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INTRODUCTION

Febrile seizure is one of the most common paediatric neurology problem encountered in Clinical practice. The incidence of febrile seizures is approximately 50/lakh population. Conventionally, febrile seizures are classified into simple febrile seizures and complex febrile seizures, based upon whether the seizures are generalised or focal, the number of seizures per febrile episode and the duration of each seizure episode. Febrile seizures that are generalised, brief (<15 minutes), and occur only once in 24 hours are classified as simple febrile seizures. Those that are focal, or prolonged (>15 minutes) or occur more than once in 24 hours are called complex febrile seizures.

The management of febrile seizures has been divided into two major categories; Intermittent prophylaxis and continuous prophylaxis. More than 90% of children with febrile seizures can be successfully managed with intermittent prophylaxis, using paracetamol and diazepam (intrarectal or p.o.) during fever episodes. However children who have frequent or prolonged febrile seizures, especially if associated with developmental delay and / or neurologic dysfunction and epileptiform discharges in the EEG may need continuous prophylaxis with either sodium valproate or phenobarbitone. Generally, sodium valproate is preferred due to the adverse effects of phenobarbitone on cognition and learning.

Aims of the study & methods

This study was under taken to evaluate the management perspectives of pediatricians and general practitioners with regard to febrile seizures. The study was conducted at “The Centre for Epilepsy and Neurology”, a referral centre for epilepsy in North Kerala. A printed questionnaire was sent to about 100 doctors, mostly pediatricians, and information collected through mail services. The questionnaire solicited information about their treatment choices with regard to febrile seizures.

Results

70 doctors responded to the questionnaire. (70% responder rate). All doctors were unanimous in agreeing that paracetamol and diazepam given during febrile episodes is the treatment modality of choice for simple febrile seizures. They felt that this alone was sufficient in more than 90% of the cases.

The most important drawbacks of intermittent prophylaxis expressed by many doctors were that the parents may fail to give the medications on time and that the fever may be noticed only after the seizure. Most of them, (70%) felt that parents were more compliant to intermittent than continuous prophylaxis.

Continuous prophylaxis was considered necessary in only ten percent of children with febrile seizures, by the vast majority (95%). The major indications for continuous prophylaxis were considered to be complex/prolonged febrile seizures (65%), abnormal neurologic signs (80%), positive family history of epilepsy (55%) and development delay (35%).

Seventy percent of the doctors preferred sodium valproate to phenobarbitone as the drug of choice for continuous prophylaxis. Most of them felt that routine examination of liver function tests were not essential with sodium valproate.

The most common indications for EEG and/or neurologist referral were focal neurologic signs (80%), prolonged or complex febrile seizures (60%), developmental delay (55%) and positive family history of epilepsy (40%). The mean duration of continuous prophylaxis was considered to be 2 years of seizure free interval (65%) or until 5 years of age (35%).

Discussion

The management decision of the doctors who participated in this study is in tune with the standard management strategies adopted for febrile seizures world wide. We know that ninety percent of all children with febrile seizures can be successfully managed with intermittent prophylaxis. The major criticism against intermittent prophylaxis is that parents may fail to give medications on time or that the fever may be noticed only after the seizure. Both these points are valid, but by themselves do not justify continuous prophylaxis in the vast majority.

Children who have complex/prolonged febrile seizures, especially if they have developmental delay and neurologic dysfunction, may be candidates for continuous prophylaxis using valproate or phenobarbitone. This is more so, if they have EEG abnormalities or if there is a history of epilepsy in the family. Due to cognitive side effects, sodium valproate is preferred to phenobarbitone, in spite of the hepato-toxic side effects of the former. The views of the doctors who participated in this study were also similar.

Generally, children need prophylaxis till 5 years of age, since they have a theoretical risk of having febrile seizures till that age. However, epidemologic studies have shown that the vast majority of febrile seizures occur in the first three years and so many pediatricians prefer to give continuous prophylaxis till two years of seizure free interval and then start tapering the medication.