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THE DIAGNOSTIC AND MANAGEMENT OF

FEBRILE SEIZURE IN CHILDREN

dr. I Gusti Ngurah Suwarba,Sp.A(K)


dr. Dewi Sutriani M, Sp.A

Neuropaediatric Division
Paediatry Department
Medical Faculty - Udayana University
Sanglah General Hospital,
Denpasar

DEFINITION OF SEIZURE

Seizure is a clinical manifestation due to the


releasing of excessive electric load from
deteriorated neurone cells in the brain.
The disturbance can be caused by
physiological, anatomical, biochemical
disorder or the combination of these
anomalies.

Seizure : is a medical emergency that have


to be handled quickly and appropriately.
SI-310508
PATOPHISIOLOGY OF SEIZURE
+++++++ Na + +++++++

Fever
Anatomis K+
,Phisiolog
y
biokimia

SEIZURE
Seizure process in the brain
Focal seizure
Focal become generalized
Generalized

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Seizure that accompanied by fever
Febrile seizure
Simple
Complex

Not Febrile Seizure


Meningitis
Encephalitis
Differentiation of febrile seizure and seizure accompanied by fever (Intracranial process)

Febrile seizure Seizure


accompanied by
fever
Genetic Yes No/ small
predisposition
Duration of seizure 1-3 minute, prolong > 10 minute
seizure is rare
Clinical manifestation During fever, mainly CNS infection
during seizure due to URTI (encephalitis,
meningitis)
Underlying None Vascularity change
pathological disorder and oedem
Post ictal neurological Rare Frequent
status (Todds
paralysis)
(NiedermeyerE: Epilepsy Guide: Diagnosis and Treatment of Epileptic Seizure Disorders ,
1985)
Febrile seizure
Definition
The onset of seizure that occur due to the increasing
of body temperature(rectal temperature) above 38C
which is caused by extracranial process. (UKK
consensus, 2006)

Note
Commonly between 6 month old - 5 year old
Not included:
Electrolyte disturbance
Below 1 month old (Neonatal seizure)
History of seizure not due to fever
(ILAE,1993)
Think of Central Nervous System Infection or Epilepsy
if it happens out of that age range.

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Epidemiology

2-4% from population children aged 6 months - 4 years


Peak incidence : 18 months
Male > Female
80-90% is simple febrile seizure
20% cases are complex febrile seizure

8% last for > 15 minutes


16% recurrent within 24 hours
2-4 % become epilepsy
Factor of fever:

Therate of increasing in body temperature


plays a vital role in causing febrile seizure.
(J.C. Millicap 1968)

Feverwhich has vital role in febrile seizure


Respiratory tract infection >>>
Gastrointestinal tract infection
Urogenital tract infection
Post immunization
(be ware, Communication, Information,
Education)
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Febrile seizure classification
Classification
Simple febrile seizure
Complex febrile seizure
Febrile seizure plus (FS+)
(ILAE,1993)

Simple febrile seizure


Last for 15 minutes,
Generalized seizure
Not recurrent within 24 hours
(ILAE,1993;Stafstrom,2002, UKK Neurologi Anak consensus 2006)

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.classification
continue

Complex febrile seizure


Seizure lasts > 15 minutes

Focal seizure or partial become


generalized

Recurrent in 24 hours (multiple)


(Camfield dan Camfield,1995; Shinnar,1999)
(Nelson dan Ellenberg,1978; Berg dan Shinnar. 1996)
(Anneger dkk, 1996)

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Febrile seizure plus (FS+)
Fixed FS until > 6 year old
FS associated with seizure without fever or epilepsy
Frequent seizure, 13 times per year
Phenotype: Febrile seizure
Genotype : mutation in sodium channel and GABA
FS+ disappear at 12 year old
When undergo EEG, the result is same with normal febrile
seizure, nothing specific can be found
One of the spectrum from GEFS+ epilepsy syndrome

Scheffer IE. Brain 1997;124:479-90


Baulac S. Lancet Neurol. 2004;3

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Diagnosis
Diagnosis of FS not always easy
Encephalopathy accompanied with fever,
encephalitis, and meningitis.
Shivering during fever (peribucal cyanosis)
Agitation or delirium during fever
Epilepsy precipitated by fever
Diagnosis
Anamnesis :
Confirm: Seizure or non seizure/Pseudoseizur
Type, duration and frequency of seizure
Find the cause of fever
Find the risk factor
Physical examination:
Evaluate post ictal consciousness is very
important
Neurological examination is in normal range
= tods paresis when long duration seizure
Find the extracranial infection sign

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Supporting examination
Laboratory : Not routine, on
indication only
Complete blood count, electrolyte, blood
sugar
(Level II-2, recommendation D)
(Gerber dan Berliner, 1981; AAP, 1996)

Lumbar puncture(to eliminate


probability of intracranial
processmeningitis)
Age < 12 month old strongly
recommended
Age 12 18 month old recommended
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..suporting
examination

Electroencephalography(EEG): not
routine
Unable to predict the recurrence of
seizure and probability of becoming
epilepsy
(Level II-2, recommendation E)
(Millichap,1991; AAP,1996)

Agreement neuro-paediatric 2008


EEG still can be done on non specific febrile
seizure : focal febrile seizure, recurrent
complex febrile seizure, febrile seizure plus
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Management

1. During seizure

2. Post seizure medication

3. Long term prophylaxis

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ALGORYTHM OF HANDLING ACUTE SEIZURE AND STATUS CONVULSIVE
Diazepam 5-
Prehospital 10mg/rect max 2x 0-10min
5 Minute gap

Hospital/ED Diazepam 0,25-0,5mg/kg/iv/io Monitoring


Airway 10-20min
(rate 2mg/min, max dose 20mg) Vital sign
Breathing
Circulation or EKG
Midazolam 0,2mg/kg/iv bolus Blood sugar
or Serum Electrolyte
NOTE : IF DIAZ RECTAL 1X PRE
HOSPITAL CAN RECTAL 1X Lorazepam 0,05-0,1mg/kg/iv (Na, K, Ca, Mg, Cl)
(rate <2mg/min) Blood Gas Analysis
Anomaly correction
Phenytoin Pulse oxymetry
20mg/kg/iv
ICU/ED 20-30min drug blood level
Note : Aditional (20min /50ml NS)
5-10mg/kg/iv Max 1000mg

Phenobarbitone 30-60min
20mg/kg/iv
Note : (rate >5-10min; max 1g)
Jika preparat (+)
ICU Refracter

Midazolam 0,2mg/kg/iv bolus Pentotal - Tiopental Propofol


19 3-5mg/kg/infusion
Continue infuse 2 4 mg/kg/iv
Post Seizure Medication
Fever therapy, find and solve the etiology of fever
Antipyretic: Strongly recommended although its not
proven can reduce the risk of seizure
(Level I, recommendation E)
= Acetaminophen 10 15 mg/kg, 3- 4 times/day
= Ibuprofen 5-10 mg/Kg, 3-4 times/day
Prescribe antibiotic when theres indication
Prevent the recurrence of seizure : Very Important!

(Camfield dkk, 1980; Schnaiderman dkk, 1993)


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Long Term Prophylaxis

I. Intermmitent Prophylaxis

II. Continuous prophylaxis

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I. Intermmitent Prophylaxis

Diazepam oral 0,3 0,5 mg/kg every 8 hours


when fever, decrease the risk of recurrent
seizure
(Level I, recommendation E)
(Knudsen, 1991; Rosman n friends,
1993)

Phenobarbital, carbamazepine, phenytoin


cannot prevent seizure when fever
(Knudsen, 2002)
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II. Continuous Prophylaxis
Recommended:
Obvious neurological abnormality before or
after seizure (paresis Tods, CP, hidrocephalus,
etc)
Long duration seizure> 15 minute
Focal seizure

Consider:
Recurrent multiple seizure within 24 hour
Infant < 12 month old
Recurrent complex febrile seizure > 4
times/year

Duration of treatment : 1 year free


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. Prophylaxis

Anticonvulsant being used:


Phenobarbital 3-5 mg/kg/day
divided into 2 dose
Valproic acid 15-40
mg/kg/day,
dividing into 2-3 dose

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Prognosis

There are 2 risks :

1. Recurrent febrile seizure


(50-75% normally at first year)

2. Epilepsy (2-5 %)

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Risk factor of recurrence and Epilepsy
Recurrence of febrile seizure

Risk factor for febrile seizure recurrence are

History of febrile seizure in family

Aged less than 12 months

Low body temperature during seizure

Quick onset of seizure after fever


Berg AT, dkk. Predictors of recurrent febrile seizure: a prospective study of the circumstances surrounding
the initial febrile seizure, NEJM 1992; 327:1122-7
AnnegersJF, dkk. Reccurrenceof febrile convulsion in a population based cohort.
Epilepsy Res 1990; 66:1009-14
Knudsen FU. Recurrence risk after first febrile seizure and effect short term diazepam prophylaxis.
Arch DisChild 1996; 17:33-8
Recurrence...
Recurrence frequency

2 times : 25-50% ( 30%)

Onset of recurrence :

first 6 months 50%

12 months 75%

2 years 90%
Risk factor for Epilepsy

(Nelson KB-Ellenberk JH,1979)

7 years 25 years
Simple febrile seizure 0.9% 2.4%
Febrile seizure
Risk factor (-) 2% 6-8%
Risk factor (1) 10% 17-22%
Risk factor (2 atau >) 13% 49%

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