5. FEBRILE SEIZURE/ SPASM - Info for/from doctors
by webmaster (father of two febrile spasm children)
from parents: special thermometer
from doctors: Hippokrates What is a febrile spasm? What risks? What todo. Which prophylaxis? Which diagnostic? What should be taken? What information to the parents?
The body temperature has to be constantly measured because recognising an increase in temperature is very important. Constantly measuring the temperature demands a lot of effort, and can lead to subjective, incorrect results. It also puts the child and the carer under stress particularly during the night. It would make more sense to use a device which automatically measures body temperature and gives off a signal when a rapid temperature increase occurs.
Does anyone have any experiences with such a device? Please write to: webmaster
5.1. Doctor‘s information from 1991
The following text was taken from the german magazine "Der Allgemeinarzt" (The General Practitioner) 1/1991.
Author: outside lecturer Dr. med. Franz Staudt.
Childhood febrile spasms
Diagnosis, therapy and prognosis
Franz Staudt
"Spasms occur in children during a high fever.....
They occur particularly frequently in young children up to the age of 7; older children and men are not sized by spasms during fever..."
Hippocrates approx. 400 B.C.
Febrile spasms and Infektkrämpfe are the most common neurological symptoms shown in childhood (2, 5, 6). They have been observed in 2–5% of all children. Despite this, the diagnostic and therapeutic approach to this problem is very varied.
Recently, some new points of view regarding therapy and prophylaxis have come to light. These, along with the usual questions on this subject, should be looked at in more detail.
The following questions will be examined:
What is a febrile spasm?
What risks is a child suffering from febrile spasms exposed to?
What diagnostic and prophylactic measures are available?
Which diagnostic measures are sensible?
What should be taken into consideration when vaccinating children with a history of febrile spasms?
What information should be given to parents and other adults?
Febrile spasms are also called Infectkrämpfe, Initialkrämpfe
and are commonly known as: Zahnkrämpfe, Gichter, Freisen
A febrile spasm is a cerebral fit which occurs in babies and infants (normally between 3 months and 5 years) only when fever is present. Febrile spasms are occasional fits. For a correct classification, one has to differentiate between them and epilepsy. Epilepsy is a series of repeated fits which are not characterised by fever (frequency 3–4%). Fits of spasms accompanied by fever in a child that has previously suffered from an acerebral fit of spasms are therefore not included here. No connection exists to an intracranial infection or to any other intracranial process.
What risks is a child suffering from febrile spasms exposed to?
The fit itself is a terrifying event for the family and is normally seen as being life threatening to the child. Normally, no injuries occur as a result of a febrile spasm. There is only a small danger of injury. Without prophylaxis, 30-40% of children suffer a second febrile spasm. The occurance of second or further febrile spasms in itself does not mean an increased risk of developing epiliepsy or brain damage caused by the febrile spasm. Only a small percentage of children who have had a febrile spasm go on to develop fits without fever, i.e. epilepsy in the narrowest sense of the word. Even then, one can assume that the original fit was not a febrile spasm, but rather a fit of epilepsy. Clear criteria differentiate between children with a high and a low risk of developing epilepsy.
The high risk group for whom developing epilepsy is estimated at 15% of children, is characterised so that at least two of the following risk factors have to be present.
Non-febrile fits in the family
Abnormal neurological state or abnormal development before the first febrile spasm
Complicated febrile spasm: long-lasting fit (more than 15 minutes), focal symptoms, postical EEG changes, fits which reccur within 24 hours. Only 2-3% of children who show none of or just one of the risk factors listed here will develope epilepsy afterwards. Death or permanent physical or psychological disturbances are not to be expected. Occasionally, neurological failures such as psychological retardation, stato-motor delay in development and/or sensory motor failures have been observed in children suffering from febrile spasms. As a rule, these CNS-attacks are already present before the first febrile spasm occurs. A complicated febrile spasm points to already existing brain-damage.
The risk of developing epilepsy depends on how old the child is. The risk for children that have their first febrile spasm before 2 and after 4 years lies between 8 and 12.5%, whilst the rate for those between 2 and 4 years is only 1.1% The existence of neurological failure before the onset of a febrile spasm is important for the prognosis of a febrile spasm with regards to the development of epilepsy. The risk is considerably higher for these children. The case history, clinical findings and descriptions of the fits are therefore very important for prognostic assessment and therefore parental consultation. The risk of later developing afebrile fits, i.e. epilepsy, increases with the length of the fit. The optimum therapy for acute cases is, therefore, especially important. A real emergency exists if a fit does not improve within a few minutes of anti-convulsive therapy.
First of all, keep calm. Loosen the child’s clothing, and turn him/her on their side. An exact observation of the fit is especially important. Under no circumstances should objects be put in the child‘s mouth, e.g. to prevent them from biting their tounge. As a rule, a fit lasts 1-3 minutes and stops of its own accord. Diazepam-Desitin rectal tubes (babies = 5 mg, young and school children = 10 mg), which have extensively taken over from the previously used Chlorahydrat – Rektiolen, represent a particular development. Their effect is almost the same as an intravenous dose of Diazepam. If this has no effect, repeat the treatment after approx. 5 minutes.
They enable the layman to carry out a reliable anti-convulsive treatment and should therefore be given to parents. One supository therapy is not enough due to the long absorption time needed. If the fit does not improve after using a diazepam clyster, the medication can be repeated without any problems. Further therapy is only seldom required. It is then recommended that the emergency doctor administers an i.v. dose of Clonazepam (Rivotril: babies 0,5 mg, small children 0,5 – 1,0 mg, schoolchildren 1,0 mg). During the fever, intermittent physical measures such as cold compresses on the forehead and extremities are well worthwhile. The child should not be covered up too much. Eventually, a dose of Acetylsalicylic acid p.o. could be prescribed (10 mg/kg/dose every 4-6 hours).
Prolonged prophylaxis (= long-term treatment with anti-convulsives) was earlier a recognised way of reducing the frequency of febrile spasms. The favoured medication was Phenobarbital. A dose (3-5 mg/kg KG) should reach a blood level in the lower therapeutic area (approx. 15g/ml). The medication had to be stopped for 25% of the children in therapy due to undesirable side effects – above all behavioural disturbances such as hyperactivity, disrupted sleeping/waking patterns and disturbances in cognitive peformance. Natrium Valproat is also effective, however, in very rare cases, life threatening liver damage can not be avoided. Therefore, this medication, as a rule, is no longer recommended on these grounds. When considering starting with prolonged prophylaxis it is important to know that it cannot prevent a cross over to epilepsy.
In recent years, the intermittent use of Diazepam has gained acceptance as a prophylactic measure, alongside the usual physical and medical antipyretic measures. As a result of this, diazepam suppositories 0.5 mg/kg KG (valium suppositories 5 mg/10 mg) are adminstered every 6 hours, as long as the body temperature lies above 38°C. A Sedierung, which is desired anyway with a feverish child, occurs as a side effect.
Which diagnostic measures are sensible?
If in doubt, and always when a CNS infection cannot be completely ruled out, admission as an inpatient can be recommended. This is normally serves as a comfort for worried parents.
First of all, the cause of the feverish illness has to be found. An exact case history, exact internal and neurological status and eventually also a blood count are needed for this. If necessary, a lumber punch will have to be made. While this, as a rule, should be carried out on children in their first year, because of the often discrete indications of meningitis, it is only necessary for older children if the normal signs of meningitis are present. A herpes encephalitis can only be thought of if the child’s condition further worsens after a focal "febrile spasm". These differential diagnoses are important because an effective antiviral medication has been at our disposal since the development of Acyclovir. The success of the therapy, however, depends on the earliest possible start of the treatment.
Normally, x-rays of the skull and further visual methods such as computer tomography or magnetic resonance tomography are not needed with a uncomplicated febrile spasm. There are controversial opinions regarding electro encephalogramms. An abnormal EEG – it is generally accepted – has a limited prognostic value for diagnosing the development of epilepsy in a febrile spasm patient. A hyper-synchrone potential or a photo sensibility can be observed in many children without finding a connection to any renewed spasms. Despite this, the importance of an EEG should not be underestimated. If a Herdbefund (focus) exists in the hours after the fit, it means the same as if the fit itself had been focal. If the Herdbefund (focus) is still present in the EEG, it is likely that the fit was no banal febrile spasms. Parietal monomorphic rythms, which continue after the post-convulsive espisode, are difficult to assess, especially if they occur together with spikewave complexities.
What should be taken into consideration when vaccinating children with a history of febrile spasms?
Many vaccinations can cause fever and many are carried out at an age when febrile spasms can occur. It is, therefore, advisable to discuss this aspect with the parents of a child that has already suffered from febrile spasms, or if there is already a relevant case history in the family.
The advantage of the protection from the disease, should be weighed against the risk of a spasm occuring. A dose of an antipyretic is reccommended to be taken on the first and second days after a DTP vaccination and on the seventh to the tenth days after a measles vaccination.
What information should be given to the parents and other adults?
Using a leaflet in individual clinics has proved to be advantagous. This cannot, however, replace the sensitive discussion with the parents.
Literature and leaflet on the editorial office "DER ALLGEMEINARZT" ("THE GENERAL PRACTITIONER") 1/1991.
Outside lecturer, Dr. med. Franz Staudt, Kinderklinik (Children‘s clinic) Ritterorden, 8390 Passau
5.2 Doctor’s information today
http://www.rz.uni-duesseldorf.de/WWW/AWMF/11/pnuer-0.5.htm
Last updated: 09.09.2005; webmaster