Fever Phobia #1: Febrile Seizures…..
I’ve been asked to speak at a upcoming city-wide nursing conference, and it took all of about three seconds to think of a topic: fever. Across the board, and that includes physicians as well as nurses and parents, an understanding of the pathophysiology of fever due to infection is lacking, and the approach to its treatment is problematic. The number of blatant misconceptions regarding childhood fever truly is staggering. Since the early 1980’s, when the seminal paper on the subject of fever phobia was published in the Journal of the American Medical Association, there have been several additional studies confirming and cataloging the causative factors and potentially dangerous resulting behaviors.
Fever is one of the most common reasons for parents to seek medical care for their children as well as a frequent impetus for late night phone calls to sleepy hospitalists. Elevated body temperature also serves as a source of unnecessary laboratory tests and imaging time and time again, which further reinforces parental fever phobia. These tests, along with the inappropriate monitoring and treatment of fever, lead to significant amounts of discomfort for children and even puts their health at risk.
My goal for the next few posts is to discuss a number of the most commonly held myths regarding childhood fever and to provide some evidence-based recommendations on what to do when the mercury, as well as the anxiety level, is rising.
**Disclaimer** The following discussion is, in my opinion, good medical advice for most caregivers but it does not constitute specific medical advice for you or your child. There do exist specific situations where children with fever are treated differently because of age or underlying medical conditions. For instance, neonates and children with sickle cell disease are treated very differently than a healthy nine-year-old with even a fever of 106 degrees. I strongly recommend that anyone reading this or any other post regarding medical topics discuss any medical concerns with their child’s primary care physician. **Disclaimer**
First up, febrile seizures.
One of the most common reasons stated by parents, as well as medical professionals, for their concern regarding the onset of fever in a child is the specter of febrile seizures. While it is true that there is an association, and likely a causal one, between fever and seizure activity in some children, the terror I often see in the eyes of caregivers is very often unwarranted albeit understandable, as is the use of antipyretic medications like acetaminophen ibuprofen (Tylenol and Motrin for most readers). Confused? I realize that it seems counterintuitive to not give medication that reduces fever to a child in order to prevent seizures most probably caused by fever, but allow me to explain.
When addressing the subject of fever and febrile seizures, it is important to ask two questions: Are febrile seizures worthy of the dread they instill in caregivers and does the routine use of antipyretic medications and non-pharmaceutical measures to reduce fever prevent their occurrence. The answer to both questions is, with rare exception, no. But before I go any further, I must differentiate between classic febrile seizures and children with underlying neurological conditions that predispose them to seizures.
This discussion is about the former. If your child has a seizure disorder or a condition that puts them at risk of having seizures, see the above disclaimer. In fact, everyone just see the above disclaimer. In addition, there is a difference between febrile seizures and seizures that can occur in the setting of fever. A child with a bacterial meningitis can, in severe presentations, seize. This is not a febrile seizure. A child can have fever from an ear infection and have a seizure after getting kicked in the head by a mule. This is also not a febrile seizure. So what is a febrile seizure?
Simple febrile seizures occur in roughly 2-4% of children (this means 96-98% of children will never ever have one) between the age of 3 months and five years during a febrile response to an infection, usually viral in nature. They are seen in this age group most probably because of some immaturity in the developing brain, the higher incidence of febrile illnesses, and the typically higher febrile response as compared to older children and adults. In otherwise healthy children, which is the overwhelming majority of children who have an occurrence of a febrile seizure, it is a benign process that typically lasts seconds to few minutes. The seizures are almost always generalized, meaning they cause abnormal movements from head to toe rather in just one limb for instance. There is a much less common entity known as the complex febrile seizures, but these are rare and do not typically result in any immediate harm either (The long term prognosis is different and beyond the scope of this post.)
So children recover from these very well. Naturally they are a scary thing for an uninitiated parent to experience, and I certainly do not intend to belittle anyone’s emotional response. My intention is to reassure, and hopefully to decrease potentially risky behaviors that result from fever phobia in the future.
Febrile seizures, in the majority of instances, will only happen once to any given child. In about a third of children who have a febrile seizure there is recurrence, but each subsequent seizure is equally benign. And the long term risk of seizures, such as with epilepsy, beyond the febrile seizure age is slightly increased. Which children are at risk? Well, they can occur in any child but they tend to occur in families. It is clear that there is a genetic predisposition in some children, but where that defect lies is as unknown as the particular physiological changes that lead to the seizure activity. The leading theory involves the lowering of the seizure threshold by cytokines, chemicals released in response to infections that, among many other end results, lead to fever. But we don’t understand why seizures only occur in certain children and not others, or why they recur only in some children.
So simple febrile seizures, the most common form of seizures in childhood, do not cause any harm in almost all cases. But they do lead to parental and practitioner anxiety, and they do lead to ambulance rides, ER evaluations, and a large amount of wasted resources in the form of testing and hospital admissions. So shouldn’t we use the wonders of modern medicine to prevent them by lowering a child’s temperature into the normal range? What the normal core body temperature is exactly is fodder for another post (hint, it ain’t 98.6 degrees), but regardless of what a temperature should or should not be, simply throwing an antipyretic or two at it does not prevent febrile seizures. This fact is fairly clear even in children we know tend to get febrile seizures recurrently.
So febrile seizures are pretty much harmless and you can’t prevent them with medication or other measures such as sponging or cold water submersion. Plus, they don’t occur after about age five. Medications such as Tylenol and Motrin are safe, but they are not risk free, and non-pharmaceutical methods do not work to lower fever anyway. There are multiple studies revealing that high percentages of parents dose these medications too high and too frequently, often because of fever phobias such as these. Taking these facts into account, there is no reason to reach for the Tylenol or Motrin, or for a rag soaked in cold water, to treat a fever if your concern is preventing a seizure. The risk clearly outweighs the benefit. There are perfectly good reasons to treat a fever though, and I will discuss them in an upcoming post.