CLINICAL FEATURES AND EVALUATION OF FEBRILE SEIZURES UPTODATE MAR 2016

Febrile seizures occur in children with fever, usually in the setting of systemic viral or bacterial infection. Affected patients are
typically between the ages of three months and six years of age and do not have epilepsy, central nervous system infection or
inflammation, or other triggers for seizures.

Febrile seizures occur in 2 to 4 percent of children younger than five years of age, with a peak incidence between 12 and 18 months.
Febrile seizures are an age-dependent phenomenon, likely related to a vulnerability of the developing nervous system to the effects
of fever in combination with an underlying genetic susceptibility. Aside from age, the most commonly identified risk factors include
high fever, viral infection, recent immunization, and a family history of febrile seizures.

The majority of children have their febrile seizures on the first day of illness and, in some cases, it is the first manifestation that the
child is ill.

Simple febrile seizures are the most common and are characterized by seizures that last less than 15 minutes, have no focal features,
and occur once in a 24-hour period. These are mainly generalized tonic-clonic seizures but may also be atonic or tonic in character.
Complex febrile seizures are characterized by episodes that last more than 15 minutes, have focal features or postictal paresis, or
occur more than once in 24 hours.

The differential diagnosis of febrile seizure includes nonepileptic events or movements, central nervous system infection (eg,
meningitis or encephalitis), and rare forms of genetic epilepsy in which seizures are particularly common with fever. While
meningitis and encephalitis are the main concerns in a child presenting with fever and seizures, a thorough history and examination
will almost always detect the child with meningitis.

Febrile seizures are a clinical diagnosis. In children with a typical history and a reassuring and nonfocal exam, diagnostic testing is
unnecessary in most cases.

Lumbar puncture is unnecessary in most well-appearing children who have returned to a normal baseline after a febrile seizure.
Post-ictal drowsiness typically resolved within five to ten minutes, depending upon the duration and type of seizure. Lumbar
puncture should be performed when there are meningeal signs or symptoms or other clinical features that suggest possible
meningitis or intracranial infection. Additional circumstances that warrant consideration of lumbar puncture include:
Infants between 6 and 12 months of age, if the immunization status for Haemophilus influenzaetype b or Streptococcus
pneumoniae is deficient or undetermined
Current treatment with antibiotics since antibiotics can mask the signs and symptoms of meningitis
Prolonged seizures, including febrile status epilepticus
Seizures that occur after the second day of a febrile illness

Laboratory testing, neuroimaging and electroencephalography are required only in specific circumstances.
 TREATMENT AND PROGNOSIS OF FEBRILE SEIZURES UPTODATE MAR 2016

Febrile seizures occur in children with fever, usually in the setting of systemic bacterial or viral infection. Affected patients are
typically between the ages of six months and six years of age and do not have epilepsy, central nervous system infection or
inflammation, or other triggers for seizures.

The initial evaluation of children with seizure in the setting of fever must distinguish febrile seizure from alternative and more
serious etiologies such as central nervous system infection. This can be accomplished with a thorough history and physical
examination in most cases, along with neuroimaging and lumbar puncture in selected circumstances.

The majority of febrile seizures have ended spontaneously by the time the child is first evaluated, and the child is rapidly returning to
a normal baseline. In such cases, active treatment with benzodiazepines is not necessary.

In children with febrile seizures that continue for more than five minutes, we recommend treatment with intravenous (IV)
benzodiazepines (diazepam 0.1 to 0.2 mg/kg or lorazepam 0.05 to 0.1 mg/kg) (Grade 1B). Buccal midazolam (0.2 mg/kg, maximum
10 mg) is an alternative when IV access is unavailable. Patients with continued seizures despite initial benzodiazepine administration
(ie, febrile status epilepticus) should be treated promptly with additional anticonvulsant medications, as are other patients with
status epilepticus.

Most children with simple febrile seizures do not require hospital admission and can be discharged safely to home once they have
returned to a normal baseline and parents have been educated about the risk of recurrent febrile seizures. Children with focal or
prolonged seizures may require a more extended period of observation, particularly if there is delayed recovery to baseline or
postictal focality.

Children with febrile seizures are at risk for recurrent febrile seizures, particularly if they have a young age of onset, a family history
of febrile seizures, brief latency between onset of fever and seizures, and a relatively low fever.

We suggest not treating patients with simple febrile seizures with antiseizure drug therapy (Grade 2B). While antiseizure drugs may
decrease the risk of recurrent febrile seizures, the prevention of febrile seizures is generally not considered worth the potential
adverse effects of treatment. There is no available evidence that the use of chronic antiseizure drugs is associated with a reduced
risk of epilepsy. Parental counseling and prompt ambulance and emergency department management are conducive to favorable
outcome.

The use of antiseizure drug prophylaxis in children with complex febrile seizures is individualized based on underlying risk factors.

Treatment with antipyretics at the first sign of febrile illness does not appear to affect the recurrence rate of febrile seizures.

Epilepsy occurs more frequently in children who have had febrile seizures than in the general population. In a normal child with a
simple febrile seizure, the risk is only slightly above that of the general population. Children with complex febrile seizures, an
abnormal developmental history, or a family history of epilepsy have an increased risk.

While electroencephalogram (EEG) is not useful in determining the risk of recurrent febrile seizures, it can be helpful in the
outpatient setting to identify children at increased risk for future epilepsy, in combination with other risk factors.
Initial management of status epilepticus in children

IV: intravenous IO: intraosseous IM: intramuscular O2: oxygen RSI: rapid sequence endotracheal intubation PE: phenytoin
equivalents EEG: electroencephalogram INH: isoniazid.
* Rapid sequence intubation should be performed if airway, ventilation, or oxygenation cannot be maintained and if the seizure
becomes prolonged.
Refer to "Ancillary studies in children with status epilepticus" (part of this document).
Empiric antibiotic regimens vary depending on patient susceptibility and likely pathogen.
Do not exceed 3 mg/kg per minute (maximum rate: 150 mg per minute). Fosphenytoin may be ineffective for toxininduced
seizures and may intensify seizures caused by cocaine and other local anesthetics, theophylline, or lindane. If fosphenytoin not
available, may use phenytoin 20 mg/kg IV, do not exceed 1 mg/kg per minute (maximum rate: 50 mg per minute) with ECG
monitoring.
Do not exceed 1 mg/kg per minute.