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General data:
T.C., 8 mos. old, female, Filipino, Roman Catholic, born on December 12, 2012, currently residing at
Captan, Tuguegarao City was admitted for the first time at CVMC on August 17, 2013.
Perinatal history:
The patient was born to an 18 y/o G1 (1-0-0-1). The mother had prenatal check up 4 times during the
entire pregnancy and had taken multivitamins and ferrous sulfate. No other drugs were taken and no
illness noted during the course of pregnancy.
Birth history:
The patient was delivered via NSD in a lying-in clinic assisted by a midwife, full term and of cephalic
presentation. The mother was noted to be febrile at the time of delivery. No other conditions were
noted.
Neonatal history:
The patient was born w/ good suck and good cry. No jaundice, no cyanosis and no sepsis were noted.
The patient was put on heplock for 1 week, of which, according to the informant, was warranted
because of the mother’s fever.
Nutritional history
The patient was breastfed from birth up to 2 months, and then was introduced to Bonna. And then on
her 6th month, she was shifted to Bonamil. Frequency and interval of feeding was dependent on baby’s
need.
Growth and development:
Immunizations:
Family history:
Paternal Maternal
CA - -
HPN - -
DM - -
Heart - -
Disease
PHYSICAL EXAM:
General survey: The patient is awake and not in cardio respiratory distress.
Vital signs:
HR- 157 bpm- tachycardia
RR-50 cpm- normal
Temp.-37.7 ºC- febrile
Weight: 8 kg
Length: 46 cm
Head circumference: 46 cm
Chest Circumference: 48 cm
Abdominal circumference: 49 cm
Neurologic Exam:
MSE: The patient is awake.
IMPRESSION:
Febrile Seizure secondary to URTI
SALIENT FEATURES:
Generalized clonic-tonic seizure lasting < 15 minutes
High grade fever
(+) Hx of URTI
(-) Neurological deficits
(-) Meningeal signs
DIFFERENTIAL DIAGNOSIS
Febrile seizures
Febrile seizures are convulsions in infants and children triggered by a fever in the absence of CNS
infection. Febrile seizures affect 4-5% of children aged 6 months to 6 years. These occur in association
with a high fever, typically above 38.5°C (101.3°F), although some believe the rate of change in body
temperature is more provoking than the absolute temperature in febrile seizures. There is often a
positive family history of febrile seizures in other family members. A second episode occurs in 33% of
children, and only 50% of those have a third episode. Few children, approximately 3-6%, with febrile
seizures develop afebrile seizures or epilepsy.
Three Groups:
Simple febrile seizure
Age, neurological status before the illness, and fever are the same as for simple febrile seizure.
This seizure is either focal or prolonged (ie, >15 min), or multiple seizures occur in close succession.
Symptomatic febrile seizure
Age and fever are the same as for simple febrile seizure.
The child has a preexisting neurological abnormality or acute illness.
Pathophysiology
EPIDEMIOLOGY
Febrile seizures are age dependent and are rare before 6 months and after 5 years of age. The peak age
of onset is approximately 14-18 mons of age, and the incidence approaches 3-4% of young children.
They most commonly occur in children between the ages of 6 months and 5 years and are twice as
common in boys as in girls.
ETIOLOGY
The direct cause of a febrile seizure is not known; however, it is normally precipitated by a recent upper
respiratory infection or gastroenteritis. A febrile seizure is the effect of a sudden rise in temperature
(>=39°C) rather than a fever that has been present for a prolonged length of time.
A strong family history of febrile convulsion in siblings and parents suggest a genetic predisposition
(chromosome 19p and 8q13-21). An autosomal dominant inheritance pattern is demonstrated in some
families. Children with febrile convulsions are more likely to suffer from afebrile epileptic attacks in the
future if they have a complex febrile seizure, a family history of afebrile convulsions in first-degree
relatives (a parent or sibling), or a preconvulsion history of abnormal neurological sign or developmental
delay.
CLINICAL MANIFESTATION
The convulsion is associated with a rapidly rising temperature and usually develops when the core
temperature reaches 39 C or greater. The seizure is typically generalized, tonic-clonic of a few seconds
to 10-min duration, followed by a post ictal period of drowsiness. Febrile seizure lasting of 15min
suggests an organic cause such as an infectious or toxic process and requires thorough investigation. If
any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the CSF
indicated.
Simple febrile seizures do not cause permanent brain injury; do not tend to recur frequently (children
tend to outgrow them); and do not make the development of adult epilepsy significantly more likely
(about 3–5%), compared with the general public (1%).
Other manifestations:
stiff body
twitching or jerking of the extremities or face
rolled-back eyes
unconsciousness
inability to talk
problems breathing
involuntary urination or defecation
vomiting
confusion, sleepiness, or irritability after the seizure
DIAGNOSIS
Laboratory Tests:
Neither computed tomography (CT) nor magnetic resonance imaging (MRI) is indicated in patients with
simple febrile seizures.
Other Tests
EEG is not indicated in children with simple febrile seizures. Published studies demonstrate that the vast
majority of these children have a normal EEG. In addition, some of those with an abnormal EEG have
remained free of seizures for the duration of their follow-up. On the other hand, some of the children
with a normal initial EEG have experienced 1 or more afebrile seizures subsequent to the EEG. Finally, no
evidence indicates that beginning anticonvulsant therapy for a child with simple febrile seizures and an
abnormal EEG will alter the child's eventual outcome.
Procedures
Strongly consider lumbar puncture in children younger than 12 months, because the signs and
symptoms of bacterial meningitis may be minimal or absent in this age group.
Lumbar puncture should be considered in children aged 12-18 months, because clinical signs and
symptoms of bacterial meningitis may be subtle in this age group.
In children older than 18 months, the decision to perform lumbar puncture rests on the clinical suspicion
of meningitis.
TREATMENT
On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is
indicated for children who have experienced 1 or more simple febrile seizures.
1. Continuous therapy with phenobarbital decreases the occurrence of subsequent febrile seizures.
oBoth therapies confer significant risks and potential adverse effects, whereas additional simple
febrile seizures have no proven risk.
o These medications are not recommended, since the potential benefits do not outweigh the
potential risks.
2. No evidence suggests that any therapy administered after a first simple seizure will reduce the risk of
a subsequent afebrile seizure or the risk of recurrent afebrile seizures (ie, epilepsy).
3. Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is intermittent, this
therapy probably has the fewest adverse effects. If preventing subsequent febrile seizures is essential,
this would be the treatment of choice.[3]
4. Although it does not prevent simple febrile seizures, antipyretic therapy is desirable for other reasons.
Anticonvulsants:
Phenobarbital
Neonates (<28 days): 3-5 mg/kg/day IV/PO in 1-2 divided doses
>12 years: 1-3 mg/kg/day IV/PO in 1-2 divided doses, OR 50-100 mg BID/TID
Antipyretics:
a) Acetaminophen (Tylenol)
Dosage: 10-15 mg/kg PO/PR q4-6h; not to
exceed 5 doses/d or 2.6 g/d
b) Ibuprofen (Advil, Motrin)
Dosage: 5-10 mg/kg/dose PO q6-8h prn; not
to exceed 40 mg/kg/d or 2.4 g/d
Prognosis
Prognosis for normal neurologic function is excellent.
About one third of children who experience a single simple febrile seizure will have another.
The lifetime rate of epilepsy in these children is slightly above that of the general population.[4]
Patient Education
Inform parents that these dramatic events do not indicate future neurologic dysfunction or disease.