febrile(1)
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Transcript of febrile(1)
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Febrile convulsions
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Meest frequente vorm van epilepsie bij kinderen
Koortsstuipen= Febriele convulsies
Is een vorm van (gegeneraliseerde) epilepsieleeftijdsgebondengenetisch bepaald : genetic susceptibility
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Fetveit A, Assessment of febrile seizures in children, Eur J Paed 2007Febrile seizures : Frequent !SimpleSelf limitingShort durationGeneralized (tonic/clonic)No recurrence within the next 24 hNo postictal signs
ComplexLonger durationNew events within following 24 h; series of eventsFocal seizuresPostictal signs
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Management of febrile seizures
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A febrile seizure is a seizureTreatment options comparable with epilepsy?
2 seizures or more should be considered as epilepsy and prophylactic treatment should be started
Versus
Febrile seizures are something specialProvoked (fever, infection) Age specificityBenign outcome
= no prophylactic treatment necessary
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Acute treatment: Benzodiazepinesworking mechanism : + Gaba receptor
Fast acting: fast penetration in the brain
Short half-life
Sedative, hypotensive, respiratory depression
Lorazepam, diazepam, clonazepam
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Prophylactic treatment? recurrence risk ? prognostic factors recognizable
(sub)acute sequels of febrile seizures ? Limited
epilepsy after recurrent febrile seizures? only in complex febrile seizures (?) epileptic syndromes including febrile seizures
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Prognosis after first febrile seizure
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1. Recurrence risk (A.Berg, 2003) 30-40% recurrence Of these children, 50% will have 3 seizuresRecurrences usually in first year after first seizure
Risk factors :Age at time of first seizure : younger age +++Familial antecedents of febrile seizureslower temperature Complex febrile seizuresNeurodevelopmental abnormalities
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2. Neurological sequelsNormal developing child with febrile seizures: no increased risk for developmental abnormalities (Ellenberg 1986, Verity 1998)
Secondary brain damage only after 30 minutes of convulsions
Normal/Improved memory functions in children with a history of febrile seizures (Chang et al, 2001)
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3. Risk for subsequent epilepsyOverall increased risk :Age 5 : risk of epilepsy 2%Age 25 : risk of epilepsy 7% In children with epilepsy: 13-19% had febrile seizures in the past
Risk factors:
Complex febrile seizures : 4-12% (partial epilepsy syndromes)
simple febrile seizures : 2% (generalized epilepsy syndromes)
Delayed neurodevelopment / brain abnormality : risk + 30%
Family history of epilepsy
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Epileptic syndromes with febrile seizuresGEFS +
Severe myoclonic epilepsy of infancy: Dravet syndrome
HHE syndrome
Mesial-temporal sclerosis
Consequence of prolonged complex febrile seizure?Predisposing hippocampal factors? (van Landingham 1998)Genetic predisposition (IL-1 metabolism Kanamoto,2000)
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I Scheffer, S Berkovic, Brain 1997, 120:479-490Generalized epilepsy and febrile seizures plusGEFS+
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Febrile seizures and MTSMTS : 30% prolonged febrile seizures
MTS consequence of a prolonged seizure or status epilepticusHippocampus in childhood vulnerable to excitotoxic damage
But why unilateral MTS?Pre-existing hippocampal abnormalityHypoxia, cortical malformations
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Prevention of recurrences does not prevent epilepsy
Phenobarbital 3mg/kg/dayLong term negative cognitive effects
Sodium valproate 20 mg/kg/day
Not effective : Phenytoin, Carbamazepine
Other anti-epileptic drugs not tested
AED treatment : IS IT NECESSARY?
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Oral Diazepam in fever episodes?
Rosman et al NEJM 1993Verrotti et al, EJPN 2004
Oral 0,35 mg/kg every 8 hours for 24 hours or until fever is gone
Side effects can mask or mimic underlying brain infection
Febrile seizure can be the very first sign of a febrile disease
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Antipyretics ?Effective in lowering fever: systematic and rigorous antipyretics
Autret 1990 : in febrile episodes:Diazepam + aspirin versus Placebo + aspirin
Results :
overall rate of recurrence lower than in literature (18% versus 30-40%)
no differences between 2 groups (diazepam not effective)
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Consensus statementsRoyal College of Pediatrics and Child Health 1991
American Academy of Pediatrics Pediatrics 1999, 103:1307-1309
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American Academy of Pediatrics
Based on the risks and benefits of the effective therapies, neither continuous nor intermittent anticonvulsant therapy is recommended for children with one or more febrile seizures.
The American Academy of Pediatrics recognizes that recurrent episodes of febrile seizures can create anxiety in some parents and their children, and, as such, appropriate education and emotional support should be provided.
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