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.
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.
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.
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.
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 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.
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.
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.
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.
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.
The following websites will give you some additional information about measuring and managing children's fevers: