The Smith's are spending a quiet evening at home. After all, it was a busy day having the entire family over to celebrate their daughter's first birthday. Being the first grandchild in the family, she was certainly the center of attention. Perhaps that is why she seemed a little "out of sorts" and fussy--but nothing really out of the ordinary. At 8 P.M. she fell asleep on the couch, and dad carefully put her in her crib as she lay fast asleep.
As mom and dad were exhausted from the excitement of the day, they decided to retire early themselves. At 10:30 P.M. they turned off the T.V., and turned off all the lights as they made their way up the stairs to their bedroom. As they passed their daughter's room, they heard her crib shake, and the mattress springs squeak--and then heard a horrendous grunting noise coming from their daughter. They quickly turned on the lights and saw her laying on her back with her eyes open in a blank stare. There was saliva coming from the corner of her mouth, and her arms and legs were jerking rhythmically without purpose. The jerking stopped after about 30 seconds, although it seemed like hours to the Smiths. Their daughter let out a long groan, and then fell fast asleep. They thought for sure that she had died. They called 911 and picked her up and shook her. Mr. Smith tried to give her mouth-to-mouth resuscitation, but stopped when he realized that she was breathing normally.
In the 6 minutes that it took the paramedics to arrive, she was able to open her eyes and cry to be held by mom. In the ambulance, one of the paramedics commented how warm she felt. Just as he was saying that, mom was noticing how flushed her cheeks appeared.
By the time she was seen in the emergency room, she seemed to be back to her normal self. She was playful and happy as if nothing had happened. The only difference however, was that her temperature was 103.8. This came as a surprise to mom because she had been fine all day.
After a detailed exam and some simple lab tests (a complete blood count and a urinalysis) the doctor declared that she had just had a febrile seizure, and that she would be just fine. The cause of the fever was a viral infection. In fact, she could go home and did not need any medicine.
This vignette is a common and typical presentation for a febrile seizure or febrile convulsion. They occur in approximately 2-4% of all children in the U.S., and typically occur between the ages of 3 months and 5 years.
Febrile convulsions usually occur early in the course of an illness. Quite often, the parents report putting the child to bed "just fine", to be awaken in the middle of the night by the terrible sound of the child having a seizure. It is only later, when in the emergency room, that a fever is discovered. This is exactly what happened to the Smiths.
The classic febrile convulsion is a tonic-clonic type of seizure. In the tonic phase, the child may grunt or cry, then becomes rigid--back arched with all four extremities stiff as a board. Then the child goes into the clonic phase which is a rhythmic jerking of the extremities. The child is not conscious during the seizure although the eyes may be wide open. After the tonic-clonic phase, the child passes into the post-ictal period during which they may seem lethargic, limp or sleep soundly.
Most febrile seizures last minutes (less than 5 minutes). In most cases, the seizure is over by the time the child is seen by a medical person. The exact cause of febrile seizures is not known. Most are associated with common childhood illnesses such as an ear infection, tonsillitis, or a non-specific viral infection. It is not known exactly why, but these convulsions only occur up until the age of five years.
When a child is seen and evaluated after having had a febrile convulsion, it is critical to be sure that there is no underlying illness that requires treatment. In younger children there is always the fear that the seizure might be due to meningitis. If there is ANY question that meningitis might be present, a lumbar puncture (spinal tap) must be done to rule it out. Most experts feel that a first febrile seizure without a source of infection deserves a spinal tap.
As a rule, diagnostic lab tests should never be "routine". They should be done on an individual basis after a thorough history and a complete physical exam are done. Sophisticated tests such as a CT scan or a MRI of the head, or a brainwave test (electroencephalogram-EEG) are rarely indicated.
No doubt febrile seizures are one of the most frightening things a parent can experience. They will tell you that they believed their child was going to die. It must be stressed however, that febrile convulsions do not cause brain damage, and that most children who have them do very well. The likelihood of developing epilepsy, or a true seizure disorder, is extremely small...slightly above the incidence in the general population.
Parents appropriately ask, "Can this happen again"? Studies have shown that about 1/3 of the children who have febrile convulsions will have one or more recurrences. Most recurrences (around 75%) occur within one year. A recent paper listed the following as the most predictive indicators of recurrent febrile seizures: young age at onset, a history of febrile seizures in a first-degree relative, low fever when seen in the emergency room, and a brief duration between the onset of fever and the initial seizure.
Strict fever control with anti-pyretics and tepid baths have been advocated to prevent febrile convulsions however, this has not been proven to be of benefit. This is partly because the seizure is often the first sign of a febrile illness. Long term treatment with anti-convulsant medications has been used in selected cases, although the success of this is questionable and the use of these drugs is not without side-effects.
The long term approach should focus on parental education and trying to decrease parental anxiety. The parents should be instructed that if another seizure should occur, they MUST remain calm. The child should be placed on his or her side and do not try to force anything between their teeth (especially your fingers!). Be sure that there is no tight fitting clothes or anything wrapped around the neck. Observe the child closely, and try to time the seizure. If it has not stopped within 10 minutes, the child should be taken to the nearest medical facility by car or ambulance. If it does stop within a matter of minutes, call the child's doctor immediately and proceed accordingly.