CRS: Febrile Seizure

Explanation

No further intervention is required at this stage; however, it is important to provide detailed advice and counselling to the parents. The parents will be petrified and deeply concerned about the prognosis. Seizures are a frightening thing for both medical and non-medical observers and often parents spend the next 48 hours taking turns to watch their children after a seizure event as they are concerned that their child will have a seizure during sleep and die.

It is very important to explain that the seizure is a reaction to the fever and not due to an underlying brain lesion. It is important to emphasise that there is no association between simple febrile seizures and brain damage, developmental delay or other serious adverse events. It is possible that children with an underlying seizure disorder will have a seizure whenever they have a febrile event but the proportion of children having afebrile seizures is so low (<1%) and the proportion of children having febrile seizures is so high (3-5%) that having a febrile seizure is not significantly associated with having epilepsy.

Lumbar punctures are not required in the management of a child over 6 months in which there are no features to suggest meningitis. In children younger than 3 months of age, it is routine to perform a lumbar puncture to exclude meningitis as it is hard to determine based on clinical examination alone. In children 3 months to 6 months, there is some controversy about whether lumbar punctures are required and most clinicians would not perform a lumbar puncture unless there were specific concerns about meningitis, or perhaps if there were pre-existing antibiotic administration that might cloud clinical diagnosis.

In children with recurrent febrile seizures that are having a significant impact on the family, it might be worth considering anti-epileptic medications after discussion with a paediatrician. However, the risks from these medications far outweigh the risks of further seizures causing complications, so they are not indicated after the first seizure. Prescription and instruction on using rectal diazepam or buccal midazolam is a more useful solution in such cases.

Explanation

No medication is required at this stage as Felix has had a simple febrile seizure. Phenobarbitone or Sodium valproate may reduce the likelihood of a subsequent seizure but they have side effects and cost money, and take time and effort for the parents to administer. .Exceedingly rarely, children with febrile seizures in whom the risk benefit equation makes medication therapy worthwhile are on anti epileptic medications. This may include children who have had a catastrophic presentation with a prolonged febrile seizure and need resuscitation or intensive care.

The provision of a written seizure management plan that may include the use of buccal midazolam or rectal diazepam (for children who have had a prolonged febrile seizure, multiple febrile seizures, or live in a remote location) can limit the duration of the febrile seizure and give frightened parents a sense of being in control. There is good evidence that anti-pyretics like paracetamol and ibuprofen help with fevers but do not prevent febrile seizures. This child has a viral illness and treatment with penicillin will have no beneficial effect and may cause harm (anaphylaxis, rash, vomiting or diarrhoea).

References

Offringa M, Newton R. Prophylactic drug management for febrile seizures in children. Cochrane Database of Systematic Reviews. 4:CD003031, 2012. onlinelibrary.wiley.com/doi/10.1002/14651858.CD003031.pub2/pdf

Meremikwu M, Oyo-Ita A. Paracetamol for treating fever in children (Cochrane Infectious Diseases Group) Cochrane Database of Systematic Reviews. 2007:3. onlinelibrary.wiley.com/doi/10.1002/14651858.CD003676/pdf