Febrile seizure

Background

• 50% of patients never have temperature >39
• Antipyretics do not offer significant improvements in recurrence rates of febrile seizures
• Febrile seizures do not increase the risk of serious bacterial illness

Prognosis

• 2-3% chance of developing epilepsy (1% for general population)
• 50% of patients <12 mo will have another simple febrile seizure
• 30% of patients >12 mo will have another simple febrile seizure

Clinical Features

• Seizure + fever

Differential Diagnosis

Pediatric seizure

• Seizure
  • Febrile seizure
  • First-Time afebrile seizure
  • Neonatal seizure
  • Epileptic seizures
  • Seizure with VP shunt
  • Impact seizure (trauma)
  • Status epilepticus
• Meningitis
• Intracranial mass
• Epidural/subdural infection or hematoma
• Toxic ingestion
• Hydrocephalus
• Pyridoxine responsive seizure

Pediatric fever

• Upper respiratory infection (URI)
• UTI
• Sepsis
• Meningitis
• Febrile seizure
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV

Evaluation

Algorithm for the differentiation between simple and complex febrile seizures. Guidelines for evaluation of each.

Simple versus Complex

• Simple
  • Generalized tonic-clonic seizure
  • <15 min in duration
  • Age 6mo - 5yr
  • Occurs only once in 24hr period
  • No focal features
• Complex
  • Any exception to above

Work-Up

• Glucose in all patients

Simple febrile seizure

• Neither labs nor neuroimaging are absolutely necessary
• Normal pediatric fever workup

Complex febrile seizure

• Consider CBC, blood culture, UA, urine culture, CSF studies
• Consider CT if:
  • Persistently abnormal neuro exam (especially with focality)
  • Signs/symptoms of increased ICP
  • Patient has VP shunt
• Consider ECG if:
  • Family history of long QT, Brugada, sudden death
• Routine EEG not indicated
  • Consider only if developmental delay or for focal symptoms
• Causes amenable to specific treatment
  • Hypoglycemia
  • Hyponatremia (water intoxication, dilution of formula)
  • Hypocalcemia
  • Hypomagnesemia
  • INH ingestion

Management

Ongoing Seizure

See Seizure (peds)

Seizure Stopped

• Treat underlying infection if indicated
  • See pediatric fever of uncertain source

Disposition

Discharge

• Simple febrile seizure if patient at baseline
  • Follow-up in 1-2d
• Complex febrile seizure if patient well-appearing, work-up normal
  • Follow-up in 24hr

Admit

• Ill-appearing
• Lethargy beyond postictal period

See Also

• Seizure
• Fever (Peds)

References

Authors

Ross Donaldson, Jordan Swartz, Daniel Ostermayer, Neil Young, Shadi Rafael, Kevin Lu, Tom Fadial, Aaron Snyder, Kelly Young, Michael Holtz, Brian Gilberti