ictus cordis is not visible
 Palpation : mass (-), tactile fremitus right = left
 Percussion : sonor on both of lungs
 Auscultation :
o Cor : regular S1-S2, murmur (-), gallop (-)
o Pulmo : vesicular +/+, wheezing -/- , rhonchi -/-

6
Abdomen
 Inspection : Convex, epigastric retraction (-), there is no a widening of the veins, no
spider nevi
 Auscultation : normal bowel sound, bruit (-)
 Percussion : The entire field of tympanic abdomen, shifting dullness (-)
 Palpation : supple, liver and spleen not palpable, fluid wave (-), abdominal mass(-)
Extremities
 Warm, no cyanosis or oedema. No gross deformities. Good skin turgor with no tenting.

Neurological Examination
Meningeal Sign
- Nuchal rigidity (-)
- Kernig sign (-)
- Laseque sign (-)
- Brudzinski I (-)
- Brudzinski II (-)

Autonom Examination

Defecation Normal
Urination Normal ( 3-4 times daily )
Sweating Normal

Motoric Examination

Power
- Hand 5555/5555
- Feet 5555/5555
Tones
- Hand Normotonus/ Normotonus
- Feet Normotonus / Normotonus
Trophy
- Hand Normotrophy / Normotrophy
- Feet Normotrophy / Normotrophy

7
 Physiologic Reflex
Upper extremities
- Biceps +2 / +2
- Triceps +2 / +2
Lower extremities
- Patella +2 / +2
- Achilles +2 / +2
Pathologic Reflex
Upper extremities
- Hoffman -/-
- Trommer -/-
Lower extremities
- Babinsky -/-
- Chaddock -/-
- Oppenheim -/-
- Gordon -/-
- Schaeffer -/-
Clonus
- Patella -/-
- Achilles -/-

1.4 LABORATORY FINDINGS

Hematology (July 29th, 2018)
Results Normal Value
Hemoglobin 11,2 13 – 16 g/dl
White blood cells 17.000 5.000 – 10.000 u/l
Hematocrit 24 40 – 48 %
Platelet count 253.000 150.000 –400.000 /ul

8
1.5 WORKING DIAGNOSIS
 Simple Febrile Seizure
 Normal Growth Development
 Normal Nutritional State

1.6 DIFFERENTIAL DIAGNOSIS

 Complex Febrile Seizure

1.7 MANAGEMENT
 Fluid Maintenance
 Intravenous hydration: Ringer Lactate 900 ml for 24h.
 Symptomatic drugs
 Paracetamol syrup 1 ml per oral three times daily.
 Ambroxol syrup 2.5 ml per oral two times daily
 Antibiotics
 Cefotaxime intravenous 450 mg two times daily.
 Anticonvulsant prophylaxis
 Diazepam syrup 1mg per oral three times daily.

1.8 PROGNOSIS
- Quo ad vitam : bonam
- Quo ad functionam : bonam
- Quo ad sanationam : bonam

9
1.9 FOLLOW UP
July 29th 2018, first day of admission, 2nd day of illness
S Mild fever (+), Seizure (-), Cough (+)
Consciousness : Compos Mentis
General condition : Moderately ill
Temperature : 38 °C
Pulse :110 x/min
Respiratory rate : 25 x/min
Head
 Normocephalic, atraumatic with thick hair.
Eyes
 Pupils equal, round and reactive to light. Extraocular muscle
appeared intact. No discharges, conjunctivitis or scleral icterus. No
ptosis. Pallor were not detected for both eyes.
Ears
 Clear external auditory canals. Pinnae shape and contour was
O normal. No pre-auricular pits or skin tags. No erythema or bulging.
Nose
 Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth
 Moist mucous membrane.
Pharynx
 Unable to visualise tonsils. Pharynx shows hyperemia.
Neck
 Grossly non-swollen. No tracheal deviation. No decrease in ROM.
No lymphadenopathy, goitre or masses detected.
Chest
 No increase of accessory muscles (no evidence of increased work
of breathing).

10
 Lungs
 Lungs are clear to auscultation bilaterally. No stridor, wheezes,
crackles or rubs.
 Good air movement.
Cor
 Normal S1-S2 rate and rhythm. No murmurs, gallops or rubs.
Abdomen
 Soft, non-tender, non-distended. Bowel signs present. No
hepatomegaly and splenomegaly.
Extremities
 Warm, no cyanosis or oedema. No gross deformities. Good skin
turgor with no tenting.
Simple Febrile Seizure
A Normal Growth Development
Normal Nutritional State
- Ringer Lactate 900 ml for 24h
- Cefotaxime intravenous 450 mg two times daily.
P - Paracetamol syrup 1 ml per oral three times daily.
- Ambroxol syrup 2.5 ml per oral two times daily
- Diazepam syrup 1mg per oral three times daily.

11
July 30th 2018, second day of admission, 3rd day of illness

S Mild fever (+), Seizure (-), Cough (+)

Consciousness : Compos Mentis
General condition : Moderately ill
Temperature : 37,7 °C
Pulse :110 x/min
Respiratory rate : 25 x/min
Head
 Normocephalic, atraumatic with thick hair.
Eyes
 Pupils equal, round and reactive to light. Extraocular muscle
appeared intact. No discharges, conjunctivitis or scleral icterus. No
ptosis. Pallor were not detected for both eyes.
Ears
 Clear external auditory canals. Pinnae shape and contour was
normal. No pre-auricular pits or skin tags. No erythema or bulging.
O
Nose
 Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth
 Moist mucous membrane.
Pharynx
 Unable to visualise tonsils. Pharynx shows no hyperemia.
Neck
 Grossly non-swollen. No tracheal deviation. No decrease in ROM.
No lymphadenopathy, goitre or masses detected.
Chest
 No increase of accessory muscles (no evidence of increased work
of breathing).
Lungs
 Lungs are clear to auscultation bilaterally. No stridor, wheezes,
crackles or rubs.
12
  Good air movement.
Cor
 Normal S1-S2 rate and rhythm. No murmurs, gallops or rubs.
Abdomen
 Soft, non-tender, non-distended. Bowel signs present. No
hepatomegaly and splenomegaly.
Extremities
 Warm, no cyanosis or oedema. No gross deformities. Good skin
turgor with no tenting.
Simple Febrile Seizure
A Normal Growth Development
Normal Nutritional State
- Ringer Lactate 900 ml for 24h
- Cefotaxime intravenous 450 mg two times daily.
P - Paracetamol syrup 1 ml per oral three times daily.
- Ambroxol syrup 2.5 ml per oral two times daily
- Diazepam syrup 1mg per oral three times daily.

13
July 31th 2018, third day of admission, 4th day of illness

S Mild fever (+), Seizure (-), Cough (-)

Consciousness : Compos Mentis
General condition : Moderately ill
Temperature : 37,5 °C
Pulse :110 x/min
Respiratory rate : 25 x/min
Head
 Normocephalic, atraumatic with thick hair.
Eyes
 Pupils equal, round and reactive to light. Extraocular muscle
appeared intact. No discharges, conjunctivitis or scleral icterus. No
ptosis. Pallor were not detected for both eyes.
Ears
 Clear external auditory canals. Pinnae shape and contour was
normal. No pre-auricular pits or skin tags. No erythema or bulging.
O
Nose
 Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth
 Moist mucous membrane.
Pharynx
 Unable to visualise tonsils. Pharynx shows no hyperemia.
Neck
 Grossly non-swollen. No tracheal deviation. No decrease in ROM.
No lymphadenopathy, goitre or masses detected.
Chest
 No increase of accessory muscles (no evidence of increased work
of breathing).
Lungs
 Lungs are clear to auscultation bilaterally. No stridor, wheezes,
crackles or rubs.
14
  Good air movement.
Cor
 Normal S1-S2 rate and rhythm. No murmurs, gallops or rubs.
Abdomen
 Soft, non-tender, non-distended. Bowel signs present. No
hepatomegaly and splenomegaly.
Extremities
 Warm, no cyanosis or oedema. No gross deformities. Good skin
turgor with no tenting.
Simple Febrile Seizure
A Normal Growth Development
Normal Nutritional State
- Ringer Lactate 900 ml for 24h
- Cefotaxime intravenous 450 mg two times daily.
P
- Paracetamol syrup 1 ml per oral three times daily.
- Diazepam syrup 1mg per oral three times daily.

15
August 1st 2018, fourth day of admission, 5th day of illness
S Fever (-), Seizure (-), Cough (-)
Consciousness : Compos Mentis
General condition : Mild ill
Temperature : 36,7 °C
Pulse :102 x/min
Respiratory rate : 24x/min
Head
 Normocephalic, atraumatic with thick hair.
Eyes
 Pupils equal, round and reactive to light. Extraocular muscle
appeared intact. No discharges, conjunctivitis or scleral icterus. No
ptosis. Pallor were not detected for both eyes.
Ears
 Clear external auditory canals. Pinnae shape and contour was
normal. No pre-auricular pits or skin tags. No erythema or bulging.
O
Nose
 Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth
 Moist mucous membrane.
Pharynx
 Unable to visualise tonsils. Pharynx shows no hyperemia.
Neck
 Grossly non-swollen. No tracheal deviation. No decrease in ROM.
No lymphadenopathy, goitre or masses detected.
Chest
 No increase of accessory muscles (no evidence of increased work
of breathing).
Lungs
 Lungs are clear to auscultation bilaterally. No stridor, wheezes,
crackles or rubs.

16
  Good air movement.
Cor
 Normal S1-S2 rate and rhythm. No murmurs, gallops or rubs.
Abdomen
 Soft, non-tender, non-distended. Bowel signs present. No
hepatomegaly and splenomegaly.
Extremities
 Warm, no cyanosis or oedema. No gross deformities. Good skin
turgor with no tenting. Purpura was noted at both arm and feet.

Laboratory Finding (31/07/2018)

 Hemoglobin 13 g/dl
 White blood 10.500 u/l
 Hematocrit 40%
 Platelet count 260.000/ul
Simple Febrile Seizure
A Normal Growth Development
Normal Nutritional State
- Azithromycin suspension 100 mg per oral once daily.
P
- Plan to discharge

17
 SECTION 2 - LITERATURE REVIEW
FEBRILE SEIZURE

2.1 DEFINITION
A conference held by the National Institutes of Health described a febrile seizure as, 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.1
Another definition from the International League Against Epilepsy (ILAE) febrile
seizure is 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.2

2.2 EPIDEMIOLOGY
Febrile seizures in United States occur in 2-5% of children aged 6 months to 5 years.
Among children with febrile seizures, about 70-75% have only simple febrile seizures, another
20-25% have complex febrile seizures, and about 5% have symptomatic febrile seizure.3
A similar rate of febrile seizures is found in Western Europe. The incidence elsewhere
in the world varies between 5% and 10% for India, 8.8% for Japan, 14% for Guam, 0.35% for
Hong Kong, and 0.5-1.5% for China.4
Febrile seizures occur in all races, some studies demonstrate a slight male predominance.
Simple febrile seizure occur most commonly in children aged 6 month to 5 years.
Risk factors for developing febrile seizures are as follows:3,5,6,7
 Family history of febrile seizures
 High temperature
 Parental report of developmental delay
 Neonatal discharge at an age greater than 28 days (suggesting perinatal illness requiring
hospitalization)
 Daycare attendance
 Presence of 2 of these risk factors - Increases the probability of a first febrile seizure to
about 30%
 Maternal alcohol intake and smoking during pregnancy - Two-fold increased risk
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 Interestingly, no data support the theory that a rapid rise in temperature is a cause of
febrile seizures. About one third of all children with a first febrile seizure experience recurrent
seizures. Risk factors for recurrent febrile seizures include the following:
 Young age at time of first febrile seizure
 Relatively low fever at time of first seizure
 Family history of a febrile seizure in a first-degree relative
 Brief duration between fever onset and initial seizure
 Multiple initial febrile seizures during same episode

Patients with all 4 risk factors have greater than 70% chance of recurrence. Patients with
no risk factors have less than a 20% chance of recurrence.
Children with febrile seizures have a slightly higher incidence of epilepsy compared with
the general population (2% vs 1%). Risk factors for epilepsy later in life include complex febrile
seizure, family history of epilepsy or neurologic abnormality, and developmental delay. Patients
with 2 risk factors have up to a 10% chance of developing afebrile seizures.8
Children younger than 12 months at the time of their first simple febrile seizure have a
50% probability of having a second seizure. After 12 months, the probability decreases to 30%.
Children with simple febrile seizures do not have increased mortality risk. However, seizures
that were complex, occurred before age 1 year, or were triggered by a temperature of less than
39°C were associated with a 2-fold increased mortality rate during the first 2 years after seizure
occurrence.8
The literature does not support the hypothesis that simple febrile seizures lower
intelligence (ie, cause a learning disability) or are associated with increased mortality.8

2.3 ETIOLOGY
The etiology of febrile seizure to date has not been known. However the age of child, the
height and speed of temperature increase affect the occurrence of seizures. The heredity factor
also has a role that is 8-22% of children who experience febrile seizure have parents who have
a history of febrile seizure in their childhood.8
Febrile seizure usually begin with a viral or bacterial infection. The most common
diseases that accompany febrile seizure are respiratory infections, otitis media and
gastroenteritis.9
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2.4 PATHOPHYSIOLOGY
This is a unique form of epilepsy that occurs in early childhood and only in association
with an elevation of temperature. The underlying pathophysiology is unknown, but genetic
predisposition clearly contributes to the occurrence of this disorder.10
To maintain cell or brain survival, an energy is needed from metabolism. The most
important raw material for brain metabolism is glucose. The nature of the process is oxidation
where oxygen is provided by means of lung function and passed to the brain through the
cardiovascular system. Brain energy source is glucose which through the oxidation process is
broken down into CO2 and water.
The cell is surrounded by a membrane consisting of a lipoid inner surface and an ionic
outer surface. In normal circumstances the neuronal cell membrane can be passed easily by
potassium ions (K+) and is very difficult to pass by sodium ions (Na+) and other electrolytes,
except chloride ions (Cl-). As a result, the concentration of K+ in the neuron cell is high and the
Na+ concentration is low, while outside the neuron cell there is a reverse condition. Because of
the different types and concentrations of ions inside and outside the cell, there is a potential
difference called the cell membrane potential of neuronal cells.
To maintain the balance of membrane potential, energy and the help of the Na-K ATPase
enzyme found on the cell surface are needed. This membrane potential balance can be changed
by its presence:
a. Change in ion concentration in the extracellular space.
b. Stimulation that comes suddenly such as mechanical, chemical or electricity from the
surroundings.
c. Changes in the pathophysiology of the membrane itself due to disease or heredity

In a fever condition a temperature increase of 1C will result in an increase in basal

metabolism of 10% -15% and oxygen demand will increase by 20%. In a 3 years old child brain
circulation reaches 65% of the whole body, compared to only 15% of adults.
So at a certain increase in body temperature, there can be a change in the balance of the
neuron cell membrane so that in a short time diffusion of potassium ions and sodium ions occurs
through the membrane which results in the release of an electric charge. The release of this
electrical charge is so large that it can extend to all cells and to other cell membranes with the
help of materials called neurotransmitters and seizures occur.
20
 Each children has a different seizure threshold and depends on the height and seizure
threshold of a child who has a seizure at a certain temperature rise. In children with a low seizure
threshold, seizures have occurred at a temperature of 38C while in children with a high seizure
threshold, new seizures will occur at temperatures of 40C or more.
Short-term febrile seizures are generally harmless. But in long-lasting seizures usually
accompanied by the occurrence of apnoe so that the need for oxygen for the brain increases and
causes damage to brain neuron cells which have an impact on the occurrence of neurological
abnormalities.8

2.5 CLASSIFICATION
Simple Febrile Seizure:2,11
 The setting is fever in a child aged 6 months to 5 years
 The single seizure is generalized and lasts less than 15 minutes
 The child is otherwise neurologically healthy and without neurologic
abnormality by examination or by developmental history
 Fever (and seizure) is not caused by meningitis, encephalitis, or any other
illness affecting the brain
 The seizure is described as either a generalized clonic or a generalized tonic-
clonic seizure
Complex Febrile Seizure:11,12,13
 Age, neurologic status before the illness, and fever are the same as for simple
febrile seizure
 This seizure is either focal or prolonged (ie, >15 min), or multiple seizures
occur in close succession

2.6 CLINICAL MANIFESTATION

Children with simple febrile seizures are neurologically and developmentally healthy
before and after the seizure. They do not experience a seizure in the absence of fever. The seizure
is described as either a generalized clonic or a generalized tonic-clonic seizure.

Fever seizures can begin with a sudden contraction of the muscles on both sides of the
child's body. Contractions generally occur in the muscles of the face, body, hands and feet.
Children can cry or moan due to the strength of muscle contraction. Contractions can take several

21
seconds or several minutes. Children will fall if they are standing, and can remove urine without
their desire.8

The child can vomit or bite his tongue. Some children do not breathe and can show
symptoms of cyanosis. Eventually the contractions stop and are replaced by short relaxation.
Then the child's body starts to beat rhythmically (in clonic seizures), or stiff (in tonic seizures).
At this time the child loses consciousness and cannot respond to the surrounding environment.

2.7 DIAGNOSTIC APPROACH

Diagnosis of febrile seizures can only be established by getting rid of other diseases that
can cause seizures, including: central nervous system infection, acute changes in the balance of
water homeostasis and electrolytes, and the presence of structural lesions in the nervous system
such as epilepsy. Anamnesis is needed, a physical examination, and thorough investigations to
establish this diagnosis.

Anamnesis:

1. Awareness before and after seizures (get rid of the diagnosis of meningitis encephalitis)
2. History of neurological disorders (rule out epilepsy diagnosis)
3. History of fever (since when, suddenly or slowly, permanently or up and down)
4. Determine the underlying disease for fever (airway infection, otitis media,
gastroenteritis)
5. Time of seizure, duration, frequency, interval between 2 seizure attacks
6. The nature of seizures (focal or general)
7. Seizure form (tonic, clonic, tonic-clonic)
8. History of previous seizures (seizures accompanied by fever or not accompanied by fever
or epilepsy)
9. History of growth and development delays
10. History of febrile seizures and epilepsy in the family
11. Trauma

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 Physical Examination:

1. Temperature body
2. Examination to determine the underlying disease for fever (airway infection, otitis media,
gastroenteritis)
3. Pathological reflex examination
4. Examination of meningeal excitatory signs (getting rid of the diagnosis of meningitis,
encephalitis)

Supporting Examination:

 Laboratory Findings

No specific laboratory test are indicated for a simple febrile seizure. Physicians should
focus on diagnosing the cause of fever. Other laboratory tests may be indicated by the nature of
the underlying febrile illness. Laboratory tests that can be done for example peripheral blood,
electrolytes and blood sugar.

Electrolyte examination, examination of liver and kidney function to get rid of metabolic
disorders that cause changes in homeostasis when a history of vomiting, diarrhea, fluid intake,
and symptoms of dehydration are found.

 Lumbar Puncture14,15

Controversy exists regarding the need for a lumbar puncture in a child presenting with a
simple febrile seizure. Lumbar puncture is not needed for young children with first simple febrile
seizure. Lumbar puncture examination is recommended for patient:

- Strongly consider lumbar puncture in children younger than 12 months,

because the signs and symptoms of bacterial meningitis may be minimal or
absent in this age group.
- Lumbar puncture should be considered in children aged 12-18 months,
because clinical signs and symptoms of bacterial meningitis may be subtle in
this age group.
- In children older than 18 months, the decision to perform lumbar puncture
rests on the clinical suspicion of meningitis.
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  Electroencephalogram (EEG)14

An electroencephalogram (EEG) is not necessary in the routine evaluation of a child with

a simple febrile seizure. EEGs in febrile seizures cannot identify specific abnormalities or predict
recurrent seizures, but can be considered in complex febrile seizures and focal febrile seizures.

 CT Scan (Computed Tomography)

Neither computed tomography (CT) nor magnetic resonance imaging (MRI) is indicated
in patients with simple febrile seizures. However, it can be considered in patients who experience
complex febrile seizures to determine the type of structural abnormality in the form of a single
or multiple complex.

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 2.8 THERAPEUTIC APPROACH

SEIZURE
5 minutes Diazepam rectal 0.5 – 0,75mg/kg or:
weight ≤ 10 kg: 5 mg
weight > 10 kg: 10 mg
SEIZURE (+)
Repeat rectal diazepam as before

In Hospital
Search for venous access
Laboratory test (peripheral blood, electrolytes, blood sugar)

SEIZURE (+)
Diazepam IV 0.3-0.5 mg/kg
(speed 0.5-1 mg/minute)

SEIZURE (-) SEIZURE (+)

Give maintenance therapy if Phenytoin bolus IV 10-20

the cause of the seizure is mg/kg (speed 0.5-1
mg/kg/minute)
estimated to be intracranial
infection. Give phenobarbital
8-10 mg/kg/day, divided by 2
doses. During the next 2 days
4-5 mg / kg / day until the risk SEIZURE (+) SEIZURE (-)
of seizures does not exist. Transfer to Maintenance
ICU phenytoin IV 4-8
mg/kg/day 12 hours
later

25
  Antipyretics and Antibiotics

Antipyretics are given as a symptomatic treatment of fever. Can be given paracetamol

with the recommended dose for children 10-15 mg / kg / day every 4-6 hours or ibuprofen 5-10
mg / kg / day every 4-6 hours. Antibiotics to treat infections that are the basic etiology of fever.

 Anticonvulsant

The use of oral diazepam at a dose of 0.3 mg / kg every 8 hours at the time of fever
decreases the risk of recurrent seizures in 30% - 60% of cases, as well as rectal diazepam at 0.5
mg / kg every 8 hours at a temperature> 38.5C. The dose is quite high and causes severe ataxia,
irritability and sedation in 25-39% of cases. Phenobarbital, carbamazepine and phenytoin during
fever are not useful to prevent febrile seizures.16

 Prophylaxis

Prevention of recurrent febrile seizures needs to be done, because it frightens the family
and if it continues it can cause persistent brain damage. There are two ways of prophylaxis:

a. Intermittent prophylaxis at the time of fever

Intermittent prophylactic treatment is given anti-convulsions immediately

when the patient has a fever (rectal temperature more than 38C. Oral
diazepam is effective in preventing recurrent febrile seizures and when given
intermittent the results are better because the absorption is faster. Diazepam
is given orally or rectally. Rectal dose every 8 hours is 5 mg for patients
weighing less than 10 kg and 10 mg for patients weighing more than 10 kg.
Oral doses are given 0.5 mg / kg / per day divided into 3 doses, given if the
patient shows a temperature of 38.5C or more.

b. Continuous prophylaxis with anticonvulsants every day

Current indications of prophylactic administration at this time are:

o Before the first febrile seizure already exists neurological

development disorders or disorders.

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 o There is a history of seizures without fever that are genetic in the
parents or siblings.
o Fever seizures longer than 15 minutes, focal or a temporary or
permanent neurological disorder is followed.
o Fever seizures occur in infants less than 12 months of age or multiple
seizures occur in one episode of fever.

Prophylactic anticonvulsants are continuously given for 1-2 years after

the last seizure, then stopped gradually for 1-2 months. Administration of
phenobarbital 4 - 5 mg / kg / per day with a level of 16 mg / mL in the blood
showed significant results to prevent the recurrence of febrile seizures. Side
effects of phenobarbital are irritable, hyperactive, irritable and aggressive in
30-50% of cases. Another drug that can be used is valproic acid which has
the same properties compared to phenobarbital. Valproic acid dosage is 15-
40 mg / kg / per day. Side effects found were hepatotoxic, tremor and
alopecia.

2.9 PREVENTION APPROACH

 Educate Parents

Seizures are always a frightening event for parents. At the time of seizure
most parents assume that their child has died. This anxiety must be reduced in
ways that include:

o Ensure that febrile seizures generally have a good prognosis.

o Notify how to handle seizures.
o Provide information about the possibility of a seizure again.
o Provision of drugs to prevent recurrence is effective but it must be
remembered that there are side effects.

Things to do if the seizure return:

1. Stay calm and not panic.

2. Loosen tight clothing especially around the neck.

27
 3. If unconscious, position the child on his back with his head tilted.
Clean up vomit or mucus in the mouth or nose. Even though the
tongue might be bitten, don't put something in the mouth.

4. Measure the temperature, observation and note the length and shape
of the seizure.

5. Stay with the patient during seizures.

6. Give rectal diazepam. And do not give if the seizure has stopped.

7. Bring the doctor or hospital if the seizure lasts 5 minutes or more

2.10 PROGNOSIS

Prognosis for normal neurologic function is excellent.

o About one third of children who experience a single simple febrile seizure will have
another.

o The lifetime rate of epilepsy in these children is slightly above that of the general
population.

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 BIBLIOGRAPHY

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3. Chung B, Wat LC, Wong V. Febrile Seizures in Southern Chinese Children: Incidence
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15. Baumer JH. Evidence Based Guideline for Post-Seizure Management in Children
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