Professional Documents
Culture Documents
and Prognosis
REESE C. GRAVES, MD; KAREN OEHLER, MD, PhD; and LESLIE E. TINGLE, MD
Baylor Family Medicine Residency Program, Garland, Texas
Febrile seizures are common in the first five years of life, and many factors that increase seizure risk have been identi-
fied. Initial evaluation should determine whether features of a complex seizure are present and identify the source of
fever. Routine blood tests, neuroimaging, and electroencephalography are not recommended, and lumbar puncture
is no longer recommended in patients with uncomplicated febrile seizures. In the unusual case of febrile status epi-
lepticus, intravenous lorazepam and buccal midazolam are first-line agents. After an initial febrile seizure, physicians
should reassure parents about the low risk of long-term effects, including neurologic sequelae, epilepsy, and death.
However, there is a 15 to 70 percent risk of recurrence in the first two years after an initial febrile seizure. This risk
is increased in patients younger than 18 months and those with a lower fever, short duration of fever before seizure
onset, or a family history of febrile seizures. Continuous or intermittent antiepileptic or antipyretic medication is not
recommended for the prevention of recurrent febrile seizures. (Am Fam Physician. 2012;85(2):149-153. Copyright ©
2012 American Academy of Family Physicians.)
F
Patient information: ebrile seizures are the most common toxoids and whole-cell pertussis (DTP); and
▲
A handout on febrile sei- seizures of childhood, occurring in measles, mumps, and rubella (MMR).13-15 A
zures is available at http://
familydoctor.org/066.xml.
2 to 5 percent of children six months Cochrane review and a review of 530,000 chil-
to five years of age.1 As defined by dren receiving the MMR vaccine showed that
the American Academy of Pediatrics (AAP), the risk of febrile seizures increased only dur-
febrile seizures occur in the absence of intra- ing the first two weeks after vaccination, was
cranial infection, metabolic disturbance, or small (an additional one or two febrile sei-
history of afebrile seizures, and are classified zures per 1,000 vaccinations), and was likely
as simple or complex1,2 (Table 11,3). Simple related to fever from the vaccine.6,9
febrile seizures represent 65 to 90 percent A genetic predisposition for febrile sei-
of febrile seizures2 and require all of the zures has been postulated, although no sus-
following features: a duration of less than ceptibility gene has been identified. Genetic
15 minutes, generalized in nature, a single
occurrence in a 24-hour period, and no pre-
vious neurologic problems.1 Table 1. Classification of Febrile
Seizures
Risk Factors
Risk factors for febrile seizures include devel- Simple (all of the following)
opmental delay, discharge from a neonatal Duration of less than 15 minutes
unit after 28 days, day care attendance, viral Generalized
infections, a family history of febrile sei- No previous neurologic problems
zures, certain vaccinations, and possibly iron Occur once in 24 hours
and zinc deficiencies.4-13 Febrile seizures may Complex (any of the following)
occur before or soon after the onset of fever, Duration of more than 15 minutes
with the likelihood of seizure increasing with Focal
the child’s temperature and not with the rate Recurs within 24 hours
of temperature rise.4
Adapted with permission from Millar JS. Evaluation
Vaccinations associated with increased risk and treatment of the child with febrile seizure. Am
include 2010 Southern Hemisphere seasonal Fam Physician. 2006;73(10):1761, with additional
influenza trivalent inactivated vaccine (Fluvax information from reference 1.
Junior and Fluvax); diphtheria and tetanus
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Family requests.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References Comments
Routine laboratory tests, electroencephalography, and C 17, 19-21, Consensus guideline and
neuroimaging are not recommended in patients with simple 24, 25 retrospective cohort studies
febrile seizures.
Parents should be reassured after a simple febrile seizure that B 1, 28, 29 Consensus guideline and prospective
there is no negative impact on intellect or behavior, and no cohort studies
increased risk of death.
Use of long-term continuous or intermittent antiepileptic B 1, 32, 33 Consensus guideline and randomized
medication after a first simple febrile seizure is not controlled trials
recommended because of potential adverse effects.
Use of antipyretic agents at the onset of fever is not effective at A 1, 31 Consensus guideline and randomized
reducing simple febrile seizure recurrence. controlled trial
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
abnormalities have been reported in per- febrile seizures present for medical care after
sons with febrile epilepsy syndromes, such resolution of the seizure and return to full
as severe myoclonic epilepsy in infancy and alertness within an hour of the seizure.16
generalized epilepsy with febrile seizures plus The initial evaluation should focus on deter-
(GEFS+).14 Most causes of febrile seizures are mining the source of the fever.3,17 Parents
multifactorial, with two or more genetic and should be questioned about a family history
contributing environmental factors. of febrile seizures or epilepsy, immuniza-
Case-control studies suggest that iron and tions, recent antibiotic use, duration of the
zinc deficiencies may also be risk factors for seizure, a prolonged postictal phase, and any
febrile seizures. One study of febrile seizures focal symptoms. During the examination,
in Indian children three months to five years attention should be given to the presence
of age showed lower serum zinc levels in of meningeal signs and to the child’s level
patients with seizures compared with age- of consciousness. In a 20-year retrospective
matched febrile patients without seizures.7 review of 526 cases of bacterial meningitis,
In another study, children with febrile 93 percent of patients presented with altered
seizures had nearly two times the incidence consciousness.18
of iron deficiency compared with febrile Routine laboratory studies in patients
children who did not have seizures.8 with simple febrile seizures are discouraged
Viral infections are a common cause of because electrolyte abnormalities and seri-
fever that triggers febrile seizures. A particu- ous bacterial illnesses are rare.16,19,20 In a ret-
lar risk for febrile seizure is associated with rospective review of 379 children with simple
primary human herpesvirus 6 infection, febrile seizures, only eight were found to have
which is typically acquired during the first bacteremia.21 Streptococcus pneumoniae was
two years of life. In a case-control study, poly- isolated in seven of the eight children, in an
merase chain reaction testing and antibody era before routine pneumococcal vaccination.
titers suggested that 10 of 55 children (18 per- The AAP recently updated its 1996 guide-
cent) who experienced a first febrile seizure line regarding the use of lumbar puncture
had acute herpesvirus 6 infection, whereas in children with simple febrile seizures.17
none of the 85 children with fever but no sei- A lumbar puncture is now an option when
zure had evidence of such infection.12 Other evaluating children six to 12 months of age
common viral infections, such as influenza, whose immunization status for Haemophi-
adenovirus, and parainfluenza, are associated lus influenzae type b and S. pneumoniae
with simple and complex febrile seizures.11 is incomplete or unknown, and in those
pretreated with antibiotics.17 This differs from
Evaluation the previous recommendation that lumbar
Children should be promptly evaluated puncture be performed in all children younger
after an initial seizure. Most patients with than 12 months and strongly considered in
150 American Family Physician www.aafp.org/afp Volume 85, Number 2 ◆ January 15, 2012
Table 2. Risk of Recurrence After an Initial Febrile Seizure
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Febrile Seizures
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Febrile Seizures
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