febrile seizures fever in pediatric .pptx

Fever seizures

1. Febrile Seizures Presenter:Dr.Vinay S Moderator:Dr.Rahul Kawade (Assistant professor )

2. Definition Classification Epidemiologuy Risk Factors Pathophysiology Causes Differential Diagnosis Management Specific Learning objectives

3. Febrile Seizures are seizures that occurs between the Age 6 months to 5 years Temperature of 38 c(100.4F) or higher , Without underlying central nervous system infection or any metabolic imbalance, Occurs in absence of prior afebrile seizure. Definition

4. Febrile seizures are further divided into categories based on clinical features: 1.Simple Febrile seizures: The most common type,characterised by seizures associated with fever that are generalized,usually tonic- clonic,less than 15 min,and do not recur in a 24 hr period. 2.Complex febrile seizures: Seizures associated with fever that are characterised by episodes that have a focal onset( eg:Shaking limited to one hand or one side of body ),last longer than 15 min,or occur more than once in 24 hrs. Febrile Status epilecticus: Febrile seizures lasting longer than 30 min or intermittent seizure without neurogenic recovery. Classification

5. The most common Neurologic disorder of infants and youngs children. They are age dependent phenomenon Occurs between the age of 6 months to 5 years. Peak incidence between 12-18 months More predominance with estimated male to female ratio 1.6:1 Epidemiology

6. Febrile seizures recur in 30% of those experience 1 st episode 50% after 2 or more episodes 50% of infants younger than 1 year at febrile seizure onset 2-7% of children experience febrile seizures proceed to develop Epilepsy.

7. Age High grade Fever Infections(Viral infections like HHV-6 and influenza virus) Immunization(DPT and MMR) Genetic susceptibility Family History of febrile convulsion(10-20%) Autosomal Dominant Trait Risk Factors

8. Major Age<1 Year Duration of fever <24hr Fever 38-39C Minor Family History of febrile seizures Family history of epilepsy Complex Febrile seizures Male gender Low serum sodium at time of presentation. Risk Factors for recurrent Febrile seizures

9. Risk Factors Risk Simple Febrile seizures 1% Complex Febrile seizures 6% Recurrent Febrile seizures 4% Fever<1Hr Before Febrile seizures 11% Family History of epilepsy 18% Complex Febrile seizures(Focal) 29% Neurodevelopmental abnormalities 33% Risk Factors for occurrence of subsequent epilepsy after a Febrile seizures

10. Few Epilepsy syndrome typically start with febrile seizures,these are GEFS+(Generalized epilepsy with Febrile seizure Plus) Onset Characterised by multiple Febrile seizures and by several subsequent type of Afebrile seizures,including generalised Tonic- clonic,absence,Myoclonic with variable degree of severity. Dravet Syndrome Onset Characterised By febrile and afebrile unilateral clonic seizures recurring every 1 or 2 month.These early seizures are typically induced by fever,but they differ from the usual febrile convulsions in that they are more prolonged ,are more frequent ,are focal and come in clusters. Other Types

11. Not all children with Fever develop febrile seizures and exact mechanism is not Known.Various postulates put forward are: Rise in Temperature: Magnitude of fever does not seem to affect the occurrence of Febrile seizures.Some children have Febrile seizures with low temperature and these children are at an increased risk of having recurrences due to Low seizure threshold. Hyperthermia can decrease gamma aminobutyric acid A(GABA-A) receptor –mediated inhibition and hence shift the balance towards excitation. This appears to be mediated by reducing GABA release from presynaptic terminals,but hyperthermia may also decrease postsynaptic GABA receptor function. Pathophysiology

12. Role of Inflammatory Mediators : Tumour Necrosis factor(TNF-Alfa),IL-1alfa,IL-1Beta and IL-6 are the proinflammatory cytokines.IL-1beta acts by increasing glutamate from glia and neurons by decreasing GABA-A receptor mediated currents. As a result there is increased excitation and decreased inhibition.

13. Genetic suseptibility : Genetics of febrile seizures is complex and is continually expanding .It may explain the high risk of Febrile seizures in certain families .Positive family history is seen in 15-40% of children with Febrile seizures.Chromosomes linked are 2q,5q,5,8q,19p,19q.

14. Hyperthermia Related Hyperventilation and Alkalosis: In children with Fever there is increase in Respiratory rate which could lead to Respiratory alkalosis resulting in Neuronal excitability. Double Hit Hypothesis: Cortical malformations such as focal critical dysplasias and microdysgenesis can lower the seizure threshold in a child with febrile seizures and can lead to prolonged status epilepticus .

15. Trace Elements: A study had found low serum zinc levels in children with Febrile seizurs as compared to control group.

16. Upper Respiratory Tract Infection Roseola Infantum (HHV-6) Gastroenteritis( Shigella or Campylobacter) Influenza Virus Urinary Tract infection Causes

17. Central Nervous system Infection( i.e Meningitis or Encephalitis) Genetic Epilepsies with Febrile seizures (GEFS+ or Dravet Syndrome) Metabolic Imbalance Differential Diagnosis

18. History Physical Examination Investigations Diagnosis

19. The Type of seizures ( Generalised or Focal) and its duration should be described to help to differentiate Simple and complex febrile seizures. History on cause of Fever(Ex-Viral illness,Gastroenteritis )should be elucidated. History of Recent antibiotic use should be noted to rule out partially treated Meningitis. History of seizures ,neurologic problems,developmental delay, or other cause like trauma should be considered. Family history of febrile seizures or Epilepsy. History of Recent vaccination. History

20. The Underlying cause for fever should be sought . A careful physical examination often reveals otitis media,Pharyngitis or viral exanthem . A Full neurologic examination should be done Serial Evaluation of patients Neurologic status are essential. Check for Meningeal signs as well as signs of trauma or Toxic Ingestion. Physical Examination

21. Blood studies ( Sr.Electrolytes,Sr.Ca,Sr.Mg , and Complete blood count) but not routinely done. Lumbar Puncture American academy of paediatrics recommends Lumbar puncture in Following conditions Signs and Symptoms of Meningitis or possible Intracranial infection In Infants between 6 and 12 months if the immunizatio status for Haemophilia influenza type B or Streptococcus Pneumonia is defecient . On Antibiotic treatment as it can mask signs and symptoms of Meningitis . Investigations

22. EEG Indicated in complex febrile seizures with abnormal neurologic examination or in Febrile status epilepticus . Neuroimaging Indicated in Children with complex Febrile seizures Children with Neurological abnormalities,Developmental delay,signs and symptoms of Raised Intracranial pressure.

23. In Hospital Setting Maintenance of Airway,Breathing,Circulation . IV access First dose of IV Benzodiazipines Dose to be repeated if Further episode Febrile status Epilepticus shouls be treated on protocol for status epilepticus . Paracetamol for symptomatic Relief Management

24. In Home Setting Parents should be instructed To Stay calm and avoid Panic Advised to observe the duration of Fever Childs clothing should be loosen Placement of child on Left lateral position Cam administer Rectal Diazepam or Intranasal Midazolam Shift to Hospital if duration>5 min

25. Measure to Control the fever such sponging ,tepid bath,antipyretics and antibiotics for proven bacterial illness. Intermittent Prophylaxis Clobazam ( Frisium ) Indication Frequent Seizures within a short period(3 or more in 6 months /4 or more in 1 year) Prolonged Seizures Requiring Antiepileptic Drug. Continous Prophylaxis Sodium Valproate has reduced the risk of recurrence in child Prophylactic Treatment

26. THANK YOU Febrile Seizures Frightening But Harmless

27. Nelson Textbook of Paediatrics Nelson Essentials of Paediatrics Piyush Gupta for Paediatrics References