“Help me!! My baby is dying”
By Dr Suleiman Makore
Talking about febrile convulsions with Dr Makore. Take a moment and imagine this: you are in your office, putting finishing touches on that monthly expenditure report your boss, the finance manager, is eagerly awaiting when you get a phone call. It’s one of your daughter’s preschool teachers and she advises you that your little girl is unwell and has not been participating in usual play activities today. After getting permission from your boss you head out to pick up your daughter and on the way you recall how she seemed a bit “fluey” this morning and didn’t finish a bowl of her favorite cereal. Well you arrive at the creche and find her sleeping on a tiny mattress in one of the siderooms.. a perfectly normal activity for a 4 year old, except that its 10.30 in the morning! You wake her up gently and immediately notice that she feels like she’s been sleeping in an oven, so out of concern you decide to take her to be seen by the doctor at the 24 HR medical centre thats located a few streets from your house.
As you drive there you recall that her medical aid card is at home and take a detour to go pick it up, all the while you are speaking gently to your daughter reassuring her that “things are gonna be okay sweetie” and just to reinforce this you stop by the ice cream parlour and get her a small vanilla cone, which she makes an effort to eat. As you pull into your drive-way it happens.. at first it you hear what sounds like gurgling sounds coming from the back seat and you calmly look behind to see what your little girl is up to and to your horror you see her lying across the backseat with her eyes wide open but seemingly rolled upwards leaving just the whites visible and her body is trembling uncontrollably. You immediately slam the brakes and jump out of the car, open the back door to help her and you frantically call out her name and hold her to try stop the shaking but she remains unresponsive and neither does the trembling stop. At this point you are panic stricken, you don’t know what’s happening to your little angel.. Are you watching your daughter’s life fading away right in front of you??
An alert, passerby notices you acting strangely in your driveway and stops to investigate and on realising the trouble that has befallen you, he reminds you that there is a medical centre very close to your house and he even offers to drive you. By this time theres a familiar pungent smell filling the car that suggests she may have soiled herself. The good samaritan jumps in the driver’s seat and floors it whilst you sit at the back with your daughter and soon you arrive at the medical centre and you rush out carrying your still shaking child and enter the reception area screaming “help me!! My baby is dying”..
Well this hypothetical scenario I have narrated above is actually quite common and some reading it may even relate to particular aspects of it and it will form the basis of a topic i will be discussing today. The child in our story suffered a seizure or convulsion and in particular, a special type that is unique to small children called a febrile convulsion. Before we delve deeper into this phenomena however, i would like to give some basic definitions and background information as well as some historical perspective on convulsions so as to try put us all on the same page. Some of the medical terms may be complex but i will do my best to explain them as i go along.
Seizures have been described for 1000s of years throughout human history. An event that matched the classic description of a seizure was recorded over 3000 years ago in ancient Mesopotamian texts but according to prevailing beliefs and knowledge at the time it was attributed to a manifestation of the Moon god. Other cultures (Chinese, Egyptian, Indian etc) have also recorded through their written and oral history similar events but invariably the seizures were linked to some divine (usually evil) origin. Hippocrates wrote a manuscript about 2500 years ago about seizural disorders where he rejected ideas of an underlying divine cause but his views were widely rejected by other scholars and religious leaders of the day. For those who studied english literature like me at high school and in particular read the book “Julius Caesar” you will also recall a number of occasions when he was said to have “fallen and became weak in his limbs and frothed at the mouth”… On this one though debate is still raging as to whether this “falling sickness” was a seizural disorder or infact a series of mini strokes. Even up to the 19th century some leading researchers even considered excessive masturbation as a cause of seizures (as well as being a cause of blindness ofcourse ).
It was only in 1929 when a researcher by the name of Berger discovered that electrical brain signals could be recorded using scalp electrodes, a discovery that eventually led to the use of the Electroencephalogram (EEG) to study and classify seizures. Despite advances in the field of science and medicine, the issue of seizures is still shrouded with some form of fear and mysticism, particularly in religious circles with some still considering a convulsion as being a sign of demonic possession as opposed to being an external manifestation of an internal pathology.
A seizure is best described as “an abnormal, paroxysmal discharge of cerebral neurons due to cortical hyperexcitability”. The term paroxysmal refers to a “sudden, random and violent outburst of any nature”, cerebral neurons are the specialized cells that make up the bulk of our brain and cortical hyperexcitability speaks of excessive activity in a particular region of our brain know as the cortex. So basically a seizure can also be described as a sudden, uncontrollable outburst of electrical activity in the brain manifesting itself as a variety of sometimes very physical symptoms.
Seizural disorders may be classified into 2 broad groups according to the INTERNATIONAL CLASSIFICATION OF EPILEPTIC SEIZURES (ICES) and these are a) Generalized onset seizures and b) Partial onset seizures. Generalized seizures originate from a region of the brain known as the thalamus or may be triggered simultaneously in both cerebral hemispheres and typically manifest as symptoms involving the whole body and tend to be associated with varying degrees of loss of consciousness. Detailed explanation is beyond the scope of this article but is available on request by emailing me.
Various forms of seizural disorders are known to exist in children and a number will overlap with the conditions seen in the adult population. However its important to note that whilst most of the definitions and classifications used in adults also apply to children, peadiatric patients are a special group that need to be dealt with care. As one of my medical school professors always used to say, “children are NOT little people/humans, you need to think of them as being almost a different species to the rest of us when it comes to managing their illnesses”. That is to say, we cannot just take principles of adult medicine and “scale them down” to suit a peadiatric patient, when you are dealing with a child you have to approach them from a totally different angle.
Remember an 8 month old baby cannot tell you where it hurts or why they are refusing to feed but as the attending clinician you have to solve this riddle and usually time will be your worst enemy. Unlike in adults where the patient or other witnesses can give clear and typical reports of the kind of convulsions they experienced, in children, particulary the younger ones it maybe very subtle things. Small children may not experience the dramatic grand mal type seizures we typically see in adults but rather the child may just go unresponsive and start blinking or smacking their lips uncontrollably.. though not as frightening as the whole body fits, these subtle forms are still jus as dangerous if left uncontrolled. Some children experience what are known as “absence” seizures and these may manifest as just brief lapses in concentration lasting a few seconds or minutes or the child suddenly appear to “stare into space” for a minutes before resuming, seemingly unaware of what just happened, with their normal activity.
For children in school these absence spells may happen frequently but still remain unnoticed by the parents or teachers but will have the unfortunate consequence of falling grades which they may just attribute to the child not being serious with school or being a slow learner. The discussion of convusions in children is VERY broad and many books have been written on them but as mentioned earlier, the focus of this article will be to shed light on a particular kind of seizural disorder and those are febrile convulsions.
Febrile seizures are also sometimes called febrile convulsions. During a febrile seizure, the child’s body usually becomes stiff, they lose consciousness and their arms and legs twitch. Some children may wet themselves. This is known as a tonic clonic seizure.
By definition, a simple febrile seizure occurs in a child who is between the ages of 6 MONTHS TO 5 YEARS OLD, develops a FEVER and then has a SINGLE SEIZURE (which typically occurs around the onset of the abnormal rise in body temperature). The seizures are usually of the generalized tonic-clonic variety, lasting less than 15 minutes and they occur in a child who was otherwise healthy, save for the fever which may be caused by an acute illness such as an attack of tonsillitis, otitis media (ear infections), “flu”, or even a bad “tummy” infection with diarrhea & vomiting, known as gastroenteritis.
Febrile convulsions are the commonest childhood seizural disorders and occur in association with an elevated body temperature. The exact mechanism by which this plays out is still unclear however but studies have pointed to a genetic predesposition, that is to say they tend to occur in families. They can be divided into simple febrile seizures and complex febrile seizures.
Types of febrile seizure
There are two main types of febrile seizure.
It is essential to note that in order for a child’s seizure to be classified as a simple febrile convulsion, they must not have any preexisting neurological abnormality (a deformity involving the brain or spinal cord) and the fever should not have been caused by any infection or disease that specifically targets the brain or spinal cord such as meningitis or encephalitis or a brain abscess (pus accumulated in portion of the brain).
Complex febrile seizures are also defined using the criteria above but in this case the seizures may be focalized, prolonged (extending beyond 15 minutes) and may be multiple seizures as opposed to just one at the onset of symptoms.
Simple febrile seizure
A simple febrile seizure is the most common type of febrile seizure, accounting for about eight out of 10 cases. It’s a fit that:
is a tonic clonic seizure (see above)
lasts less than 15 minutes
doesn’t reoccur within 24 hours or the period in which your child has an illness
Complex febrile seizure
Complex febrile seizures are less common, accounting for two out of 10 cases. A complex febrile seizure is any seizure that has one or more of the following features:
the seizure lasts longer than 15 minutes
your child only has symptoms in one part of their body (this is known as a partial or focal seizure)
your child has another seizure within 24 hours of the first seizure, or during the same period of illness
your child doesn’t fully recover from the seizure within one hour
It is important to note at this point that the diagnosis of a febrile convulsion is one of exclusion, that is to say a qualified clinician should only make it AFTER ruling out all other possible causes of child in a particular age range, with fever presenting to hospital with fits. For example, amongst the multitude of known causes of seizures, one of the main ones in children especially is what is termed as hypoglycemia (this is when the blood sugar levels drop below the acceptable lower limit at which the body’s cells can function properly), now if a child is very sick with a feverish illness it is very likely that they will refuse to feed which in turn results in their blood sugar falling.. A child like this may have a fit because of the fever itself or because of the low sugar or both and so its essential for the clinician to determine this quickly.
No specific blood tests or imaging (scanning) tests exist for diagnosing febrile convulsions but when facing a child with suspected febrile convulsions the focus should be finding the cause of the fever and hence treating.. i.e. treat the cause (the infective agent) not the symptom (the seizure). If, as was the case with the child in our hypothetical case at the beginning, the child is actually still experiencing a fit when they arrive at the hospital/medical rooms, the initial management is the standard emergency protocol. That is to say, the first responder should call for help from other trained colleagues (teamwork), they should check the patient’s A B Cs (Airway, Breathing & Circulation) and if any of the above are compromised they should respond appropriately including putting an oxygen face mask or nasal prongs for the smaller children, they can give a type of sedative drug known as a benzodiazepine via the rectal route to suppress the current fit or any recurrent fits but use of such drugs will also depend on factors such as age and weight of the patient and as such should only be used with care by skilled staff. Once the patient has been stabilized, investigations should begin (though in reality these things should occur simultaneously.. stabilization,investigation treatment etc), the exact choice of tests will depend on availability of appropriate lab suppport, cost and also location (certain conditions are more prevalent in certain regions or countries than others). Examples of basic tests a clinician may run in our African setting are: i) glucometer for a rapid assessment of blood sugar; ii) blood for malaria parasites + rapid malaria paracheck so as to check if malaria infection was the primary cause of the fever; iii) blood cultures to detect specific bacteria in the blood that may have caused the infection and also to help in treating appropriately; iv) widal test to check for infection by the bacteria that causes typhoid (another so called febrile illness); v) urea & electrolytes so as to rule out electrolyte derangements as the cause of the fits; vi) urine sample to look for signs of an ongoing urinary tract infection; vii) if they are having diarrhea, they can take a stool sample and it can be examined further at the lab for the causative organisms; viii) if theres reason to suspect another cause of seizures such as poisoning, drug overdose or toxic substance ingestion the clinician may also to a toxicology screen; ix) in children less than 18 months of age but above 6 months it may be prudent for the clinician to perform a lumbar puncture and send the child’s cerebrospinal fluid (csf) sample for further investigation because at this age, even if the child has meningitis, the signs are not always as clear as in the older population and x) for the older children and especially for us in Africa with the high HIV burden, if the child has other signs of meningism, a lumbar puncture should be done and the csf analysed; xi) throat +/- pus swabs where appropriate to determine the exact infective organisms.
Remember as well that when the patient initially came in the clinician should have thoroughly examined the patient so they would have picked up any other obvious signs pointing to the cause of the fever such as inflamed tonsils, a runny nose, a pus-like discharge from one of the ears or a nappy that contains very foul smelling stool or urine. Imaging studies such as a brain CT scans are rarely needed nor would they be helpful unless the patient came with suggestive history such a report of recent head injury or gradual loss of visions (things that point to a focalized problem in the brain), whilst an EGG is unlikely to yeild any beneficial results unless done whilst the patient is actually fitting.
Once the clinician gains a clearer picture as to whats going on, as emphasized earlier the thrust should be to treat the cause of the fever.. if it was an ear infection or tonsillitis they should commence the child on a course of antibiotics empirically (based on knowledge of the common infective organisms in that country/region) whilst awaiting definitive blood culture/ throat swab etc results for example.. If results show malaria or typhoid, they should manage as per national guidelines for these conditions. If the child’s other results show that they have indeed got meningitis, though now falling outside the definition of a true febrile convulsion, the clinician should now treat it appropriately. An anti-pyretic drug (a drug that lowers temperature) should also be given, the commonest and probably most widely available in our setting being paracetamol.
A convulsion, especially a grand mal type, is a distressing event to watch, more so for parents of a young child, so it is also very crucial that the clinician reassures the caregivers, especially where a likely cause has been identified, that their child IS NOT dying and that they are unlikely to have a permanent brain abnormality or that they there is very little chance of them having seizures throughout the rest of their lives. Children who experience one or 2 episodes of febrile convulsions rarely require long term anticonvulsant therapy, i.e. once you treat the causative infection, life goes back to normal.
The take home message is that febrile seizures occur in young children at a time in their development when their so called “seizure thresh-hold” is low (the “trigger” for them having a fit is set very low) and this happens to coincide with the time in their lives when they are affected the most by ear, throat, chest, urinary infections etc most of which cause a rapid rise in temperature.
We cannot end this discussion without touching on epilepsy. Now as a form of seizural disorder, epilepsy is also very broad and would require a separate discussion by itself in order to do it justice but i will very briefly mention the condition here so as to contrast it with what we have been discussing.
Epilepsy is a brain disorder characterised by an ENDURING predisposition to generate seizures and by the neurobiologic, cognitive, pyschological and social consequences resulting from it.. A mouthful i know. The hallmarks of epilepsy are the RECURRENT and UNPROVOKED seizures that are associated with it. A key feature in making a diagnosis of epilepsy is the history that is usually given by the caregiver or person who has closest contact with the patient and typically epileptic seizures are very STEREOTYPICAL (the patient may act in certain fashion, then have the fit which may take a specific characteristic fashion such as jerking of one side of the body for 3 – 5 minutes etc). This is very important to note because the seizures seen in patients who have febrile convulsions are preceded by feverish illness (”provocation”), they tend to be isolated events, although they may recur at a later date but almost always in association with a fever and may not follow any prescribed fashion (the first episode may be a full blown grand mal fit whilst the 2nd episode may consist of just continous blinking and lip smacking).
I will emphasize again, A SINGLE SEIZURE DOES NOT EQUAL EPILEPSY and as such long term anticonvulsant therapy should not be commenced after a single or even 2 unrelated events in the absence of sufficent supporting evidence from either the patient or competent witnesses (usually adults in a sober state). Anticonvulsants carry many side effects and so should only be prescribed by a suitably qualified clinician who has been provided with information that strongly suggests that the patient has a seizural disorder whose progression can be halted or at least controlled by pharmacological agents only.
Well allow me to close by giving some “feedback” on the story i shared at the beginning. After bursting into the reception area of the medical centre carrying the shaking body of your little girl, you were immediately directed into the treatment room by one of the nurses whilst they raised the doctor on duty. A quick temperature check showed her to be spiking at 39.8 0C whilst a glucometer prick test had a normal value of 4.9 (mmol/l). When the doctor arrives, the fitting has stopped but the girl is still in a drowsy state and she (the doctor) orders a rapid malaria test (after hearing that you had gone with your daughter to visit her grandmother in Mutoko about 2 weeks prior), the rapid test is negative for malaria but she also takes a blood sample which will be examined further at the lab just to be certain with results later expected that afternoon. The doctor examines her further whilst you frantically try and get a hold of her daddy and as you do this you hear the doctor say to the nurse assisting her, “there’s our problem”. Whilst checking inside her mouth with a wooden spatula she catches sight of 2 bright red tonsils, a sign of inflammation.. your daughter has acute tonsillitis. The doctor informs you of the most likely diagnosis and that she wishes to admit your child into their observation ward for the rest of the day and probably overnight whilst they commence injectable antibiotics, painkillers as well as something to lower the temperature. The doctor also gives you option to contact the on-call peadiatrician if you so wish but you opt to wait to see her progress through the rest of the day.
By the end of the day, after the initial doses of meds, your daughter looks a bit more livelier, her temperature has started coming down (38.2 0C, still above normal but much lower than the dangerous levels it had reached), helped in part by the fact that the doctor also advised you to remove most of her clothing down to just her underwear. Her first set of blood results are starting to come in and they have confirmed that its definitely not malaria and the doctor advises you that she feels more comfortable to keep your daughter admitted overnight to give her another dose of injectable antibiotics and will most likely discharge her in the morning on liquid medicine.
Well as you narrate the day’s events to your hubby who is now sitted next to you, you can’t help but chuckle when you hear your daughter ask in her sweet little voice “mhamha, ndinoda macartoon” (mummy, i want to watch cartoons).
May I in conclusion say, if your child is having a febrile seizure, place them in the recovery position. Lay them on their side, on a soft surface, with their face turned to one side. This will stop them swallowing any vomit, keep their airway open and help prevent injury. Stay with your child and try to make a note of how long the seizure lasts. If it’s your child’s first seizure, or it lasts longer than five minutes, take them to the nearest hospital as soon as possible, or call for an ambulance. While it’s unlikely that there’s anything seriously wrong, it’s best to be sure. If your child has had febrile seizures before and the seizure lasts for less than five minutes, phone your doctor for advice. Don’t put anything, including medication, in your child’s mouth during a seizure because there’s a slight chance that they might bite their tongue. Almost all children make a complete recovery after having a febrile seizure.
This article was compiled by Dr Suleiman Makore who is a Senior House Officer in anaesthetic department at Mpilo Central Hospital in Bulawayo, Zimbabwe. He is now a guest writer on our website www.docbeecee.co.uk and can contact him via our usual email firstname.lastname@example.org
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Dr. Makore has used all reasonable care in compiling the information, but makes no warranty as to its accuracy. Consult a doctor or other health care professionals for diagnosis and treatment of medical conditions.