Seizures in Children: Less Severe Seizures (Febrile Seizure)
Guest: Dr. Bernie Maria - Pediatrics
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Bernie Maria who is Professor of Pediatrics and Neurosciences here at MUSC. Dr. Maria, one of your areas of great interest and expertise is in seizure disorders of children. Let’s walk through, take a tour of that disorder, starting with a question: what is the least severe form of a seizure disorder.
Dr. Bernie Maria: We see children presenting in the hospital for new onset seizures and we see children in our clinics. What I like to explain to families is that there’s a whole range in the severity of seizures and that, oftentimes, the mildest form are seizures that occur in children between the ages of six months and five years. Those are febrile seizures.
So, these seizures that occur in the context of a fever, an infection, could be otitis media, pneumonia, or a simple cold. These seizures tend to occur when the temperature is rising quickly. It involves the whole body. It usually lasts less than 15 minutes. It seems like an eternity, sometimes, for families. Most of them last less than five minutes and are totally benign events. They’re more likely to have happened before in their family; there’s a genetic contribution to it. It doesn’t damage the brain. It doesn’t damage the child and usually doesn’t lead to seizures without fever, what we would call epilepsy.
Dr. Linda Austin: What temperature does it need to get before you can see a seizure?
Dr. Bernie Maria: Most children have a temperature that’s greater than 102, or 39 degrees Centigrade, at the time of the seizure. Children who are in daycare or children who have a shorter period of fever before they have the seizure are more likely to have more. Children who have their first febrile seizure in infancy are more likely to have more than if they’re a little older, approaching three, four, five years of age. It’s actually very reassuring to be meeting with the families of children with seizures that are febrile because we can be very reassuring in the way of them not likely having lifelong epilepsy or recurrent nonfebrile seizures.
Dr. Linda Austin: Now, you mentioned that these are very benign seizures. Should a parent take a child to the ER, though, or at least call a pediatrician when this is going on?
Dr. Bernie Maria: Oftentimes, if this is the first seizure that they have witnessed in their child, they’re going to call EMS, go to an emergency room or call the pediatrician. The most important thing is to find the source of the fever, but also to recognize that though meningitis and encephalitis are infections of the brain that can trigger seizures, the overwhelming majority of children are just going to have the fever itself from a cold or another easy to treat infection that produced the seizure.
Now, since most of them are benign, the great majority are benign and the overwhelming majority last less than five minutes, by the time the child has been seen by EMS or in the hospital emergency room, the seizure is over and the child is sleeping and beginning to wake up. So, for the most part, if it’s a first-time occurrence, especially in a younger child, it’s better that they be evaluated.
Dr. Linda Austin: Right away, or can you wait and call the pediatrician, take the child in the next day?
Dr. Bernie Maria: Because children who are the under the age of two can have meningitis without having a stiff neck and can have fever that produces seizures, it would be best, for a first event, at any age, that they be seen as soon as possible.
On the other hand, if it’s something that’s happened before, the family is usually very comfortable keeping them at home, cooling them off, getting the temperature down. We also supply them with Diastat which is a rectal gel that can break a seizure in the unlikely event that it goes on for more than four or five minutes.
Dr. Linda Austin: What’s the best way to bring a fever down?
Dr. Bernie Maria: It’s the old cooling them off, if at all possible, in the bathtub, using motrin or Tylenol. I know it seems a little contrary, but it turns out that very aggressive measures to reduce temperature have little or no effect on the recurrence of febrile seizures. We think the reason for that is that the temperature, as it’s climbing most rapidly, is when it’s going to be producing the seizure, rather than when it’s already up there. So, we tell parents not to get overly excited or worried when they’re not able to reduce the temperature quickly.
Occasionally, children who present to us with a first seizure that isn’t caused by fever, what we call a first unprovoked seizure, are seen. Those are children who are usually developmentally normal, doing well in school. The question that’s often posed to us is, well, what’s the chance of it happening again? The answer, generally, is 50/50. Even if the first seizure was a prolonged seizure, what we call a status epilepticus (SE), it doesn’t really increase the risk of recurrence of a second seizure. So, we don’t call that epilepsy and we don’t usually start a child on an anti-epileptic medication.
If they’ve had a second seizure, particularly if it’s happened within six months, that’s not provoked, meaning, you know, no fever, no trauma, then we call that epilepsy. We need to determine, then, what kind of epilepsy it is so that the treatment is appropriate. Different medications target different forms of epilepsy. In about a third of children who have epilepsy, they develop what’s called intractable epilepsy, meaning, it’s hard to treat. Medications aren’t getting us there. We need to think about surgery or a diet, a ketogenic diet, or a vagal nerve stimulator (VNS).
These are, if you will, the tools of the toolbox that can be used for this small piece of ice that sits outside of the water of the iceberg, that is, that small group of children who are having very difficult seizures and epilepsy to control.
Dr. Linda Austin: Dr. Maria, thank you very much for talking with us today.
Dr. Bernie Maria: My pleasure.
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