Febrile seizure

Background

• 2-3% chance of developing epilepsy (1% for general population)
• 50% of pts never have temp >39
• 50% of pts <12 mo will have another simple febrile seizure
• 30% of pts >12 mo will have another simple febrile seizure

Clinical Presentation

• Seizure + fever

Differential Diagnosis

Pediatric seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
  • Non-compliance with or "outgrowing" AEDs
• Non-epileptic seizure
  • Febrile seizure
  • Brain inflammation
    • Meningitis
    • Encephalitis
    • CNS abscess
    • Intracranial hemorrhage
    • Neurocysticercosis
  • Increased ICP
    • Seizure with VP shunt
    • Hydrocephalus
    • Intracranial mass
  • Toxicologic
    • Alcohol withdrawal
    • Benzodiazepine withdrawal
    • Toxic ingestion
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia
  • Pyridoxine responsive seizure
  • Eclampsia
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
• Other mimics
  • Psychogenic nonepileptic seizure (pseudoseizure)
  • Syncope (peds)
  • Breath-holding spell
  • Hyperventilation syndrome
  • Migraine headache
  • Movement disorders
  • Narcolepsy/cataplexy
  • Post-hypoxic myoclonus (Status myoclonicus)
  • Infantile Spasms/West Syndrome

Pediatric fever

• Upper respiratory infection (URI)
• UTI
• Sepsis
• Meningitis
• Febrile seizure
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV
• Specific virus
  • COVID-19 (peds)

Diagnosis

Simple versus Complex

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

Work-Up

• Glucose in all pts
• Simple febrile seizure
  • Neither labs nor neuroimaging are absolutely necessary
  • Normal pediatric fever workup
• Complex febrile seizure
  • Consider CBC, blood cx, UA, Ucx, CSF studies
• Consider CT if:
  • Persistently abnormal neuro exam (esp w/ focality)
  • Signs/symptoms of increased ICP
  • pt has VP shunt
• Routine EEG not indicated
  • Consider only if developmental delay or for focal symptoms

Treatment

Ongoing Seizure

See Seizure (peds)

Seizure Stopped

• Treat underlying infection if indicated

Disposition

• Discharge
  • Simple febrile seizure if pt at baseline
    • Follow-up in 1-2d
  • Complex febrile seizure if pt well-appearing, work-up normal
    • Follow-up in 24hr
• Admit:
  • Ill-appearing
  • Lethargy beyond postictal period

See Also

• Seizure
• Fever (Peds)