Abstract
BACKGROUND:
Febrile convulsions (FCs) are the most common type of seizures in children. They usually occur between the ages of 6 months and 5 years and affect 2%–5% of children worldwide. The aim of this study was to describe the epidemiological and clinical characteristics of children who have been diagnosed with FCs and admitted to a tertiary care hospital in Riyadh.
MATERIALS AND METHODS:
The study included pediatric patients aged between 3 months and 5 years who presented to the emergency department of King Abdullah Specialist Children’s Hospital in Riyadh, Saudi Arabia and were admitted to hospital with FC diagnosis during 2015 to 2021. The hospital’s electronic medical records system was reviewed to obtain patients’ information on age, gender, clinical characteristics, laboratory investigations, length of hospital stay, and outcome. Data was analyzed using Stata 12; Chi-square test was used to determine association between categorical variables, while t-test or Mann–Whitney U test compared continuous data between two groups.
RESULTS:
A total of 247 children with FC diagnoses were included in the analysis; 0.4% of pediatric patients were admitted to the hospital with the diagnosis of FC. Most of the patients (77%) convulsions were triggered by upper respiratory tract infections and median duration of the convulsion episode was 4 min; 55% of the patients had a simple FC, and 40% had recurrence of FCs. Developmental delays were more common in children with recurrent FCs (15%) compared to children who had only one episode of convulsion (2.7%) [P < 0.001].
CONCLUSION:
During the study period, 0.4% of pediatric patients were admitted to hospital with FC diagnoses. Larger multicenter studies are needed to evaluate FCs based on their clinical and operational characteristics to improve the quality of care, decrease the length of patient hospital stay, and lower the recurrence rate.
Keywords: Children, development, febrile convulsion, Saudi Arabia, seizure
Introduction
Febrile convulsions (FCs) are the most common types of seizures in children.[1] They usually occur between the ages of 6 months and 5 years and affect 2%–5% of children in Western Europe and the United States.[2] Although it is considered a self-limiting condition, FCs cause anxiety in parents who perceive them as terrifying.[3] FCs are defined as seizures accompanied by a fever (100.4°F [38°C] or greater) without the central nervous system infection and can be classified as simple or complex.[4] In total, 80% of FC cases are identified as simple, while 20% are complex.[5,6] Simple FCs are primary generalized seizures that do not recur within 24 h and last <15 min. In contrast, complex FCs are defined as having one or more of the following characteristics: focal, prolonged seizures lasting 15 min or more, or recurring within 24 h of the first episode.[4] Multiple studies have found that the most common trigger for FCs is viral upper airway infections.[7,8] Children who experience a FC tend to have close relatives with a history of FCs, though the exact mode of inheritance is unknown.[9] These convulsions very rarely cause permanent motor disability or death; however, 0.4% of children experience a transient focal weakness or Todd’s paralysis following the seizure.[10] Still, the risk of intellectual impairment in children who have had a FC are no higher than that of their peers.[11]
Those who have experienced a simple FC have almost the same risk of having epilepsy as the general population (1%). However, children with a family history of epilepsy, who were <12 months old at the time of their first febrile seizure, and/or who had recurrent FCs have an increased risk of developing epilepsy (2.4%).[12]
Many children have a single FC event, whereas others have multiple early childhood events.[13] The recurrence of FCs is influenced by many factors, including age at the time of the first episode, family history of FCs, family history of epilepsy, a complex first FC episode, and neurodevelopmental delays.[14] The likelihood of the recurrence of FC varies with age, increasing the younger a child is at the time of the first FC episode. Research has reported that 50% of children who were younger than 12 months at the time of their first FC will have at least one recurrence, whereas only 20% of children who have their first episode after the age of 3 years will have a recurrence.[15]
Routine laboratory studies on FC patients have indicated the only trigger to be fever.[11] Brain imaging is also not typical for these patients.[11] However, children with suspected meningitis or who are under 12 months old should have a lumbar puncture (LP) to rule out meningitis as the cause of fever. The American Academy of Pediatrics (AAP) does not recommend routine electroencephalograms (EEGs) to evaluate healthy children who have had simple FCs;[4] the use of EEG in complex FC cases is also quite controversial.[16] FCs are mainly addressed by treating the underlying etiologies causing the febrile illness.[13]
There is a paucity of literature on FCs in Saudi children. One study conducted of Saudi infants and children showed the prevalence of recurrent FCs to be 6.8%.[17,18] Another study conducted of the Saudi population in turn argued that FCs occurred in 3.55/1000 children under the age of 6 years.[19] A third Saudi study conducted of children diagnosed with seizures found that FCs were the most common seizure etiology (72.2%) at 66.7% in females and 75.0% in males.[20] In Iran, a study also found FCs to be the most common etiology (82%) in children diagnosed with seizures.[21]
Understanding this type of seizure is important so that families may be reassured and physicians helped to determine admission of these children into hospital for the appropriate treatment to be given. Most of the studies done at the national level have been cross-sectional with limited data on the follow up hospital stay. Therefore, the aim of this study was to estimate the overall prevalence of the FCs in the pediatric population admitted to a single tertiary care center in 6 years and provide data on the clinical characteristics and hospital stay of those admissions.
Materials and Methods
A descriptive retrospective study of hospital records was carried out at King Abdullah Specialist Children Hospital in Riyadh, Saudi Arabia from 2015 to 2021. Pediatric patients aged between 3 months and 5 years who presented to the emergency department and had been admitted into hospital with a FC diagnosis were included in this study. The hospital has been utilizing the electronic medical records system since 2015 to capture and document patient information on admission, clinical information, medication, referral, and outpatient visits. Clinical diagnoses are recorded according to the International Classification of Diseases, 10th Revision (ICD-10). For this study, diagnosis of the FC was based on (ICD)-10 code (R56.00, R56.01). Thus, the diagnosis of FCs was defined as seizures accompanied by a fever (100.4°F [38°C] or greater) without central nervous system infection occurring in infants and children 6–60 months of age.[4] All patients admitted with febrile seizures were identified regardless of whether they had been admitted for the first FC. Patients previously diagnosed with preexisting neurological disorders, epilepsy, seizures due to causes other than fever, neurological congenital anomalies, or cerebral palsy were excluded. Ethical approval was obtained from the Institutional Review Board (IRB) vide Letter No. NRC22R/068/02 dated 17/02/2022 with a waiver of informed consent since there was no direct relation with human subjects in this study.
Each patient’s clinical variables were collected from electronic data records. These included demographic data such as age, gender, child order in the family, family history of FC, clinical data (fever grade, seizure type, semiology, duration, previous history of FCs, developmental history, primary pathology), and hospital investigations that were carried out (brain imaging, EEG, and LP). Outcomes of the admission, including length of hospital stay in days and recurrence of FCs, were extracted from each file.
The prevalence of FCs in admitted pediatric patients per calendar from 2015 to 2021 was estimated by dividing the number of admitted patients who met the study inclusion criteria by the total number of the overall admitted pediatric patients aged between 6 and 60 months into hospital in the corresponding year. All admitted children during the study period with recorded diagnosis of a FC were included in the final analysis. The demographic and clinical characteristics of this study population wre described as the mean and standard deviation for normally distributed variables or median and interquartile ranges (IQRs) for continuous variables. The Shapiro–Wilk test was used to test for normality. For categorical variables, we reported frequency and percentage. We categorized the study population into those who had one FC episode and those who had recurrent FCs. Chi-square and t-tests (the Mann–Whitney U-test for skewed data) were used to measure the association between clinical characteristics and the two subpopulations.
Further, we categorized the length of hospital stay based on the third quartile into length of stay of more than 3 days (defined as a prolonged hospital stay), and 3 days or less (defined as a short hospital stay). A P < 0.05 was set as the cutoff for statistical significance. All analyses were done using the Stata 12 software system (Stata Corp L. P., College Station, TX, USA).
Results
A total of 247 children with FC diagnoses were included in this study. The estimated prevalence of children admitted for FC was 0.22% in 2015, 0.58% in 2016, 0.47% in 2017, 0.35% in 2018, 0.48% in 2019, 0.31% in 2020, and 0.44% in 2021 [Figure 1].
Figure 1.
Percentage of hospital admissions with febrile convulsions among all pediatric admissions aged 6–60 months at King Abdullah Specialist Children’s Hospital, Riyadh, Saudi Arabia from 2015 to 2021
The majority (88.9%) were aged 6 months to 6 years, were male (55.9%), and resided in urban areas (84.7%) [Table 1]. The common primary pathology that triggered the FC was upper respiratory tract infection (URTI) (76.9%), followed by gastroenteritis (9.3%). The median age of the study population was 1 year and 6 months (IQR: 1–3 years), and median documented fever grade was 39°C (IQR: 38.3°C–39.4°C). The duration of the FC in minutes for the study population was 4 min (IQR: 1–4 min). Regarding convulsion type, 55.5% children experienced a simple FC. Multiple FC attacks were reported among 40% of the study population, of which 26% had FC episodes more than twice in their lifetime. Around 25% of the children’s first degree relatives had FCs, and 12% children had a family history of epilepsy. The median length of hospitalization was 2 days (IQR: 1–3 days), and 23.4% children had hospital stay of more than 3 days (Table 1).
Table 1.
Clinical characteristics of children admitted at King Abdullah Specialist Children’s Hospital with febrile convulsions by number of FC episodes, Riyadh, Saudi Arabia from 2015 to 2021 (n=247)
| Parameter | Total (n=247) N (%) | First FC (n=146) N (%) | Recurrent FC (n=101) N (%) | P-value |
|---|---|---|---|---|
| Age | < 0.001 | |||
| Under 6 months | 20 (8.1) | 18 (12.3) | 2 (1.9) | |
| 6 months to 2 years | 122 (49.4) | 81 (55.4) | 41 (40.5) | |
| 2 years to 6 years | 98 (39.6) | 46 (31.5) | 52 (51.4) | |
| More than 6 years | 7 (2.8) | 1 (0.6) | 6 (5.9) | |
| Gender | 0.503 | |||
| Male | 138 (55.8) | 79 (54.1) | 59 (58.4) | |
| Female | 109 (44.1) | 67 (45.8) | 42 (41.5) | |
| Hospital Department | 0.237 | |||
| Emergency | 99 (40.0) | 63 (43.1) | 36 (35.6) | |
| Inpatient | 148 (60.0) | 83 (56.8) | 65 (64.3) | |
| First Child in Family | 0.260 | |||
| Yes | 137 (55.4) | 78 (53.4) | 59 (58.4) | |
| No | 49 (19.8) | 34 (23.2) | 15 (14.8) | |
| Missing | 61 (24.7) | 34 (23.2) | 27 (26.7) | |
| Primary Pathology | 0.006 | |||
| Upper respiratory tract infection | 190 (77.0) | 101 (69.2) | 89 (88.1) | |
| Lower respiratory tract infection | 13 (5.2) | 10 (6.8) | 3 (2.9) | |
| Gastroenteritis | 23 (9.3) | 19 (13.1) | 4 (3.9) | |
| Other | 21 (8.5) | 16 (10.9) | 5 (4.9) | |
| Fever Grade (median-IQR) | 39 (38.3-39.4) | 39 (38.4–39.4) | 38 (38.1–39.3) | 0.192 |
| Febrile Convulsion Classification | 0.175 | |||
| Generalized tonic-clonic | 213 (86.2) | 129 (88.3) | 84 (83.1) | |
| Generalized atonic | 32 (12.9) | 17 (11.6) | 15 (14.8) | |
| Generalized tonic | 2 (1.9) | 0 | 2 (1.9) | |
| Febrile Convulsion Type | 0.195 | |||
| Simple | 137 (55.5) | 76 (52.1) | 61 (60.4) | |
| Complex | 110 (44.5) | 70 (47.9) | 40 (39.6) | |
| Febrile Convulsion Duration in Minutes (median-IQR) | 4 (1-10) | 5 (1–10) | 4 (2–10) | 0.790 |
| Family History Of Febrile Convulsion | 64 (25.9) | 39 (26.7) | 25 (24.7) | 0.730 |
| Family History of Epilepsy | 30 (12.1) | 23 (15.7) | 7 (6.9) | 0.106 |
| Developmental History | < 0.001 | |||
| Appropriate | 227 (91.9) | 142 (97.2) | 85 (84.1) | |
| Inappropriate (Delayed) | 20 (8.1) | 4 (2.7) | 16 (15.8) | |
| Length of Hospital Stay in Days (median-IQR) | 2 (1-3) | 3 (2–4) | 2 (1–3) | < 0.001 |
| LP Performed | 121 (48.9) | 81 (55.4) | 40 (39.6) | 0.014 |
| EEG Performed | 28 (11.3) | 8 (5.4) | 20 (19.8) | < 0.001 |
| Brain Imaging Performed | 84 (34.1) | 53 (36.3) | 31 (30.6) | 0.360 |
IQR: interquartile range
Table 2 presents the management and investigations done during the patients’ hospital stay. A total of 84 children (34%) underwent urgent brain imaging and 90.4% of them had normal images. EEG studies were performed for 28 patients (11%), 64% of whom had normal results. Lumber puncture (LP) was performed for 48% of the sample, of which 99% had results within normal LP parameters.
Table 2.
Hospital testing and outcomes of pediatric patients admitted with febrile convulsions at King Abdullah Specialist Children’s Hospital in Riyadh, Saudi Arabia from 2015 to 2021 (n=247)
| Parameter | N (%) |
|---|---|
| Brain imaging performed | 84 (34.1) |
| Type of brain imaging* | |
| CT | 81 (96.4) |
| MRI | 3 (3.5) |
| Results of brain imaging | |
| Normal | 76 (90.4) |
| Abnormal | 8 (9.5) |
| EEG performed | 28 (11.3) |
| Result of EEG* | |
| Normal | 18 (64.2) |
| Abnormal (epileptic discharges) | 3 (10.7) |
| Abnormal (postictal charges) | 7 (25.0) |
| LP performed | 121 (48.9) |
| Result of LP* | |
| Normal | 120 (99.1) |
| Abnormal | 1 (0.8) |
| Subsequent diagnosis (during same admission or at follow-up) | |
| FC | 241 (97.5) |
| Epilepsy | 4 (1.6) |
| Other | 2 (0.8) |
| Antiepileptic drug given at discharge | 12 (4.8) |
*Percentage taken from patients who underwent testing. IQR=Interquartile range, LP=Lumbar puncture, EEG=Electroencephalogram, CT=Computed tomography, MRI=Magnetic resonance imaging, FC=Febrile convulsion
The comparison of clinical data for children who experienced one FC episode and those who had recurrent FCs is shown in Table 1. There was variation in the age distribution of the children with recurrent FCs compared to children who experienced just one FC (55% aged 6–12 months compared to 40% of the recurrent convulsion group; P < 0.001). The primary pathology was similar in both groups; however, children who had just one FC more often had gastroenteritis as a primary pathology (10% vs. 4.9%; P = 0.006). The majority (92%) of the patients with one FC had a normal result of neuroimaging. In contrast, 12% of the patients with recurrent FCs had abnormal neuroimaging. For the EEG results, 15% of patients who had recurrent FCs had abnormal epileptic discharges, and 15% had abnormal postictal charges.
As a result of recurrent episodes, children with recurrent FCs had a higher prevalence of developmental delays than children who had only one convulsion episode (15% vs. 2.7%; P < 0.001). Children who had experienced one FC had statistically significantly longer hospital stay (median 3 days, IQR: 2–4) compared to those with recurrent convulsions (median 2 days, IQR: 1–3) (P < 0.001) [Table 1].
With regard to the length of hospital stay, 189 children (76%) had short hospital stays, whereas 58 children (23%) had prolonged hospital stay. Table 3 summarizes the main clinical differences between these groups by length of hospital stay. Girls tended to have longer hospital stays than boys (56% vs. 43%; P = 0.025). Seventy-seven percent of children with simple convulsion stayed for more than 3 days in hospital, whereas 22% of children with complex convulsion stayed in hospital more than 3 days (P < 0.001). The median duration of convulsion was higher among children who had a prolonged hospital stay (median 5.5 min, IQR: 2–20) compared to those who had a short stay (median 4 min, IQR: 1–10) (P = 0.023).
Table 3.
Clinical characteristics of children admitted at King Abdullah Specialist Children’s Hospital with febrile convulsions by length of hospital stay, Riyadh, Saudi Arabia from 2015 to 2021 (n=247)
| Parameter | Hospital stay ≤3 days (n=189) N (%) | Hospital stay >3 days (n=58) N (%) | P-value |
|---|---|---|---|
| Age | |||
| Under 6 months | 15 (7.9) | 5 (8.6) | 0.941 |
| 6 months to 2 years | 93 (49.2) | 29 (50.0) | |
| 2 years to 6 years | 76 (40.2) | 22 (37.9) | |
| More than 6 years | 5 (2.6) | 2 (3.5) | |
| Gender | |||
| Male | 113 (59.7) | 25 (43.1) | 0.025 |
| Female | 76 (40.2) | 33 (56.9) | |
| Primary pathology | |||
| URTI | 150 (79.3) | 40 (68.9) | 0.268 |
| Lower respiratory tract infection | 10 (5.2) | 3 (5.2) | |
| Gastroenteritis | 16 (8.4) | 7 (12.1) | |
| Other | 13 (6.8) | 8 (13.7) | |
| Fever grade, median (IQR) | 39 (38.2–39.4) | 38.9 (38.4–39.3) | 0.386 |
| FC classification | |||
| Generalized tonic-clonic | 160 (84.6) | 53 (91.3) | 0.508 |
| Generalized atonic | 27 (14.2) | 5 (8.6) | |
| Generalized tonic | 2 (1.1) | 0 | |
| FC type | |||
| Simple | 92 (48.6) | 45 (77.5) | <0.001 |
| Complex | 97 (51.3) | 13 (22.4) | |
| FC duration (min) | 4 (1–10) | 5.5 (2–20) | 0.023 |
| Family history of FC | 43 (28.1) | 11 (18.9) | 0.168 |
| Family history of epilepsy | 24 (12.7) | 6 (10.3) | 0.189 |
| Developmental history | |||
| Appropriate | 176 (93.1) | 51 (87.9) | 0.205 |
| Inappropriate (delayed) | 13 (6.8) | 7 (12.1) | |
| LP performed | 85 (44.9) | 36 (62.1) | 0.023 |
| EEG performed | 15 (7.9) | 13 (22.4) | 0.002 |
| Brain imaging performed | 51 (26.9) | 33 (56.9) | <0.001 |
IQR=Interquartile range, LP=Lumbar puncture, EEG=Electroencephalogram, FC=Febrile convulsion, URTI=Upper respiratory tract infection
Discussion
The AAP defines FCs as seizures occurring in children between 6 months and 5 years accompanied by a fever (100.4°F [38°C] or greater) without central nervous system infection.[4] The results of the current study highlighted that the median age of our population which presented with a FC was 1 year and 6 months, which is concurrent with the AAP definition of FCs and the findings of many international studies.[22,23,24] This study also investigated FCs with atypical age presentation. We found that a small proportion of our study population not previously described in the literature was younger than 6 months and older than 5 years. The risk of developing epilepsy following a complex FC has been reported to be related to gender.[25] However, little is known about the gender predisposition to a FC. In this study, as seen in many other studies, males outnumbered females.[22,23,24] Similar to most research that assesses the characteristics of FCs, URTIs were the leading cause in our population.[7,22,23,24] One study conducted on a Chinese population stated that influenza A was most often the cause. In patients presenting with URTIs complicated by FCs[26] However, this study did not investigate the virology of URTI in the included patients. Furthermore, another study proposed that the height of the fever grade is the actual risk factor for experiencing a FC rather than the rapidity of the rise in temperature, as posited by recent reports.[27] In our study, the median documented fever was 39°C.
As for the type of convulsion, more than half (55%) of our population had a simple FC. Other studies have likewise reported higher numbers of simple FCs in their population.[22,28,29] Despite the self-limiting nature of simple FCs, they are believed to be one of the most prevalent causes of children’s admissions to the emergency department.[30] However, the nature of a FC, whether simple or complex, is not a risk factor for recurrence.[30] In general, FCs have a good prognosis and are self-limiting, with children expected to outgrow them by the age of 6 years old.[29,31] Even so, it is estimated that one-third of the children who experience an FC will have another during their early childhood.[32] The rate of convulsion recurrence in this study was higher than previously reported, with 40% of our population having had a recurrent FC and nearly half of that number having had more than two recurrences.
Family and twin studies have demonstrated that genetics play an important factor in the pathogenesis of FCs. Notably, there is a 30% risk of FC occurrence if one of the parents also experienced a FC and in one-third of patients if there is a positive family history of FC.[28,32,33] In our study, 25% of our population reported a family history in a first-degree relative, which aligns with these statistics. Only 12% of our patients had a positive family history of epilepsy in a first-degree relative, which is significantly lower than that of another recent study.[33]
The median length of hospital stay in our population was 2 days, which is concurrent with findings of previous studies as well. This indicates that unnecessary hospital stays with multiple patient tests have no significant diagnostic role beside the cost to the healthcare system and distress to patients’ families.[29,34,35] Tests such as neuroimaging and EEG showed a limited role in our study, as most patients had normal results during their hospitalization. Abnormal EEG results or signs of brain injury in neuroimaging are more likely associated with subsequent epilepsy, which one study has described as a risk factor for future epilepsy (In our study the abnormal urgent neuroimaging finding were likely to be incidental or considered not as seizure causing or requiring urgent intervention). None of the abnormal neuroimaging in this study required acute intervention or was deemed epileptogenic just as some previous studies with abnormal neuroimaging had not needed intervention.[36,37,38,39] Two studies found that the majority of LP and cerebrospinal fluid (CSF) results were normal, underlining the limited benefit of routine LP in FC treatment.[40,41] Similarly, less than half of our study population underwent LP, and almost all had normal CSF findings.
The limitations of our study include its nature as an observational and single-institution study with a limited sample size. The results, therefore, cannot be generalized. In this study, electronic medical records used to extract the clinical and investigation information of the study population, showed that some 3% of the total study population had abnormal brain imaging finding. Thus, misclassification bias cannot fully be ruled out, However, this should not affect the overall finding as the percentages are very small. In addition, the history regarding the characteristics of the seizure, its description, and duration taken from the patients’ parents after presenting to the ER might not be accurate given their anxiety during their child’s episode. Large multicenter studies are needed to fully evaluate FCs based on their clinical and operational characteristics to improve quality of care, decrease length of patient hospital stay, and lower recurrence rates.
Conclusion
During the study period, 0.4% of pediatric patients were admitted into hospital with FC diagnoses. Recurrence occurred in 40% of the included patients, though it was more common among neurodevelopmentally delayed patients compared to children who had experienced only one convulsion. This proportion underscores the importance of early diagnosis to provide appropriate management to prevent unnecessary hospitalization. Further research is needed to explore the long-term outcome of this population in terms of schooling, neurodevelopment, and progress. This will help in targeting strategies to the improvement of the care for this population.
Larger multicenter studies are needed to evaluate FCs based on their clinical and operational characteristics to improve the quality of care, decrease the length of patient hospital stay, and lower the recurrence rate. In addition, the recurrence of FCs in patients with neurodevelopmental delays warrants further evaluation and follow-up.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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