KIDS
March 8, 2011

When A Child Has A Seizure

Seizures that occur when a child has a fever are scary, but are they dangerous? Sometimes.

There are several types of seizures than can occur in babies and children under the age of five. All are scary for parents, of course, but not all are cause for excessive worry. Recently, the American Academy of Pediatrics (AAP) revised its guidelines for doctors regarding simple febrile seizures, the most common type of seizures seen in children between the ages of six months and five years. It is helpful for parents to understand what they need to worry about and what they don't. The new guidelines also underscore just why staying up-to-date with vaccines is so important.

What A Simple Febrile Seizure Looks Like

Simple febrile seizures occur in normally-developing children between ages 6 and 60 months (five years) who have a temperature of 100.4 or higher and do not have central nervous system infections. ("Febrile" means related to fever.) They involve uncontrolled movements of the child's entire body.

Even though these seizures are anxiety-provoking for parents and children, they do not lead to brain damage, death, paralysis, or retardation... The trick is ruling out more serious causes.

A simple febrile seizure lasts for less than 15 minutes and does not recur within 24 hours. During simple febrile seizures, the baby or child will lose consciousness. His or her eyes may remain open, but be rolled back. They may wet or soil themselves and possible vomit or develop foam at the mouth. Non-febrile seizures (seizures that occur in the absence of fever), may involve abnormal movements of the entire body or of an isolated part or few parts of the body. They may also involve staring spells.

Simple febrile seizures occur in 2 to 5 % (percent) of children under 5 years old and are not considered to be dangerous or to be sign of epilepsy. Even though these seizures are anxiety-provoking for parents and children, they do not lead to brain damage, death, paralysis, or retardation. The main risk they carry is that the child will have another simple febrile seizure during a subsequent illness, or possibly injure themselves during the seizure.

The New Guidelines

The new current standard of care is to approach simple febrile seizures less aggressively, both in diagnosis and treatment, than other types of seizures.

The American Academy of Pediatrics' new guidelines replace those from 1996 and make clear the importance of diagnostic tests including spinal taps, brain wave tests, blood tests, and neurological imaging studies. The goal of the update was to reassess the risks and benefits of the tests that had been routinely done for children with febrile seizures and determine which were more helpful than harmful and which made significant differences in immediate and long term treatment planning.

A missed diagnosis of meningitis can lead to permanent neurologic damage, hearing loss, or death, so your doctor's first step is to make sure the seizure is not due to meningitis.

The guidelines reflect the improved pediatric care including changes in immunizations (discussed below) and increased understanding of the underlying mechanisms of febrile convulsions. This has reduced the need for overly aggressive work-ups for children with this condition.

The AAP is one of several professional organizations which works to set standards for safe and appropriate medical care. The Academy puts out Clinical Practice Guidelines on specific conditions or procedures that are made available to the medical community and taught to trainees. They are based on reviewing all the available, relevant research on a particular treatment or condition and weighing the risks and benefits of various approaches. They are updated periodically, taking into account new research and technology.

Seizures can be signs of brain abnormalities and infections. To rule these out, various tests and brain scans may be required. It is helpful to understand what you doctor may need to consider when you bring your child in after a seizure.

Ruling Out Meningitis; When A Spinal Tap Is Necessary

When a child has a fever and has had a seizure, the first step is to determine the cause of the fever and to decide whether the seizure fits the category of simple febrile convulsions. Seizures can be caused by meningitis, an infection of the lining of the spinal column, and meningitis can cause fever. A missed diagnosis of meningitis can lead to permanent neurologic damage, hearing loss, or death, so your doctor's first step is to make sure the seizure is not due to meningitis. He or she will ask about the nature of your child’s illness – when and how it began, how long it had gone on before the seizure – examine your child and possibly, perform a spinal tap.

The new AAP guidelines suggest that children between ages 6 and 12 months of age who are not up-to-date with their vaccines and who have had a seizure and a fever may need a spinal tap even if they look relatively well.

A spinal tap is a must if meningitis is suspected as the source of the seizure, for it is the only way to identify or rule out the disease before it can cause severe neurologic damage or death. Meningitis would be considered a possibility if your child appears very ill or lethargic, or has a stiff neck or legs when the physician attempts to move them in specific ways. Among the symptoms that are consistent with meningitis are severe headache, a characteristic rash, sensitivity to light, or vomiting.

However, if the child has a fever but is otherwise appears only mildly ill, or has a clearly-identified reason for her fever (such as an ear infection or sore throat or bronchitis/sinusitis), a spinal tap is not always necessary.

If A Child's Vaccines Are Not Up-to-Date
In the years since the 1996 recommendations have been drafted, major advances in medicine overcome the most common causes of meningitis in young children. The immunizations for Haemophilus influenza type B (HIB) and streptococcus pneumoniae which are given during infancy have protected thousands of children from these illnesses, making it even less likely that a child with a simple febrile seizure has a dangerous bacterial meningitis.

However, if children are not up-to-date on their immunizations, they are not fully protected from two common causes of bacterial meningitis. The new AAP guidelines suggest that children between ages 6 and 12 months of age who are not up-to-date with their vaccines and who have had a seizure and a fever may need a spinal tap even if they look relatively well.

The reason for this is that children under 12 months of age often do not develop the stiff neck and abnormal response to leg movements that older children get, so their clinical exam is not as reliable in ruling out physical signs of meningitis. Therefore, the new recommendation is that if a child's vaccination status is unknown or is deficient, a spinal tap should be considered. Children who are older than 12 months are not included in this recommendation, as they are typically much more likely to have classic clinical exam findings if they do indeed have bacterial meningitis.

Antibiotics May Complicate the Picture
Children who have been given antibiotics in the days preceding the seizure may require a spinal tap, just to be on the safe side, even if they don't look like they have meningitis and they have had all their immunizations. The reason for this is that If the child actually has meningitis, the antibiotic may have started killing the bad bacteria enough so the child doesn't appear to be as sick as she would with no treatment. But the antibiotics may not be the most appropriate choice, the right dose, and may not have been given long enough to provide complete treatment for the meningitis.

If the prior treatment has only suppressed, but not actually destroyed, the infection, it will flare up and the child may have serious consequences. Meningitis caused by bacteria requires specific antibiotics for several days delivered intravenously.

Using Brain Wave Tests and Brain Imaging

Electroencephalograms (EEGs)
Children with seizure disorders often have abnormal brain wave patterns which show up when an EEG or electroencephalogram is done. Doctors used to routinely perform EEGs on children with seizures to make sure there wasn't evidence of a permanent brain wave abnormality that would suggest that the seizure could recur or that the child needed daily anti-seizure medicine to prevent the abnormal brain wave pattern from flaring into a seizure again.

Today, EEGs are no longer recommended for children who are neurologically healthy and have had a simple febrile seizure. The patterns seen in the brain waves at the time of a simple seizure, or within a month of its occurrence are no help in predicting whether a febrile seizure will happen again or whether a either a seizure disorder will develop. Since the EEG doesn't help predict the likelihood of further seizures, it also doesn't provide any help regarding any interventions that would change the child's health such as starting anti-seizure medication.

MRIs or CT Scans
Scans are costly, cause radiation exposure, and may require sedation. They are not recommended for children with simple febrile seizures because abnormalities of brain structure have been shown to be very rare in children with simple febrile seizures in neurologically healthy children.

The source of the fever needs to be determined and should always be treated; the fever itself, not always.

Seizures may be caused by brain abnormalities, such as brain tumors, abnormally formed brains, or brain abscesses. A child who has had a seizure might have neuro-imaging in the form of CT scans or MRIs to look at the actual physical structure of the brain if the seizure was not related to fever and if other signs and symptoms are present. Structural problems in the brain often have other symptoms in addition to seizures, such as changes in the vision and eye movements, headaches, vomiting, changes in walking or coordination.

Blood Tests
A variety of blood tests have been done in the past when a child has a seizure. Here, too, the new AAP guidelines suggest a less is more approach. These tests have not proven to be helpful in the majority of cases and the current recommendation is that the blood tests be chosen to help determine the cause of the fever, rather than the cause of the seizure.



The Bottom Line For Parents

The basic approach to febrile seizures in 2011 is visit your pediatrician to confirm that the seizure fits the criteria for febrile seizures — a temperature of 100.4 or higher no central nervous system infections. The next step is to identify and treat the source of the fever. It is important to note that treating the source of the fever refers to treating the infection, dehydration, etc. It doesn't necessarily or immediately mean treating the fever itself with Tylenol.

The source of the fever needs to be determined and should always be treated; the fever itself, not always. If, as described above, the source of the fever is not clear and meningitis cannot be ruled out by exam, your doctor may consider a spinal tap.

If your child is between 6 months and five years of age and has a fever, she may develop a seizure. The following are some guidelines for what to do if she does:

  • Place your child on his or her side, somewhere where he or she won't fall.
  • Stay close to watch and comfort your child.
  • Remove any hard or sharp objects near your child.
  • Loosen any tight or restrictive clothing.
  • Don't restrain your child or interfere with your child's movements.
  • Don't attempt to put anything in your child's mouth.
  • Do not try to give food, liquid, or medications by mouth to a child who has just had a seizure.

Pay attention to the details of the event. Is the whole body moving or just a particular part? How long does it last? (It's best to time it with your watch). Is he having trouble breathing, or is he turning white, blue in the lips or finger tips? What is she like when it ends: Is she back to normal, or "out of it," or just wanting to sleep? Do all parts of her body move normally or does an arm or leg appear to be weak or paralyzed.

When your child has a fever, consult with your physician. If a seizure occurs, do not conclude on your own that it is a simple seizure; call your doctor or get follow up in an ER or urgent visit unit to evaluate the seizure and to diagnose and treat the source of the fever.

Make sure your child is up-to-date on immunizations as that will prevent the most common causes of early childhood meningitis and possibly eliminate the need for a spinal tap if your child has a febrile seizure. You can call your doctor or your local health department to review your child's immunization status.

Helpful resources:
For immediate first aid:
http://www.aboutkidshealth.ca/En/ResourceCentres/Epilepsy/AboutEpilepsy/FrequentlyAskedQuestions/Pages/What-Should-I-Do-When-My-Child-Has-a-Seizure.aspx
http://familydoctor.org/online/famdocen/home/children/parents/infants/066.html

The following websites will give you some additional information about measuring and managing children's fevers:
http://familydoctor.org/online/famdocen/home/children/parents/common/common/069.html
http://www.thechildrenshospital.org/wellness/info/parents/21656.aspx

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