Q&A COUNT: 30*
FEBRILE SEIZURES:
Q&A count: 30*
Note: This case doesn't have any clinical findings other than fever and history of seizures, so this case won't be kept for exams for sure! Model case sheet is given in the end!
Questions related to Febrile Seizures:
HISTORY: (10)
Q&A count: 30*
Note: This case doesn't have any clinical findings other than fever and history of seizures, so this case won't be kept for exams for sure! Model case sheet is given in the end!
Questions related to Febrile Seizures:
HISTORY: (10)
Criteria , Definition for Febrile Seizures:
3 criteria:
Febrile seizure is a seizure which:
1. Occurs between 6 months to 5 years of age
2. Accompanied by fever and
3. Not associated with any CNS infection
3 criteria:
Febrile seizure is a seizure which:
1. Occurs between 6 months to 5 years of age
2. Accompanied by fever and
3. Not associated with any CNS infection
What are the Types of Febrile seizures?
Simple and Complex types
Simple seizure is a generalised seizure , occurs only once in 24 hours and lasts for less than 15 minutes
If any of these three features are opposite, then it is said to be complex febrile seizure
That is..
A complex febrile seizure should have any 1 of the following:
1. Focal seizure
2. Recurrence within 24 hours
3. Lasts for more than 15 minutes
Other types:
1. Febrile seizure +
2. Status epilepticus
Simple seizure is a generalised seizure , occurs only once in 24 hours and lasts for less than 15 minutes
If any of these three features are opposite, then it is said to be complex febrile seizure
That is..
A complex febrile seizure should have any 1 of the following:
1. Focal seizure
2. Recurrence within 24 hours
3. Lasts for more than 15 minutes
Other types:
1. Febrile seizure +
2. Status epilepticus
How to differentiate between seizure and abnormal movements?
Seizure have associated features like loss of consciousness, altered sensorium and aura.
Abnormal movements do not have such.
Also, most of the abnormal movements do not occur during sleep. Seizures can!
Difference between seizure and epilepsy?
Seizure is a "single" abnormal paroxysmal electrical activity in a brain.
Occurence of two such unprovoked seizures over a day - denotes "epilepsy"
Abnormal movements do not have such.
Also, most of the abnormal movements do not occur during sleep. Seizures can!
Difference between seizure and epilepsy?
Seizure is a "single" abnormal paroxysmal electrical activity in a brain.
Occurence of two such unprovoked seizures over a day - denotes "epilepsy"
Types of epilepsy/seizures?
Generalized onset epilepsy:
1. Tonic clonic seizure
2. Myoclonic seizure
3. Atonic seizure
4. Spasm
5. Absence seizures
6. Tonic seizures
Focal onset epilepsy or Partial seizures:
1. Simple partial seizures
2. Complex partial seizures
1. Tonic clonic seizure
2. Myoclonic seizure
3. Atonic seizure
4. Spasm
5. Absence seizures
6. Tonic seizures
Focal onset epilepsy or Partial seizures:
1. Simple partial seizures
2. Complex partial seizures
Pre and post tictal symptoms?
Pre tictal - Aura, Hallucinations
Post tictal - Autonomic disturbances, Confusion, Amnesia, Headache, Todd's palsy or motor weakness
Post tictal - Autonomic disturbances, Confusion, Amnesia, Headache, Todd's palsy or motor weakness
Types of Fever?
Causes of RIGOR + Fever:
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| This picture is taken from Aruchamy textbook of Paediatrics |
- Malaria
- Filaria
- UTI
- Follicular Tonsillitis
Age required to produce RIGOR?
3-6 months
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
Causes for evening rise in temperature?
1. TB
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
EXAMINATION: (3)
How to record Axillary Temperature?
Axillary temperature is usually recorded (dont prefer recording oral temperature as baby may bite or suck it)
Bulb should be pointing upwards towards apex of axilla (if axillary temperature is recorded)
Mercury thermometer can be kept for 3-5 minutes for recording
Digital thermometer will give a Beep once it finishes recording (there is no fixed duration to keep thermometer)
Rectal , Axillary, Oral temperature - difference?
Note that: R > O > A (each by 1°F)
R - Rectal temperature
O - Oral temperature
A - Axillary temperature
Ideal Site to record core body temperature - Tympanic membrane
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
EXAMINATION: (3)
How to record Axillary Temperature?
Axillary temperature is usually recorded (dont prefer recording oral temperature as baby may bite or suck it)
Bulb should be pointing upwards towards apex of axilla (if axillary temperature is recorded)
Mercury thermometer can be kept for 3-5 minutes for recording
Digital thermometer will give a Beep once it finishes recording (there is no fixed duration to keep thermometer)
Rectal , Axillary, Oral temperature - difference?
Note that: R > O > A (each by 1°F)
R - Rectal temperature
O - Oral temperature
A - Axillary temperature
Ideal Site to record core body temperature - Tympanic membrane
INVESTIGATIONS: (2) Investigations for Febrile seizures:
1. CNS related investigations like CT scan, MRI or Lumbar puncture are NOT indicated for an initial attack of Febrile seizures
2. If meningitis is suspected, do Lumbar puncture
3. Basic workup for ARI is done
Clinical sign for Increased Intracranial pressure which occurs only in children less than 2 years
Bulging of Anterior Fontanelle
(This is considered to be a contra-indication for Lumbar puncture)
TREATMENT: (4)
Treatment for Febrile seizures
1. Paracetamol
2. Anti-epileptic (IV Lorazepam or Midazolam)
3. Antibiotics for ARI which caused the fever
Paracetamol - Dose
15 mg/kg per dose QDS (6th hourly) (note that it is calculated per dose* - not per day)
Formulations (forms) of Paracetamol
1. Tablets
2. Capsules
3. Syrups
4. Suppositories
Syrup formulation for less than 1 year (1 ml contains 25 mg)
Tablet formulation for more than 1 year (1 tab contains 500 mg)
Routes of Paracetamol
1. Oral
2. Rectal suppositories
3. IV
DISCUSSION: (11)
What needs to be assessed in a Febrile seizure case?
Prognosis of the baby for RECURRENCE - to get seizures, if any fever occurs in future.
Prognosis of the baby for RECURRENCE - to get seizures, if any fever occurs in future.
What are the Major and Minor criteria which, if positive , can increase the risk of recurrence of seizures for a future fever?
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| This picture is taken from Google search |
How to counsel mother of a febrile seizure child?
Counsel about risk of recurrence again, when fever comes. Ask her to bring child to hospital as soon as fever occurs again in future.
Counsel about preventive measures for fever and infection.
Counsel about preventive measures for fever and infection.
Genes involved in Febrile seizures?
- FEB1 (chromosome 8)
- FEB2 (chromosome 19)
- Sodium channel beta1 subunit gene (SCN1B (chromosome 19) and alpha1 subunit gene (SCN1A) (chromosome 2)
- FEB4 (chromosome 5)
Intermittent prophylaxis in a case of Febrile seizures
Intermittent oral or rectal Diazepam
Given upto 3 days after onset of fever, in a known case of Febrile seizure
Oral Diazepam dose: 0.6-0.8 mg/kg/day in 3 divided doses
Given to reduce the risk of recurrence in a Febrile seizure child
This does not eliminate risk of recurrence
Instead of Diazepam, other Benzodiazepines like Clonazepam can be given
Clonazepam dose: 0.8-1 mg/kg/day in 2 divided doses
What are the causes of Seizures in neonates and beyond neonatal age?
Commonest form of seizures in a newbornIntermittent oral or rectal Diazepam
Given upto 3 days after onset of fever, in a known case of Febrile seizure
Oral Diazepam dose: 0.6-0.8 mg/kg/day in 3 divided doses
Given to reduce the risk of recurrence in a Febrile seizure child
This does not eliminate risk of recurrence
Instead of Diazepam, other Benzodiazepines like Clonazepam can be given
Clonazepam dose: 0.8-1 mg/kg/day in 2 divided doses
What are the causes of Seizures in neonates and beyond neonatal age?
Neonatal seizures - Causes:
- Birth asphyxia and Trauma (most common)
- Intracranial bleeding
- Hypoglycemia
- Electrolyte disturbances (Hypocalcemia and Hypomagnesemia)
- Inborn metabolic error
- Infections (Meningitis, sepsis, tetanus neonatorum, intrauterine infections)
- Deformities of brain
- Narcotic withdrawal in mother
- Aminophylline given for apnea
- Pyridoxine dependency (day 1 seizures)
- Local anesthesia injected accidentally into fetal scalp (day 1 seizures)
- Benign sleep myoclonus
- Benign 5th day seizure (due to low Zn2+ level)
- Benign familial neonatal convulsions
Note: Those who are boldened comes under causes for seizures after neonatal age also
Causes of Seizures beyond neonate period:
1. Simple febrile seizures (most common cause)
2. Epilepsy syndromes
3. Infections (Bacterial meningitis, Intrauterine infections, TB meningitis, aseptic meningitis, encephalitis, cerebral malaria, Reye syndrome)
4. Hypoglycemia
5. Electrolyte disturbances (Hypocalcemia and Hypomagnesemia)
6. Inborn metabolic error
7. Space occupying lesions
8. Vascular - AV malformations, intracranial thrombosis, intracranial hemorrhage
9. Sequelae of birth trauma and asphyxia
10. Miscellaneous - Hypertensive encephalopathy, Grey matter degeneration, storage disorders
11. Drugs, Poisons - Phenothiazines, Salicylates, Phenytoin, strychnine, CO, Lead
Causes of Seizures beyond neonate period:
1. Simple febrile seizures (most common cause)
2. Epilepsy syndromes
3. Infections (Bacterial meningitis, Intrauterine infections, TB meningitis, aseptic meningitis, encephalitis, cerebral malaria, Reye syndrome)
4. Hypoglycemia
5. Electrolyte disturbances (Hypocalcemia and Hypomagnesemia)
6. Inborn metabolic error
7. Space occupying lesions
8. Vascular - AV malformations, intracranial thrombosis, intracranial hemorrhage
9. Sequelae of birth trauma and asphyxia
10. Miscellaneous - Hypertensive encephalopathy, Grey matter degeneration, storage disorders
11. Drugs, Poisons - Phenothiazines, Salicylates, Phenytoin, strychnine, CO, Lead
SUBTLE SEIZURES
What are SUBTLE SEIZURES?
Clinically missed forms of mild seizures - in neonates. GTCS cannot occur due to incomplete myelination. This results in subtle seizures.
It can be in the following forms:
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| This picture is taken from Google search |
Why GTCS cannot occur in a newborn?
Reason: Myelination is incomplete**
Types of newborn seizures (this refers to various forms of Subtle seizures)
- Blink eyes, conjugate movements
- Orobuccal
- Facial
*******
Annexure: CASE SHEET MODEL
HISTORY:
Mantoux, Chest X ray (for ARI workup)
Lumbar puncture (if meningitis is suspected)
TREATMENT
Annexure: CASE SHEET MODEL
HISTORY:
1) Demography - Name, Age**, Gender, Area, Order of Birth, Consanguinity, Informant and reliability
Age very important to assess risk of recurrence* (<1 year - more risk)
Age important for Febrile seizure criteria (6 months to 5 years age)
Gender - Male (more risk recurrence)
Age very important to assess risk of recurrence* (<1 year - more risk)
Age important for Febrile seizure criteria (6 months to 5 years age)
Gender - Male (more risk recurrence)
2) Chief complaints - Fever followed by Seizures
3) History of presenting illness:
History about fever - onset, duration, high or low grade, type of fever, aggravating or relieving factors
Seizure - Onset (how many hours within onset of fever), how many episodes in how many hours/days, type (GTCS, eye rolling, focal), any associated loss of consciousness, any pre or post tictal symptoms
When brought to hospital and admitted?
No H/O headache (if child can tell), nausea (if child can tell), vomiting ** - to rule out CNS infections
Reasons for Fever: H/O URI, LRI, UTI
Seizure - Onset (how many hours within onset of fever), how many episodes in how many hours/days, type (GTCS, eye rolling, focal), any associated loss of consciousness, any pre or post tictal symptoms
When brought to hospital and admitted?
No H/O headache (if child can tell), nausea (if child can tell), vomiting ** - to rule out CNS infections
Reasons for Fever: H/O URI, LRI, UTI
4) Past History - H/O similar episodes in past along with any treatment given
5) Antenatal History - all 3 trimesters (no significant role in this case)
6) Birth History (no significant role in this case)
7) Postnatal History (breastfeeding/weaning) (no significant role in this case)
8) Developmental History - all 4 milestones (Milestones attained appropriate for age, Developmental quotient = 100%)
9) Diet History ( if malnourished, more chances of future infection or fever which can trigger seizures)
10) Family History - Important** (increases chances of recurrence)
11) Socio-environmental History (Socio economic class & Environmental history) (poor socio environmental status for infections)
12) Immunization History (no significant role in this case)
13) Contact History (no significant role in this case)
14) Allergy History (no significant role in this case)
EXAMINATION:
1) General examination - Normal
2) Vitals - Normal
3) Anthropometry - Normal
4) Head to Toe examination - Normal
In case of malnutrition, anthropometry and Head to Toe examination gets abnormal
In case of malnutrition, anthropometry and Head to Toe examination gets abnormal
5) Systemic examination - all 4 systems
Normal** (CNS must have no focal neurological deficit)
DIAGNOSIS
1. A case of Febrile seizures associated with risk factors for recurrence such as ____
2. Normal Immunization status (or) not immunized upto date,
3. Normal Anthropometry (or) mention abnormal anthropometric measure,
4. Protein deficit in %, Calorie deficit in % (or) No protein or calorie deficit,
5. Normal Developmental status (or) Developmental delay with DQ of ___%,
6. (And Mention if any) poor socio-environmental conditions like _____
1. A case of Febrile seizures associated with risk factors for recurrence such as ____
2. Normal Immunization status (or) not immunized upto date,
3. Normal Anthropometry (or) mention abnormal anthropometric measure,
4. Protein deficit in %, Calorie deficit in % (or) No protein or calorie deficit,
5. Normal Developmental status (or) Developmental delay with DQ of ___%,
6. (And Mention if any) poor socio-environmental conditions like _____
INVESTIGATIONS
CBC, Hb%, TC, DCMantoux, Chest X ray (for ARI workup)
Lumbar puncture (if meningitis is suspected)
TREATMENT
1. Paracetamol 15 mg/kg/dose QID (IV followed by oral)
2. Anti-epileptic (IV Lorazepam or Midazolam)
3. Antibiotics for ARI which caused the fever
2. Anti-epileptic (IV Lorazepam or Midazolam)
3. Antibiotics for ARI which caused the fever