eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Febrile Seizures

Author: Nooruddin R Tejani, MD, Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center
Contributor Information and Disclosures

Updated: Feb 5, 2010

Introduction

Background

Febrile seizures are the most common type of seizures observed in the pediatric age group.

Although described by the ancient Greeks, it was not until this century that febrile seizures were recognized as a distinct syndrome separate from epilepsy. In 1980, a consensus conference held by the National Institutes of Health described a febrile seizure as, "An event in infancy or childhood usually occurring between three months and five years of age, associated with fever, but without evidence of intracranial infection or defined cause."1 It does not exclude children with prior neurological impairment and neither provides specific temperature criteria nor defines a "seizure." Another definition from the International League Against Epilepsy (ILAE) is "a seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures".2

For other information, see Medscape's Pediatrics Specialty page.

Pathophysiology

Febrile seizures occur in young children at a time in their development when the seizure threshold is low. This is a time when young children are susceptible to frequent childhood infections such as upper respiratory infection, otitis media, viral syndrome, and they respond with comparably higher temperatures. Animal studies suggest a possible role of endogenous pyrogens, such as interleukin 1beta, that, by increasing neuronal excitability, may link fever and seizure activity.3 Preliminary studies in children appear to support the hypothesis that the cytokine network is activated and may have a role in the pathogenesis of febrile seizures, but the precise clinical and pathological significance of these observations is not yet clear.4,5

Febrile seizures are divided into 2 types: simple febrile seizures (which are generalized, last <15 min and do not recur within 24 h) and complex febrile seizures (which are prolonged, recur more than once in 24 h, or are focal).6 Complex febrile seizures may indicate a more serious disease process, such as meningitis, abscess, or encephalitis.

Viral illnesses are the predominant cause of febrile seizures. Recent literature documented the presence of human herpes simplex virus 6 (HHSV-6) as the etiologic agent in roseola in about 20% of a group of patients presenting with their first febrile seizures. Shigella gastroenteritis also has been associated with febrile seizures. One study suggests a relationship between recurrent febrile seizures and influenza A.7,8

Febrile seizures tend to occur in families. In a child with febrile seizure, the risk of febrile seizure is 10% for the sibling and almost 50% for the sibling if a parent has febrile seizures as well. Although clear evidence exists for a genetic basis of febrile seizures, the mode of inheritance is unclear.9
 
While polygenic inheritance is likely, a small number of families are identified with an autosomal dominant pattern of inheritance of febrile seizures, leading to the description of a "febrile seizure susceptibility trait" with an autosomal dominant pattern of inheritance with reduced penetrance. Although the exact molecular mechanisms of febrile seizures are yet to be understood, underlying mutations have been found in genes encoding the sodium channel and the gamma amino-butyric acid A receptor.10,11,12

Frequency

United States

Between 2% and 5% of children have febrile seizures by their fifth birthday.13

International

A similar rate of febrile seizures is found in Western Europe. The incidence elsewhere in the world varies between 5% and 10% for India, 8.8% for Japan, 14% for Guam,14 0.35% for Hong Kong, and 0.5-1.5% for China.15

Mortality/Morbidity

  • Children with simple febrile seizures do not have increased mortality risk. However, seizures that were complex, occurred before 1 year of age, or were triggered by a temperature <39°C were associated with a 2-fold increased mortality rate during the first 2 years after seizure occurrence.16
  • Children with febrile seizures have a slightly higher incidence of epilepsy compared with the general population (2% vs 1%). Risk factors for epilepsy later in life include complex febrile seizure, family history of epilepsy or neurologic abnormality, and developmental delay. Patients with 2 risk factors have up to a 10% chance of developing afebrile seizures.17,18

Race

Febrile seizures occur in all races.

Sex

Some studies demonstrate a slight male predominance.

Age

By definition, febrile seizures occur in children aged 3 months to 5 years.

Clinical

History

  • The type of seizure (generalized or focal) and its duration should be described to help differentiate between simple and complex febrile seizures.
  • Focus on the history of fever, duration of fever, and potential exposures to illness.
  • A history of the cause of fever (eg, viral illnesses, gastroenteritis) should be elucidated.
  • Recent antibiotic use is particularly important because partially treated meningitis must be considered.
  • A history of seizures, neurologic problems, developmental delay, or other potential causes of seizure (eg, trauma, ingestion) should be sought.

Physical

  • The underlying cause for the fever should be sought.
  • A careful physical examination often reveals otitis media, pharyngitis, or a viral exanthem.
  • Serial evaluations of the patient's neurologic status are essential.
  • Check for meningeal signs as well as for signs of trauma or toxic ingestion.

Causes

  • Risk factors for developing febrile seizures13,19,20,21
    • Family history of febrile seizures
    • High temperature
    • Parental report of developmental delay
    • Neonatal discharge at an age greater than 28 days (suggesting perinatal illness requiring hospitalization)
    • Daycare attendance
    • Presence of 2 of these risk factors increases the probability of a first febrile seizure to about 30%.
    • Maternal alcohol intake and smoking during pregnancy has a 2-fold increased risk.
    • Interestingly, no data support the theory that a rapid rise in temperature is a cause of febrile seizures.
  • About one third of all children with a first febrile seizure experience recurrent seizures.22
    • Risk factors for recurrent febrile seizures include the following:23,24
      • Young age at time of first febrile seizure
      • Relatively low fever at time of first seizure
      • Family history of a febrile seizure in a first-degree relative
      • Brief duration between fever onset and initial seizure
      • Multiple initial febrile seizures during same episode
    • Patients with all 4 risk factors have greater than 70% chance of recurrence. Patients with no risk factors have less than a 20% chance of recurrence.

More on Pediatrics, Febrile Seizures

Overview: Pediatrics, Febrile Seizures
Differential Diagnoses & Workup: Pediatrics, Febrile Seizures
Treatment & Medication: Pediatrics, Febrile Seizures
Follow-up: Pediatrics, Febrile Seizures
References
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References

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  2. [Guideline] Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. Jul-Aug 1993;34(4):592-6. [Medline].

  3. Matsuo M, Sasaki K, Ichimaru T, Nakazato S, Hamasaki Y. Increased IL-1beta production from dsRNA-stimulated leukocytes in febrile seizures. Pediatr Neurol. Aug 2006;35(2):102-6. [Medline].

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  13. Verity CM, Butler NR, Golding J. Febrile convulsions in a national cohort followed up from birth. I--Prevalence and recurrence in the first five years of life. Br Med J (Clin Res Ed). May 4 1985;290(6478):1307-10. [Medline].

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  16. Vestergaard M, Pedersen MG, Ostergaard JR, Pedersen CB, Olsen J, Christensen J. Death in children with febrile seizures: a population-based cohort study. Lancet. Aug 9 2008;372(9637):457-63. [Medline].

  17. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. Nov 4 1976;295(19):1029-33. [Medline].

  18. Berg AT, Shinnar S. Unprovoked seizures in children with febrile seizures: short-term outcome. Neurology. Aug 1996;47(2):562-8. [Medline].

  19. van Esch A, Steyerberg EW, van Duijn CM, Offringa M, Derksen-Lubsen G, van Steensel-Moll HA. Prediction of febrile seizures in siblings: a practical approach. Eur J Pediatr. Apr 1998;157(4):340-4. [Medline].

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  35. Rosman NP, Colton T, Labazzo J, Gilbert PL, Gardella NB, Kaye EM. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med. Jul 8 1993;329(2):79-84. [Medline].

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  37. Berg AT. Febrile seizures and epilepsy: the contributions of epidemiology. Paediatr Perinat Epidemiol. Apr 1992;6(2):145-52. [Medline].

  38. Verity CM, Butler NR, Golding J. Febrile convulsions in a national cohort followed up from birth. II--Medical history and intellectual ability at 5 years of age. Br Med J (Clin Res Ed). May 4 1985;290(6478):1311-5. [Medline].

  39. Verity CM, Greenwood R, Golding J. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med. Jun 11 1998;338(24):1723-8. [Medline].

  40. Tarkka R, Paakko E, Pyhtinen J, Uhari M, Rantala H. Febrile seizures and mesial temporal sclerosis: No association in a long-term follow-up study. Neurology. Jan 28 2003;60(2):215-8. [Medline].

  41. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. Nov 4 1976;295(19):1029-33. [Medline].

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Further Reading

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Keywords

febrile seizures, febrile seizures in children, febrile seizure symptoms, febrile seizure causes, febrile seizure treatment, pediatric febrile seizures, fever in children, fever, seizure activity, upper respiratory infection, otitis media, viral syndrome, simple febrile seizures, complex febrile seizures, meningitis, encephalitis

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Contributor Information and Disclosures

Author

Nooruddin R Tejani, MD, Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center
Nooruddin R Tejani, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Wayne Wolfram, MD, MPH, Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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