All About Febrile Seizures – PediaCast 072
- Febrile Seizures
Announcer 1: This is PediaCast.
Dr. Mike Patrick: Bandwidth for PediaCast is provided by Nationwide Children's Hospital, For Every Child For Every Reason.
Katie 2: Welcome to PediaCast. A pediatric podcast for parents, the In-Depth Edition. And now direct from Birdhouse Studios here is your host, Dr. Mike.
Dr. Mike Patrick: Thanks Katie and hello everyone. It is Tuesday October 30th 2007. This is PediaCast Episode number 72. We're going to an in-depth edition on Febrile Seizures. It's been a while since we did that. I looked back in the archives and way back in Episode number 12 we touched on Febrile Seizures but you know we're getting into viral season, lots of kids are having fevers and some of those kids are going to have seizures with those fevers, so I thought it'd be a good time to review that topic.
Before we get started though, I upgraded over the weekend to Leopard. See, I'm a Mac guy. And it was pretty smooth, overall good experience had to make some adjustments, couple of my programs that I typically use had some hiccups. But overall we got everything ironed out. So if you have a Mac at home and you haven't made the upgrade to Leopard yet, I would recommend it. Very pleased with it so far. And of course any excuse that I get to go to the Apple Store, I take. In fact it's the only place outside of my practice area where I'm recognized. [Laughs] My kids think it’s pretty cool because Tim over at the Apple Store knows me and I walk in he says, “Hey Dr. Mike. How are you doing?” And you know I feel like a celebrity for all of about 10 seconds. [Laughs]
So now of course you know where I practice, I practice in live in two different places. So where I live, I can go to the grocery store in my sweat pants and I don't have people saying, "Hey there's doctor." You know it's kind of nice I guess. But when I'm out and about in the town where I practice, I can't go through a drive-thru without someone saying, "Hey, how are you doing?" which is fine too. So anyway, I don't even know where I'm going with that but just thought I'd share.
So all right. Again we're going to talk about Febrile Seizures. It is a misunderstood problem and largely responsible for the unnecessary fever phobia that pervades parenthood, so we'll discuss that.
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OK. So we're going to talk about Febrile Seizures, now this is an example of someone writing in and getting the topic done. So this comes from Jane in Grand Rapids Michigan. Jane says, "I was looking a podcast about Febrile Seizures. I'm doing a teaching project for my Pediatric Nurse Practitioners course and need to suggest different resources available to parents. Do you have anything on PediaCast? Thanks, Jane."
Well again, of course thanks for writing in Jane. I appreciate you thinking about us and to include us in your search for parenting educational materials. Again way back in Episode 12 we did discuss Febrile Seizures but it's been over a year now and PediaCast was still just a very small gathering of friends with a tiny, tiny audience and the sound quality really stunk back there and I probably rambled, we'll I guess I still do that, but Febrile Seizures are an important topic because they are misunderstood and they're scary. Even though they are usually in the vast majority of cases, not life threatening or anything in the end to worry about. When you're there and your child is seizing, it's scary. And I can tell you from personal experience that's true because when I was, gosh I think I must have been a second year Pediatric Resident.
So here I am a pediatrician in training, my daughter at that time was 15 months old, yes so I would have been a second year resident and we are moving from a town house to our very first house. And it was actually the night before the moving people were going to come. We're going to pack up, the U-Haul's and all that. So we decided to not make dinner at home because everything was packed up and we might have gone out to dinner but as it turns out, Katie my daughter, she's 13 now but at this point she was 15 months old, she had a fever, she was sick, not feeling well. And I just had gotten home from work and Karen really sort of wanted to get out of the house anyway for a little while. So I held Katie on my lap and Karen went out to pick up dinner and bring it back, I don't remember, something very unhealthy I'm sure at that point. 'Cause when you're in your mid-20's you don't really think about what you eat. So I can't remember what it was now, maybe Kentucky Fried Chicken, it could have been McDonald's, Wendy's, I don't remember.
That's not the point. The point is that Katie had the fever and I was holding her in my arms, rocking her in a rocking chair and all of a sudden her eyes went up in the back of her head, she sort of stiffened, begin to shake both arms and both legs and was pretty limp and unresponsive other than the shaking, and the whole thing seemed like it lasted forever but it really only lasted probably a minute. She'd never turn blue, didn't stop breathing. And by the time Karen got home it was all over and I calmly told her she had a seizure, "What? She had a What?"
I mean it was scary. I recognized it for what it was. We called our pediatrician and at that time, you know I'm a pediatrician in training and you want to make sure, you know it's your own kid; you don't make the wrong decision. And our pediatrician at that time basically, we knew she was sick, she had a fever, it was over, she was fine, didn't really need to do anything else except go to their office the next day and I don't remember maybe she had croup or an ear infection. Been way too many years to know for sure. But again it's a scary thing.
Now when we talk about Febrile Seizures, it is the most common childhood seizure disorder and we can divide Febrile Seizures into three types; Simple Febrile Seizures, Complex Febrile Seizures, and then what we call Symptomatic Febrile Seizures. Now the one that I described that Katie had would have been in the realm of Simple Febrile Seizures. They occur in the presence of a fever in children who are six months of age through five years of age. It's what we call a Generalized Tonic-Clonic Seizure, and that means that both arms, both legs are involved and there's stiffness and shaking, although the trunk and neck can be sort of limp during this time. So it's sort of stiffness and shaking of the extremities and it's going to last for no more than 15 minutes to be a Simple Febrile Seizure.
The vast majority of them last a lot shorter of amount of time than that. Also the child has no history of any significant neurological problem; they don't have a history of a head injury, never had any other types of neurological issues in the past. Also once the seizure episode is over, including what we call the Postictal state where after the seizure you're just sort of sleepy and tired and sort of out of it for a few minutes to half hour to an hour probably at the most with a Febrile Seizure. But as long as you get past that period then the neurological exam is normal and you know the fever in the end is not caused by Meningitis or Encephalitis; infection of the brain or the fluid and membranes that cover the brain, as long as all those things are true, then we just call it a Simple Febrile Seizure.
Now a Complex Febrile Seizure and it's important to differentiate them because the way we approach them and treat them is going to be different depending on which type of Febrile Seizure it is. So a Complex Febrile Seizure, you would call it that if the seizure is focal rather than generalized. And by that we mean, maybe just one arm is involved or one leg is involved. It's not both arms, both legs but just one part of the body is having the seizure rather than it being generalized to the entire body. Also if it's a prolonged seizure, greater than 15 minutes or they have multiple seizures in close succession, then we would call that a Complex Febrile Seizure.
Now a Symptomatic Seizure, this is a child who has a pre-existing known neurological abnormality or the neurological exam after the seizure episode is over including that Postictal Phase is somehow abnormal and we'd also call it a Symptomatic Febrile Seizure if in the end the child had Meningitis or Encephalitis at the time of the fever and the seizure.
OK. So what causes Febrile Seizures? And then we'll talk about what you do for them based on those three categories of types of Febrile Seizure. Well we don't know for sure. We don't know for sure what causes Febrile Seizures. Current thinking suggests that most Febrile Seizures occur as a result of a rapid change in body temperature after a sort of longer period temperature stability in a person with a genetic predisposition to having this happen.
OK now I used a lot of big words there. So let me step back and just explain what this means. It means that if a person is cruising along at a certain body temperature, a range. So let's say the say the range is in the high 90's obviously, 98, 99 sometimes 97. And you're cruising there for weeks or months and then you get sick and you have that first temperature spike and all of a sudden your body temperature goes from 98 to bang, pretty fast you're 102 degrees. It's that rapid change in body temperature that tends to set-off a Febrile Seizures.
Notice I did say most Febrile Seizures happen this way. There are exceptions, there are some people who have their Febrile Seizure not when the temperature is going up but after that first spike, as the temperature is going back down to normal, that may provoke it. And that type is less common than the type when the fever is rapidly rising.
It tends to follow a family pattern, again with the rapid rise being the most common trigger. And that's why I said that in a person with a genetic predisposition to this happening, it tends to run in families. So if you have a family history of Febrile Seizures, then it's more likely to happen to your child. So you can take two kids and they can be the same baseline temperature for the same length of time and then you get them both sick at the same time and their fever is both spiked at the same time, they get to the same height; one of them may have a Febrile Seizure and the other one may not. So a lot of it depends on how you're built and genetics and your family history of whether you're prone to this or not.
The take home note here is you'll notice I didn't say that how high the fever goes is what causes the Febrile Seizure, so it's not the height of the fever, it's that rapid change in body temperature that typically does this and this is where the big misunderstanding comes. People tend to think that a fever that's really high somehow damages the brain and that's what makes you have a seizure. But that's not it at all. It's really just the brains way of responding to a rapid change in body temperature. It's more like a reboot of the brain when the temperature changes quickly. If you think in terms of a computer, basically just everything shuts down, reboots and meaning it just sends signals like crazy out to all the muscle groups and they have the seizure as the brain sort of reboots. It's over-simplifying it a little bit but that's the best way that I can think to explain it and that's how this whole thing happens.
Now you'll also notice that because it's this rapid rise, most of the time for most of these kids the seizure is the first sign that they're sick. Now as it turns out with Katie, that was not true. She had a fever we knew that day and then in the evening, she did have a normal body temperature and perhaps, you know what, it's coming back to me now. Karen didn't give her Motrin or Tylenol to help keep the fever down once we knew she had a fever. And the reason was because Katie, it's been 12 years ago so I don't think Children Services is coming after us. But Katie was not a very loving cuddly baby by any stretch of your imagination. And I remember when she was sick she would let us hold her and rock her and I think we may have stretched out the dosing intervals of the Tylenol and Motrin a little bit 'cause she was cuddly and cute when she didn't feel good [Laughs] she would be still in your lap and then she had the fever and then the seizure.
And so it was probably with the rapid rise but I don't think it was with the fever of that illness, like it is in the majority of cases. For a lot of these kids, the parents didn't even know they were sick, maybe that little runny nose or something but nothing terrible and suddenly their kids having a seizure and they feel really hot. So it's usually with that first temperature spike of an illness when you see it. So when I see kids who are 100 and 304 degrees in the office and the parents are worried about febrile Seizure, for most of those kids, if they were going to have one, it would have happened by that time.
Now, how common is this?
In the United States 2 to 5% of children between the ages of six months and five years end up having a Febrile Seizure. And of those kids, 70 to 75% will have Simple Febrile Seizures, another quarter of them will have Complex Febrile Seizures, and only about 5% end up having the Symptomatic form that we talked about.
Children who have had a Febrile Seizure are more likely to have another. In fact one third of all children who have one Febrile Seizure will have another one at some point before age five. And this is important to understand. It shows you that these kids have a propensity, a tendency to have this sort of thing happen when their body temperature changes quickly. If the first seizure is prior to 12 months of age, the chance of recurrence is about 50% and if the first Febrile Seizure is after 12 months of age, then the chance reduces down to about 30%. And again this reflects the fact that there is a genetic component to Febrile Seizures.
Also kids with a history of Febrile Seizure do have a slight increased risk of Epilepsy which is a chronic seizure disorder or seizures occur sort of randomly and not necessarily just with fevers, but they can occur at any time. And the rate of Epilepsy for kids with a history of Febrile Seizure ends up being around 2.5% which is about twice the risk of the general population. So it's still a small risk but it's a little bit more risk of them developing Epilepsy than a kid who has never had a Febrile Seizure in the past.
So what do we do the first time this happens?
Well again often the seizure is often the first sign that there is a problem and as a parent when your child has a Febrile Seizure, you know the first thing you don't know for sure exactly what's going on when it first happens. So the first thing that you want to do is address their ABC's. And as parents you should now that ABC's don't just mean the alphabet, it's Airway, Breathing, and Circulation. And really I think all parents should consider a CPR class at your local Red Cross or whatever other facilities in your area offer those. Really parents should know basic first aid and be able to do child CPR if you needed to. Because you know, what if they're not really having a Febrile Seizure and they're choking on something, what are you going to do? I mean what if they are having their seizure because they have no oxygen going to the brain because they're choking? Or what if they have a heart arrhythmia and that what's decreasing the oxygen to the brain and they're having a seizure because of that.
So if you see your kid having a seizure, you don't want to think, "Oh it must be a Febrile Seizure." I mean the first thing you got to do is make sure that their airway, their breathing, and their circulation is fine. And if you rely on the paramedics or your doctors to be the only ones who know about how to address the ABC's and to rescue someone, then it may very well be too late for your child to do anything. So I think all parents, really you do need to invest the time and effort to go to a CPR training class. I do think that's important.
Once you've done that, you've got the ABC's out of the day, you know obviously if you need to start some rescue breaths or heart compressions because you've learned CPR, you have someone yelling for someone to call 911 that sort of thing but if they haven't stopped breathing, they're pink, they have a heart rate, they're breathing fine, or maybe they're a little blue on the lips, sometimes you do see that. But if it's basically a Simple Febrile Seizure, it's lasting less than 15 minutes and they haven't stopped breathing, there's no other issues with it, you want to call your doctor and certainly every child should be examined to determine the cause of the fever. But is it an emergency thing where you have to run out and go to the emergency room, I would let your doctor decide. I mean if it's a little baby, six month old and they have not been sick and suddenly they have this fever and had a seizure, that's a kid that probably should be seen sooner rather than later.
On the other hand, you know if you're working on your third Febrile Seizure and your kid's older and you're more comfortable with it, then it's probably something that could just wait till morning. Call your doctor but they'll probably tell you, "Well if things are going fine, we'll see you tomorrow." That sort of thing. So it really depends on, is it the first time, what's the age of the child, if there's any doubt in your mind what you need to do, just call your doctor and ask.
Now, little work up is needed for Simple Febrile Seizures, especially if the fever has a known source. Your doctor might get a blood count to help determine if there's a bacterial process versus a viral process occurring, also getting electrolytes; sort of the salt levels in the blood may be useful if your child has a history suggesting they might have a problem with their electrolytes such as diarrhea. But in general, and the reason that that's important because some abnormalities in the salts of the body can also cause seizures although those are usually seizures that don't go away until you correct the underlying salt imbalance. So those usually, those kids end up in the emergency room anyway.
An EEG which is how we diagnose seizure disorders, where they put the electrodes on your head and hook you up to a machine, those are not indicated for Simple Febrile Seizures. Again if your child is six months to twelve months of age, your doctor will probably recommend you go to the emergency room at a children's hospital or right to their office, and some of those kids may need a spinal tap to rule out Meningitis. But if your child is older, spinal tap is certainly not necessary unless there are clinical reasons to do it. So if your child has a stiff neck, they're extremely irritable, if there're signs that they might have meningitis along with their fever and their Febrile Seizure, then they may still get a spinal tap.
But spinal taps aren't needed especially for kids over 15 to 18 months who just have the fever and the seizure, unless they have some other thing to make you think about meningitis again such as stiff neck and extreme irritability.
OK. Of course then I guess I should mention very briefly here, for the kids that have the Complex Febrile Seizures and the Symptomatic Febrile Seizures which we defined earlier, those kids usually do get more of work up because it's not just a Simple Febrile Seizure. So a lot of times they will get an imaging study of their head, like a CAT scan or an MRI to make sure that there's not a tumor or a bleed or a skull fracture or sign of child abuse,; those kinds of things. They may end up needing a spinal tap regardless of their age or other symptoms to rule out Meningitis. There're kids that may get an EEG, may get an electrolyte panel and will probably end up needing to see a Pediatric Neurologist before all is said and done.
So again those are going to be the kids where the seizure lasts for more than 15 minutes or if there's a focal aspect to the seizure, it's not just a generalized tonic-clonic seizure, but there's a focus, there's one part of the body that's seizing. And that's always more worrisome than when it's a general seizure.
OK. So how do we treat it?
Well Simple Febrile Seizures do not need any treatment. However, prolonged Complex Febrile Seizure history especially when those are recurrent; they may need anti-convulsant medicines, but that's very unusual. And then children with Symptomatic Febrile Seizures, a lot of times they already have some underlying neurological issue or they do by definition, and so they may need some treatment to correct their underlying disorder to help them not have seizures anymore with fever.
So treatment of the Complex and the Symptomatic Febrile Seizure's a little bit different but for Simple Febrile Seizures which is really what we're talking about here, no treatment is necessary.
How do you prevent them?
Really there's no good prevention, unless you keep your child from getting sick which is pretty hard to do. But it's one of those things that if you have a kid who's prone to having Febrile Seizures and they're in a daycare and they're more likely to get illnesses and get the fevers, then they're more likely to have their seizures. So these are kids you might not want in daycare, if they have a history of recurrent Febrile Seizures.
Now the downside to that is not being in daycare when they go to school, they get exposed to all the stuff and they're more likely to be sicker than the kids who are in daycare and caught those viruses when they were in pre-school. And we've talked about this before, but as you get older you do outgrow the tendency to have the Febrile Seizure. So it may be better to get sick when you are a little bit of an older kid than when you're younger, for those kids.
So recurrent Febrile Seizures, you might want to think about not doing daycare in order to prevent. But you know that's tough because sometimes both moms and dads have to work and there's no family, and there's certainly circumstances you shouldn't feel guilty if you have no other choice.
Remember the seizure usually happens with the first temperature spike only and once that seizure is over and the child is awake enough, you can give them Tylenol or Motrin to help them feel better and also to help prevent another seizure with another temperature spike. But again it's unusual for that to happen anyway. But still, if your child is sick and prone to getting fevers, certainly you can give Tylenol or Motrin to help prevent that initial big spike in fever which would set off their seizure.
Now if you have a kid who's never had a Febrile Seizure and have a runny nose, I would not give them Motrin or Tylenol to try to prevent a fever spike because it's probably not worth it to do that, plus you don't want to mask a fever if you don't have to because doctors use that in trying to decide what's wrong with your child, how long that they had the fever is a helpful thing. So I mean you don't wan to mask fevers unless you have to and of course you wouldn't want them if they already have a Febrile Seizure to decide whether that's something you want to mask. In any case talk to your doctor about it. You know I always say that.
The good news at the end is that the overwhelming majority of Febrile Seizures are not harmful even when they recur and that kids usually do outgrow the tendency after they're about age five or so. And remember again the fever is not a result of damage to the brain caused by the height of the fever. It's simply a way that some brains react to a rapid change in temperature.
Now I do have a Febrile Seizure fact sheet for you from the National Institute of Neurological Disorders and Stroke and you can find that in the show notes at Pediacast.org. Just click there and it's got a whole lot more information about Febrile Seizures, just in case you're interested.
All right that concludes our in-depth review of Febrile Seizures. And I really sincerely hope Jane that you do let all of the folks know in the teaching thing that you're doing, don't stir them toward Episode 12, steer them toward this one Episode number 72. And hopefully they'll all subscribe to PediaCast and become regular listeners and then tell their future patients about the show. Because that is my goal. [Laughs] See, I'm a little selfish that way.
All right. Let's take a quick break and we'll wrap things up right after this.
Thanks go out to; Nationwide Children's Hospital for providing the bandwidth for this podcast, and also Vlad over at Vladstudio.com; we really appreciate his artwork. Please support him by going to Vladstudio.com. If you're in the process of setting up a nursery, his pictures will look great as nursery decorations, and great shower gifts, Christmas ideas. So please support Vlad over at Vladstudio.com because he's very generous by letting us use his artwork. Thanks to you for stopping by and joining us today. Don't forget reviews in iTunes are very, very helpful. If you haven't done that yet, I would appreciate you doing so. Also the Poster Page is available and let all your friends and family know about PediaCast, if you haven't already.
So tomorrow we're going to answer some of your questions. We're going to have a Listener Question show. And until then, this is Dr. Mike saying "Stay safe, stay healthy, and of course stay involved with your kids." So long everybody.