الفهرس 
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Abstract
Febrile seizures are defined as seizures that occur in association with a fever
in children 6 months to 5 years of age, but in whom there is no evidence of a
central nervous system infection or another definable cause of seizure, and
which are not preceded by a history of an afebrile seizure.
Febrile seizures are the most common form of childhood seizures,
affecting approximately 2–5% of children. Usually occur between 3 months and 5 years of age, with a-peak incidence at 18 months, Boys are affected slightly more often than are girls.
Febrile seizures are usually categorized as either simple or complex. A
simple FS is defined as a self-limiting tonic-clonic seizure of short duration (<15 min) that does not usually recur within the next 24 h, and that does not leave any postictal pathology. On the other hand, a complex FS is defined as having a focal onset or focal features during the seizure, Prolonged duration (>15 min), Recurrent seizures within the same febrile illness over a 24-h period, Previous neurological impairment, such as cerebral palsy or developmental delay. Risk factors include a first-degree relative with a history of a febrile seizure, a neonatal nursery stay of more than 28 days, developmental delay, and attendance at a day care center. Approximately 30% to 40% of children who experience a febrile seizure will have a recurrence, but less than 10% will have
three or more recurrences. Various risk factors for recurrences of febrile seizures have been identified and include a younger age of onset (15 months), relatively lower temperature at the time of the first febrile seizure, shorter interval between the onset of fever and the initial seizure, epilepsy in a first-degree relative, febrile seizure in a first-degree relative, frequent febrile illnesses (day care attendance), and a first febrile seizure that is complex. The greater the number of risk factors, the higher is the rate of recurrence. The etiology and pathogenesis of febrile seizures have yet to be fully elucidated, particularly at the molecular level. However, some environmental aspects are already understood and believed to be essential to development of the condition , The underlying cause of the infectious process does not appear to be a determining factor of febrile seizures, The presence of fever is of course essential, even though its mechanism of action is unknown. Febrile seizures are also most common in the first day of fever, and correlate more with peak temperature than with speed of onset.
There is a genetic predisposition to febrile seizures. The risk for the
development of a febrile seizure is approximately 20% when a sibling is
affected, and the risk increases to 33% when both parents also are affected,
Recently, several mutations in the GABAA receptor _2 subunit gene have been reported to be associated with febrile seizures. These receptors mediate the majority of fast synaptic inhibitions in the brain.
The seizure threshold varies between individuals. Children prone to
febrile seizures produce more proinflammatory cytokines in the central nervous system, such as interleukin-1, which might induce seizures. The type of infection plays a role in the pathogenesis. Roseola infantum (exanthema subitum), caused by human herpesvirus 6, is an important cause of first-time febrile seizures . Viral upper respiratory tract infection, otitis media, pharyngitis, and gastroenteritis (especially due to shigellosis) are other important causes of febrile seizures.
Influenza A infection is associated with a higher incidence of febrile
seizures and of recurrent seizures during the same febrile episode than are
infections with adenovirus or parainfluenza.
Vaccination against diphtheria, tetanus, and pertussis is an important cause
of febrile seizure .Conversely, measles, mumps, and rubella vaccination is less likely to be associated with a febrile seizure.
The 2011 AAP febrile seizure guideline states, ”A lumbar puncture should
be performed in any child who presents with a seizure and a fever and has
meningeal signs and symptoms (e.g., neck stiffness, Kernig and/or Brudzinski
signs)”.
No evidence exists that epileptiform discharges in children with febrile
seizures have any diagnostic or prognostic implications, even in the subgroup with complex febrile seizures. Therefore, no rationale exists for doing an electroencephalograph in febrile seizures.
Acute care of the febrile seizure should be as for any epileptic seizure.
General principles of emergency care, such as assessment with the ABCs
(airway, breathing, and circulation), should precede administration of any
specific drugs. Furthermore, most seizures cease spontaneously prior to arrival at the emergency department, and the clinician will often assess a child in the post-ictal state.
The seizure can be terminated with intravenous diazepam (0.2mg/kg) or
lorazepam (0.05 mg/kg) , Diazepam administered rectally (0.5mg/kg) and
midazolam administered intranasally (0.2 mg/kg) also have been found to be
safe and effective ,Supplemental oxygen should be administered if necessary, and vital signs should be monitored during a seizure. The fever should be controlled with an antipyretic medication and by removal of excessive blankets and clothing. Although normalization of the body temperature might not prevent
seizures, the use of an antipyretic medication might make the child more
comfortable.
The goal of long term treatment is to prevent recurrent seizures. This is
achieved either by continuous long term anticonvulsant therapy or intermittent prophylaxis.
Continuous anticonvulsant therapy with phenobarbital or valproic acid has
been shown to prevent recurrent febrile seizures. But both have significant side
effects and continuous therapy with these drugs as a prophylaxis for febrile
seizures is not advised, Benzodiazepines, given intermittently only during the febrile episodes, were found to be effective in preventing recurrence of febrile
convulsions, Diazepam has been commonly used either orally or rectally, but adverse effects were also observed such as somnolence, ataxia and irritability.
Because there are significant adverse events associated with preventative
therapy, the present consensus is that ongoing prophylaxis is not necessary for children with either simple or complex febrile seizures, In situations where parental anxiety is high, particularly in patients at risk for prolonged or multiple febrile seizures, intermittent therapy with diazepam at the onset of a febrile illness might be considered.
from this study we can conclude the following:
1- Febrile seizures are the most common form of seizures seen in children
and may be simple or complex.
2- Affected patients are typically between the ages of six months and five
years of age and do not have epilepsy, central nervous system infection or
inflammation, or other triggers for seizures.
3- Simple febrile seizures are the most common and are characterized by
seizures that last less than 15 minutes, have no focal features, and, if they
occur in a series, the total duration is less than 30 minutes. These are
mainly generalized clonic seizures but may also be atonic or tonic in
character.
4- Complex febrile seizures are characterized by episodes that last more than
15 minutes, have focal features or postictal paresis, and occur in a series
with a total duration greater than 30 minutes.
5- Febrile status epilepticus (FSE) lasts 30 minutes or longer, but otherwise
shares the characteristics of febrile seizures of shorter duration. Attacks
should be treated with antiepileptic medication as are other patients with
status epilepticus.
6- Risk factors for recurrent febrile seizures are younger age of onset, a
family history of febrile seizures, brief latency between onset of fever and
seizures, and a relatively low fever.
7- Risk factors for subsequent epilepsy are neurodevelopmental
abnormalities, focal complex febrile seizure, family history of epilepsy,
fever <1 hr before febrile seizure, Complex febrile seizure, recurrent
febrile seizures and simple febrile seizure.
8- Almost any type of epilepsy can be preceded by febrile seizures,
and a few epilepsy syndromes typically start with febrile seizures. These
are generalized epilepsy with febrile seizures plus (GEFS+), severe
myoclonic epilepsy of infancy (Dravet syndrome), and, in many patients,
temporal lobe epilepsy secondary to mesial temporal sclerosis.
9- The main task in the initial assessment of FS is the first-aid
management of an ongoing seizure, and then to exclude serious medical
illnesses that may have caused the fever.
10- Treatment to lower fever does not appear to affect the recurrence rate of
febrile seizures.
11- Criteria for hospital admission include:
• Children who present with an underlying infection requiring inpatient
stay.
• Children whose parents have ”disabling” anxiety.
• Children that lack a safe home or safe transportation home require
admission and may require social work consultation.
• Children who are clinically unstable neurologically (e.g., not returning
to baseline, very somnolent following doses of anti-seizure medications)
should be admitted for observation and support.
12- Discharge criteria:
• Because by definition all cases have presented with a fever, patients
always have at least 2 discharge diagnoses: one for the febrile seizure and
a second for the cause of the fever.
• Children who appear non-toxic and are at their neurologic baseline
following a febrile seizure may be safely discharged home.
• Children who present with a complex febrile seizure should be observed
for a minimum of 2 hours, and then may be discharged home if they
appear non-toxic and have returned to their neurological baseline.
This study recommended that:
1- Lumbar puncture should be performed in any child who presents with a
seizure and a fever and has meningeal signs and symptoms (e.g., neck
stiffness, Kernig and/or Brudzinski signs), lumbar punctures should be
strongly considered in children experiencing their first febrile seizure,
particularly if < 12 months of age particularly if the immunization status
for Haemophilus influenzae type B or Streptococcus pneumoniae is
deficient or undetermined.
2- LP is also recommended when the patient is on antibiotics because
antibiotic treatment can mask the signs and symptoms of meningitis.
Other possible indications are febrile seizures occurring after the second
day of illness, or other concerns for possible central nervous system
infection.
3- Neuroimaging like CT scan and MRI are not recommended in simple
febrile seizures. Patients with complex febrile seizures, especially those
with focal motor manifestations, should undergo a neuroimaging study to
rule out structural lesions.
4- Routine brain imaging and EEG is not indicated following a FS
5- It is recommended to treat patients with simple febrile seizures with
antiepileptic drug (AED) therapy.
6- The use of AED prophylaxis in children with complex febrile seizures is
individualized based upon underlying risk factors.
7- Prophylactic antipyretic or anticonvulsant therapies are not recommended
to reduce the recurrence rate.
8- Use of continuous prophylactic antiepileptic medication is not
recommended
9- Parents should receive guidance on responding to a seizure, not allowing
the insertion of any objects into the child’s mouth, preventing aspiration
in the post-ictal period, and monitoring seizure duration.