Febrile Seizures: An Overview
Guest: Dr. Tim Givens – Medical Director
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Tim Givens, Medical Director of the brand new Children’s Hospital pediatric emergency department. Now, I should clarify that, Dr. Givens, we’ve certainly had a pediatric ED for a long time, but this is its own separate emergency department. We’re so excited about that, and happy to have you here with us. In an earlier podcast, we talked about fevers. Let’s talk about a special occurrence that happens sometimes with fevers, which is seizures; a very scary event. What does a seizure in a baby look like?
Dr. Tom Givens: Well, generally they’re shaking all over the place. They don’t respond to you. Their eyes may be rolled back in their head, or twitching. And if you’re a parent seeing your child go through something like that, you’re right, it’s awfully frightening.
Dr. Linda Austin: What causes a febrile seizure?
Dr. Tom Given: There are lots and lots of causes for seizures. The vast majority of the ones in normal healthy children are caused by fever. And there are two theories to explain why a fever would do that. Some people think it’s the height of the fever that matters. I’m of the camp that thinks that it’s how quickly the temperature changes, and that’s just from my own experience. I’ve seen children at 105 that don’t have seizures, and I’ve seen kids that jump really quickly from 98 to 101. Mom says, I went to get the Tylenol and I came back, and he was seizing. I think it’s how quickly the temperature changes.
Dr. Linda Austin: Are some children more particularly prone to seizures; seem to have them repetitively when they have a fever?
Dr. Tim Givens: Well, there are groups of children who are at risk. Particularly, if you have a family history of febrile seizures, your threshold may be lower than other people’s. Generally, in order to be classified as a febrile seizure; because we think this has to do with an immature, or developing, brain, you have to be between six months and six years of age; up to school age. The fever has to be associated with a fever. Obviously, if you don’t have a fever, you can’t label it febrile seizure. It has to be brief, which in medical terminology is less than 15 minutes. If you had to watch your child seize for 20 seconds, it would be an eternity, but we have to have a cut off somewhere, and that’s 15 minutes. It has to be generalized, which means your whole body is involved; not one arm or one leg, not looking one way. It’s your whole body. After the seizure, you have to return to normal within a brief period of time. And it usually occurs within the first 24 hours of your illness.
In other words, this isn’t something where you’ve had fever for a week and then all of sudden develop a seizure disorder. That would worry me that you had some infection in your system and now it’s spread to involve your brain, and that’s why you’re having it. So, usually this is, child was playing, looking great, had a little sniffle, and then all of a sudden, bang, developed a high fever, and seized. And oftentimes we’ll see children in the emergency department, where their first presentation is the seizure. The family didn’t even know they were ill. And when we check their temperature, they’re 102 or 103.
Dr. Linda Austin: What should a parent do while the child is having a seizure?
Dr. Tim Givens: I would say, if you’re able to, open, or protect, their airway; you know, the whole thing about not letting them swallow their tongue. Lay them on their side, in case that they would vomit, in the fetal position, and then make sure that they’re safe; that they won’t hit anything or injure anything, and have someone contact EMS (911), and have them transported to the nearest medical facility. That’s the thing to do.
Dr. Linda Austin: So, let’s say a child has had several seizures. Each time, they need to go by ambulance to the emergency department?
Dr. Tim Givens: Yes. Let me start off by saying that most children who have a febrile seizure, 70 percent or more, will never have another one. It’s a unique event, and they’ll outgrow it, and no problem. If you have a second febrile seizure, you’re more likely to have a third, and then a fourth, and then a fifth. It’s a question of threshold and your response, just like some people have skin that’s more sensitive than others, or some people wheeze at certain provocations and other people other are relatively resistant. Some people have seizures at the drop of a hat, and a slight elevation in temperature will do it.
I think it’s kind of like running up, you know those polar bear things where they jump in the water, the icy lake, when you hit the water and just shiver all over? That’s the way I think your brain reacts when your temperature rises really quickly, internally. It just doesn’t know what to do. It has this brief shiver, and you have this uncoordinated discharge, and a seizure, and then it’s over. And that’s it.
Dr. Linda Austin: But then what is the reason that a child needs to be transported by ambulance to an ED?
Dr. Tim Givens: Well, let me, I guess, give you some history. In the old days, when we weren’t as knowledgeable about febrile seizures, if you had a febrile seizure, you would get blood work and a spinal tap, and all these tests. What we found is that we were doing a lot of tests on normal children that were coming back normal. They were unnecessary, and they didn’t affect the management or the outcome of the child. In fact, when I was in my training, 20 some years ago, I remember chasing kids around the room trying to catch them to do their spinal tap. And that’s silly. I mean, those children did not have meningitis. But that’s the way we were trained at that time to treat febrile seizures.
Now we know that febrile seizures don’t necessarily mean you’ll have epilepsy, do not necessarily mean you’re going to have any kind of long-term outcome. You don’t lose IQ points. It’s not a big deal. And so our primary assessment, now, is to look the child over, make sure they’re okay, reassure the family, and let them go on their way. We don’t even do CAT scans, or EEGs, or anything or that nature anymore.
If you have a second one, or a third one, sometimes we start to think, you know, maybe that child has epilepsy, because children with epilepsy, when they get sick, or have a febrile illness, it’ll lower their threshold, and they’re more likely to have seizures. So we don’t necessarily do the workup after the first time, but maybe after the second, or the third. The other thing is that we don’t want to become cavalier about it. We don’t want to say, oh, there’s Johnny again, having another febrile seizure, when this time he may be really ill and have meningitis. So I think it’s important for the parents and the child to be checked out each and every time, have someone look them over and say, yes, this was just another febrile seizure, and to discuss whether or not any further workup as an outpatient is indicated.
Dr. Linda Austin: So, let’s talk, if we could, for a moment, about meningitis, because that is the big scary thing that you worry about, I’m sure. What, exactly, is meningitis?
Dr. Tim Givens: The meninges are the covering of the brain and the spinal cord. When they get inflamed, or irritated, that is meningitis. So, that will present with a number of signs. You can have high fever. You can have headache. You can have photophobia, which means the light bothers your eyes. You can have a stiff neck. You can have seizures. So, seizure would be one possible presentation, and particularly if you have fever in association with it, of someone with meningitis. What we like to make sure is that, after these seizures, febrile seizures, you have a full recovery, and you have no signs or symptoms of meningitis afterwards, and that we don’t need to do any further tests.
Dr. Linda Austin: And, of course, meningitis is rare, but it can be really deadly. It seems like every few years, I hear of a case of meningitis where it just hits out of the blue, sometimes in a really tragic way. A child will have a fever, they call the pediatrician, or don’t. They’re just watching it, and, boom, it’s meningitis. And it can be fatal.
Dr. Tim Givens: Right, right. And there used to be a higher rate of fatality from meningitis before we had a number of the vaccines that we have today: the pneumococcal vaccine, the haemophilus influenzae vaccine; it’s fairly routine now, menactra, the meningococcal vaccine that we suggest for college students now, and teenagers. So, we have controlled the organisms that cause a lot of the devastating meningitis in the past. But it seems like some new organism always sneaks up, and then starts causing problems. Right now, we think we’ve covered the big players, but there are still some out there that rear their ugly heads every now and then.
So, again, if you have a seizure, even if it’s benign, have your child checked out in the hospital, and have someone tell you it’s benign and nothing further needs to be done.
Dr. Linda Austin: Dr. Givens, we’re so thrilled to have you with us here at MUSC, and we’re just so proud of our new emergency department and the services that it can offer children in the Lowcountry, and beyond. Thank you for joining us today.
Dr. Tim Givens: My pleasure.
If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.