Objectives. Vignette. Febrile Seizures 8/29/2011

Transcription

1 Madeleine Grace M. Sosa, MD., FPPS, FPNA,FCNSP, MSCE Faculty & Consultant De La Salle Health Science Institute, College of Medicine, Dasmarinas, Cavite Objectives Review the diagnosis and management of Febrile Seizures To give an update in the preventive and therapeutic management of children with Febrile Seizures Vignette 2 month old male, came in at the ER for convulsions. HPI: Child was having on and off fever, about 38 deg cent since 8 hours PTC, described as generalized, with tonic movements of both UE and LE for 5 mins, with drooling of saliva, thus rushed to the ER. He was having URTI and fair appetite since onset of fever. PE: T: 39C RR:34/min HR: 97/min BP: 80/60 Heart, Lungs, Abdomen, extremities : Unremarkable Neuro: irritable, with equivocal neck rigidity Febrile Seizures An event in infancy or childhood, usually occurring between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous non-febrile seizure are excluded. Febrile seizures are to be distinguished from epilepsy, which is characterized by recurrent non-febrile seizures. Rev Assoc Med Bras 2010; 56(4):

2 Febrile Seizures Febrile seizures have defined by The International League Against Epilepsy (ILAE) as a seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure, and not meeting criteria for other acute symptomatic seizures Vignette 2 month old male, came in at the ER for convulsions. HPI: Child was having on and off fever, about 38 deg cent since 8 hours PTC, described as generalized, with tonic movements of both UE and LE for 5 mins, with drooling of saliva, thus rushed to the ER. He was having URTI for 3 days and fair appetite since onset of fever. PE: T: 39C RR:34/min HR: 97/min BP: 80/60 Heart, Lungs, Abdomen, extremities : Unremarkable Neuro: irritable, with equivocal neck rigidity Febrile Seizures Symptoms Duration Recurrence in first 24 hours Focal signs in post-ictal period Simple Generalized <15 minutes No recurrence Absent Complex Focal >15 minutes May recur Present While the majority of febrile seizures are simple (70-75%) 9-35% of febrile seizures are complex 2

3 Epidemiology Incidence, worldwide : 1 14% (Hauser,1994). Febrile seizures recur in approximately 30% of patients, most commonly between the ages of six months and three years. Epidemiology Children who have had febrile seizures also have increased odds of developing epilepsy (2% to 7%) than the general population Why should rise in temperatures cause seizure? Hyperthermia (>38.3 C) can decrease gamma aminobutyric acid A (GABA(A) receptormediated inhibition to a greater extent than it decreases excitation, which may shift the balance towards excitation and contribute to seizure generation This appears to be mediated by reducing GABA release from presynaptic terminals, but hyperthermia may also decrease post-synaptic GABA(A) receptor function While this phenomenon has only been studied in hyperthermic models, it also likely occurs when temperature is increased from physiologic fever Risk Factors early age at first seizure family history of febrile seizures, temperature (inversely proportional to grade), duration of febrile illness (the shorter the febrile period) presence of prior neurological abnormalities and a history complex febrile seizures 3

4 Risk Factors The risk of initial febrile seizures has also been studied after receipt of pediatricvaccinations such as diphtheria-tetanus-whole cell pertussis(dtp) and Measles, Mumps and Rubella (MMR) Studies by Barlow and associates (2001) and Walker and colleagues (1988) found a 4-fold increase in theriskof febrile seizures within 1-3 days of receipt of DTP vaccination. Risk Factors With regard to MMR vaccination, the risk of febrile seizures increases by 1.5 and 3.0 fold, with the peak occurring 1-2 weeks after vaccination an additional febrile seizures have been estimated to occur per 100,000 doses of MMR administered Int. J. Med. Sci. 2007, 4 Int. J. Med. Sci. 2007, 4 Risk factors of the first febrile seizures in Iranian children. MahyarA, AyaziP, FallahiM, JavadiA.IntJ Pediatrics 2010 Source: Int J pediatrics2010;2010: Epub 2010 Jun 24 Department of Pediatrics, Quds Children Hospital, Qazvin University of Medical Sciences, Quds Square, Qazvin , Iran. Abstract Objective. Febrile seizures are the most common type of convulsion in children. The identification of influencing factors on incidence of the first febrile seizures is of prime priority. The aim of this study was to identify the risk factors of the first febrile seizures in Iranian children. Methods. In this case-control study 80 children aged 9 month to 5 years with their first febrile seizures were compared with 80 children with fever without seizure based on different risk factors in Results. There was significant difference between two groups regarding the gender, family history of febrile seizures, breast-feeding duration, and the body temperature (P <.05). Conclusion. Our study showed that factors including the gender, family history of febrile seizures, breast-feeding duration, and the body temperature are among the risk factors in occurrence of the first febrile seizure. Preventive measures to remove such risk factors could lead to lower the incidence of febrile seizures. Predictors of recurrent febrile seizures include: a history of focal, prolonged, and multiple seizures Influenza A viral infection family history of febrile seizures onset of febrile seizure <12 months of age temperature <40 C (<104 F) at time of seizure and a history of complex, initial febrile seizures A low proportion (2-4%) of children who experience at least one febrile seizure event go on to develop recurrent afebrile seizures (epilepsy) Int. J. Med. Sci. 2007, 4 4

5 Role of Genetics in the Pathogenesis Genetic aspects have been clearly established in the etiologyand pathogenesis of febrile seizures. A history of febrile seizures in first-degree relatives is common, and concordance rates of febrile seizures are much higher in monozygotic than in dizygotic twin pairs Reports in the literature have described a connection between febrile seizures and various chromosomes, including 2q, 5q, 5, 8q, and 19, which appear to be associated with changes in neuronal sodium channel function. Febrile Seizure Evaluation CNSP Recommedation Are these tests necessary? Lumbar Puncture Practice guidelines have recommended that lumbar punctures be strongly considered in children experiencing their first simple febrile seizure, particularly if < 18 months of age 5

6 Febrile Seizure Evaluation CNSP Recommendation EEG CNSP Guidelines used for complex type of FS Febrile Seizure Evaluation CNSP Recommendation Neuroimaging- does not have any role for FS Antipyretic for Febrile Seizures Is it necessary to give RTC Antipyretics to children with febrile seizures? Antipyretic Agents for Preventing Recurrences of Febrile Seizures Randomized Controlled Trial ; Teemu Strengell, MD et alo Objective: To evaluate the efficacy of different antipyretic agents and their highest recommended doses for preventing febrile seizures. Participants: A total of 231 children who experienced their first febrile seizure between January 1, 1997, and December 31, The children were observed for 2 years. Interventions: All febrile episodes during follow-up were treated first with either rectal diclofenacor placebo. After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo 6

7 Antipyretic Agents for Preventing Recurrences of Febrile Seizures Randomized Controlled Trial ; Teemu Strengell, MD et al Results: The children experienced 851 febrile episodes, and 89 of these included a febrile seizure. Febrile seizure recurrences occurred in 54 of the 231 children (23.4%). There were no significant differences between the groups in the main measure of effect, and the effect estimates were similar, as the rate was 23.4% (46 of 197) in those receiving antipyretic agents and 23.5% (8 of 34) in those receiving placebo (difference, 0.2; 95% confidence interval, 12.8 to 17.6; P=.99). Fever was significantly higher during the episodes with seizure than in those without seizure (39.7 C vs38.9 C; difference, 0.7 C;95%confidence interval, 0.9 C to 0.6 C; P.001), and this phenomenon was independent of the medication given. Antipyretic Agents for Preventing Recurrences of Febrile Seizures Randomized Controlled Trial ; Teemu Strengell, MD et al Conclusions: Antipyretic agents are ineffective for the prevention of recurrences of febrile seizures and for the lowering of body temperature in patients with a febrile episode that leads to a recurrent febrile seizure Antipyretic agents act mainly by the alteration of prostaglandin synthesis. It has been found in animal studies that some prostaglandins inhibit seizures (eg, prostaglandins D2, E1, and E2) and that some provoke seizures (eg, prostaglandin F2). Elevated levels of prostaglandins E2 and F2 in the cerebrospinal fluid have been found to be associated withfebrile seizures. Because antipyretic agents have different effects on prostaglandin synthesis, it may be that some would, in fact, provoke seizures Is it necessary to give anticonvulsants to prevent recurrence of FS after the first febrile seizures? 7

8 According to Nelson and Ellenberg, 50% of children experience a second febrile seizure within six months of the first, 75% within a year and 90% within two years of the first episode. INTERMITTENT DIAZEPAM AND CONTINUOUS PHENOBARBITAL TO TREAT RECURRENCE OF FEBRILE SEIZURES. A systematic review with meta-analysis Arq Neuropsiquiatr 2003;61(4): ABSTRACT - Convulsions triggered by fever are the most common type of seizures in childhood, and 20% to 30% of them have recurrence. The prophylactic treatment is still controversial, so we performed a systematic review to find out the effectiveness of continuous phenobarbitaland intermittent diazepam compared to placebo for febrile seizure recurrence. Method: Only randomized, double-blind, placebo-controlled trials were analyzed. The recurrence of febrile seizure was assessed for each drug. Results: Ten eligible clinical trials were included. Febrile seizure recurrence was smaller in children treated with diazepam or phenobarbitalthan in placebo group. Prophylaxis with either phenobarbitalor diazepam reduces recurrences of febrile seizures. The studies were clinical, methodological, and statistically heterogeneous. Conclusion: The effectiveness of phenobarbitaland diazepam could not be demonstrated because clinical trials were heterogeneous, and the recommendation for treatment recurrence should rely upon the experience of the assistant physician yet. INTERMITTENT DIAZEPAM AND CONTINUOUS PHENOBARBITAL TO TREAT RECURRENCE OF FEBRILE SEIZURES. A systematic review with meta-analysis Arq Neuropsiquiatr 2003;61(4): Febrile Seizure Information & Education What is Febrile Seizure? Febrile seizures are convulsions brought on by a fever in infants or small children. Most febrile seizures occur within the first 24 hours of an illness/fever. Febrile seizures may last from a few seconds to more than 15 minutes. The link between fever and febrile seizures (FS) in children. Febrile Seizures occur in 3% -5 % of otherwise healthy children 6-60 months of age. It is debated by experts whether it is the quickness of the rise in temperature or the height of the temperature which triggers the seizure. The seizure is often the first sign of a fever. During a febrile seizure, a child may lose consciousness or responsiveness, shake and move limbs on both sides of the body. The child becomes rigid or has twitches in only a portion of the body, such as an arm or a leg, or on the right or What may happen to the the left side only. child during the febrile The child may vomit or pass urine. seizure? 8

9 Febrile Seizure Information & Education Do stay calm. Focus your attention on bringing the fever down. Insert rectal acetaminophen (Tylenol) (if available). Apply cool washcloths to the forehead and neck. Sponge the rest of the body with lukewarm (not cold) water. Loosen any restrictive clothing. What measure(s) should be Don t try to hold or restrain the child or stop the seizure movements. Don't try to force anything into taken or avoided his mouth to prevent him from biting his tongue as this increases the risk of injury. Move the child during the only if in a dangerous situation. Remove any objects that may injure him. febrile seizure event 1. Children should consult a healthcare provider as soon as possible after the first febrile seizure. 2. Call 911 if the seizure lasts more than a few minutes. When to consult a 3. Contact a healthcare provider or go to the ER if any other symptoms occur before or after the seizure: healthcare nausea, vomiting, rash, tremors, abnormal movements, problems with coordination, drowsiness, agitation, provider, when to call confusion, sedation, etc. 911 and when take the child directly to an ER What does not happen to the child s brain during a febrile seizure? The likelihood of reoccurrence There is no evidence that simple febrile seizures (<10 minutes) cause death, brain damage, epilepsy, mental retardation, a decrease in IQ, or learning difficulties. A third of children will have another febrile seizure with a subsequent fever. Of those who do, about ½ will have a 3rd seizure. If there is a family history, if the first seizure happened before 12 months of age, or if the seizure happened with a fever below 102, a child is more likely to have >1 febrile seizures. What may occur during the healthcare provider s evaluation and/or testing of the Blood and urine tests may be examined to detect infections. Typically, a full seizure workup including an EEG, head CT, and lumbar puncture (spinal tap ) is not warranted. child Injuries caused by falling or bumping into objects. Biting oneself What are the Pneumonia secondary to fluid aspiration. possible sequelae Injury from prolonged or complicated seizures. of febrile seizures? Febrile Seizures Information & Education Medication side effects related to the treatment and prevention of seizures (if prescribed). Complications if a serious infection, such as meningitis caused the fever. What are the Seizures unrelated to fever (afebrileseizures) possible sequelae Parental perception of increased child vulnerability to medical or developmental problems. of febrile seizures? What treatments may be prescribed The list of epilepsy medications used depends on clinical plan devised Summary Childhood febrile seizures, although primarily benign, can be frightening and anxiety-provoking events for parents and caregivers. It is important that health care providers understand potential parental misconceptions, anxieties and fears about fever and febrile seizures so that they may allay those fears effectively. 9