Febrile convulsion in Libyan children
Nissren S.S. Majeed, Nahed Abd ALRaziq, Naima I. Abdullah and Safaa S. Muhammed
Abstract: Febrile convulsions have been defined as any convulsion associated with fever of more than 38 oC without central nervous system infection in a child aged six months to five years. Febrile convulsion can be divided into two groups of simple and complex seizure. This study was aimed to determine the prevalence of febrile convulsions in Libyan children and to investigate the associated risk factors related to this type of seizures in children. 120 cases of febrile convulsions with one day - 12 years old were collected during the period of April to August, 2022. A study has conducted in the Pediatrics Hospital in Bayda city, Libya about the prevalence of febrile convulsions in children, the data collected tool was a self-designed pre-tested validated questionnaire including general information such as age, gender, family history, admission to the hospital. In addition, data such as body temperature, recurrent of convulsion attack, the condition of hospital admission, discharge status, the treatment in-hospital and out-hospital. The collected data were analyzed by using descriptive methods. Among the 120 children, the majority of the cases were aged between two years and five years old. Gender prevalence rate in this study was 55.0% in male and 97 of the children were hospitalized due to simple febrile seizure (80.8%), 92 of the cases with no family history to febrile convulsions (75.0%) and respiratory tract infections is the main cause of febrile convulsions. In conclusion, this study indicated that the respiratory tract infections is the most common cause of febrile convulsions among the Libyan children, however, a large sample study is needed to support this issue in Libya.
Febrile seizures or convulsions (FCs) are seizures that happen in young children . FCs are the most commonly occurring epilepsy syndrome experi-enced in infants or children between six months to six years with an incidence of less than 04.0% . FCs describe any seizure that occur in response to a febrile stimulus without meningitis, encephalitis, serum electrolyte imbalance and other acute neurologic illnesses. Several studies on molecular genetics and pathogenesis of the FCs have been
reported. Thus, it has been recognized that there is a significant genetic component for susceptibility of FCs with different described mutation. Others have tried to correlate FCs to immunologic problems through interleukin, cytokines, immune globulin and interferon . FCs present the most common issue in pediatric neurology. This is changed with time. In 1949, Lennox described FC may cause brain pathology as evidenced by transient or permanent neurological deficit [1, 2]. In difference, in 1991, Robinson  referred to children with FCs as having an excellent prognosis. There is a change in opinion due to reason, one reason is that earlier studies of the relatively poor prognosis of children with more severe problems attending specialized clinic or hospital were balanced by more optimistic findings of population - based studies of less selected group of children [4 - 6]. Another reason is that the results of studies depend on way FC are defined - some investigators have included children with underlying meningitis or encephalitis in their studies of FCs [7 - 9].
It is now recognized that in a small number of children, FCs are the first sign that the child has an inherited seizure disorder that include as FC is an event in infancy or childhood, usually occurring between three months and five years of age, associated with fever but without an evidence of the intracranial infection or defined cause. This excludes seizures with fever in children who have had a prior of FCs. The American Academy of Pediatrics  reported clinical practice guideline defining a FC as a seizure accompanied by fever (temperature ≥ 38 °C), without central nervous system infection that occurs in infants and children six through 60 months of age. FCs are further classified as simple or complex and most common type of seizures observed in the pediatrics. Additionally, FC is a long - term management of children with fever - associated seizures . Does not exclude children with prior a neurological impairment and neither provides a specific temperature criteria nor defines a seizure. Another definition from the International League Against Epilepsy  is reported. Thus, FCs are seizures that occur in childhood after one month of age associated with a febrile illness not caused by an infection of the central nervous system. It is without a previous neonatal seizures or a previous unprovoked seizure and it is not meet the criteria for other acute symptomatic seizures [12, 13]. This type of seizure represents a unique response of a child's brain to fever specially at the first day . However, children represented with seizures in association with illness, particularly gastroenteritis, fever was not present at the time of presentation. Even though, their prognosis become normal, the risk of having subsequent epilepsy is higher than those with FCs [15, 16]. Approximately 03% - 05% of children between the ages of six months and six years will have FCs, most seizures are less than five minutes in duration and the child completely back to normal within one hour of the event. During FCs, the body becomes stiff, arms and legs will begin twitching. Irregular breathing, losing conscious-ness with alert eyes and skin may look a little bit darker. The child may return quickly to the normal activity because it usually lasts for a few seconds, but there is a specific rare conditions including that the seizure lasts for 15 minutes . However, 2.0% - 7.0% of the FC cases develop accompanied with epilepsy and the risk increases by the presence of complicated FCs . A previous published study has shown that there is no increase in the risk or incidence of mortality in children with FCs . Recurrence frequency is 10.0% in patients with no risk factors 25% - 50% in the presence of few risk factors; 50% - 100% in the presence of more risk factors . The risk of epilepsy is estimated around 01.5% in the patients with simple FC  while, the risk of epilepsy in patients with complex febrile convulsion (CFS) is estimated between four and 15.0% . A little is known about incidence or prevalence of FCs in Libya, therefore, this study was aimed to determine the prevalence of FCs in Libyan children and to investigate some associated risk factors related to this type of seizures in children.
Materials and methods
An analytical cross sectional study was carried out from April to August, 2022 in Bayada, Libya. A total of 120 Libyan children from one day old to 12 years old visiting the Bayda Medical Center were included in this study by a systematic random sampling technique. Medical data of participants were collected using a structured self-designed questionnaire. The questionnaire was validated by the staff members of Faculty of Pharmacy, Omar Mukhtar University. It is established to determine the prevalence of FCs in children in Bayda and to determine the association risk factors which related to FCs.
The collecting data included the following criteria age, gender, family history, body temperature, convulsions the child, type of FCs, number of attacks, diagnosis, the time of recurrent, symptoms, treatment and admission status. The date of entry and discharge, the condition of admission to the hospital, the treatment in the hospital and outside have also been recorded. Excluded criteria were children that deteriorate from FCs to epilepsy. The study was conducted after having an approval from Bayda Medical Center and Faculty of Pharmacy, Omar Mukhtar University and approval (informed consent) has been obtained from parents of the participants.
Data presentation: An analysis of the data were carried out by using SPSS version 17. A descriptive presentation of the data by standard deviation, range and percentage have been used for all the variables.
Age and prevalence of febrile convulsions: In Table 1, 01.7% of the cases were more than eight years, 13.3% of the cases from five years to eight years while 39.2% of the cases from one day to two years old. A large proportion of them were between the age of two years to five years old with a 45.8%. With regard to the gender, number of male subjects in this study was 66 which represented 55.0%, while the female subjects was 54 which represented 45.0% from the total sample. The ratio of male to female between the subjects was small.
Table 1: Age and prevalence of febrile convulsions in Libyan children
Age Frequency Percentage Valid Percent
1 day - 2 years 47 39.2 39.2
2 - 5 yreas 55 45.8 45.8
5 - 8 years 16 13.3 13.3
> 8 years 2 1.7 1.7
Total 120 100.0 100.0
In this study, there was 28 of the cases out of 120 (23.3%) have family history of FCs while the majority of the cases reported no history of parents, brothers and sisters as shown in Figure 1. Further, in Table 2, the distribution of the cases with type of seizures is shown. Thus, 80.8% from the total sample suffering from simple FCs while 19.2% with complex FCs. In Figure 2, the distribution of the cases according to the body temperature of children with FCs is shown. Almost in all the cases, the average of the body temperature was between 37 °C and 40 °C with some cases of normal body temperature and some with more than 40 °C (15.0%).
Figure 1: Distribution of Libyan children according family history
Table 2: Libyan children with attack of simple or complex seizures
Seizures Frequency Percentage
Simple 97 80.8
Complex 23 19.2
Total 120 100.0
Figure 2: Distribution of the cases according to the body temperature of children with FCs
In Table 3, frequency of attack of FCs among the participated children is shown. The most common group of children with one attack revealed that 70 from 120 children have one attack followed by 34 children with two attacks, 10 patients with more than two attacks. Only six children with complex number of attacks. Figure 3 shows diagnosis of the Libyan children with FCs. Almost one third of the cases were diagnosed with fever and general convulsions while the other third was diagnosed with convulsions, eve rolling, forth secretion and fever. The other was diagnosed with convulsions, ear infection, diarrhea, tonsillitis and pneumonia. Few cases diagnosed with convulsions, increase in brain electricity and hypoglycemia.
Table 3: Frequency of febrile convulsion attack in Libyan children
Number of attacks Frequency Percentage
1 Attack 70 58.3
2 attacks 34 28.3
> 2 attacks 10 8.3
Complex 6 5.0
Total 120 100.0
Figure 3: Diagnosis of the Libyan children
with febrile convulsions
In Figure 4, different causes lead to admission to the hospital with FCs is shown. Thus, respiratory tract infections accounted for more than half of the admission (53.3%), followed by almost equal ratio of pneumonia, acute gastrointestinal disturbances, urinary tract infections, abscess and meningitis. While the less cause for hospital admission of the children with FCs was urinary tract infections (06.7%).
Figure 4: Conditions of hospital admission of
children with febrile convulsions
In this study, 96 children with FCs were discharged from the hospital after complete the course of treatment with good condition (80.0%). 21 children were discharged under the responsibility of their parents (17.5%) while three children died (02.5%).
Table 4: Distribution of treatment among the Libyan children
Drug treatment Frequency Percent Valid Percent
Antipyretic 04 03.3 03.3
Diazepam 07 05.8 05.8
Antibiotic 08 06.7 06.7
Antipyretic & antibiotic 20 16.7 16.7
Antipyretic, antibiotics & Diazepam 36 30.0 30.0
Antipyretic & diazepam 03 02.5 2.5
Antibiotics & diazepam 05 04.2 4.2
Antibiotics & salbutamol 01 0.8 0.8
Antibiotics, salbutamol & vitamin D 01 0.8 0.8
Salbutamol 02 01.7 01.7
Antipyretic & normal saline 10 08.3 08.3
Anticonvulsant 12 10.0 10.0
Others 11 90.2 09.2
Total 120 100.0 100.0
In Table 4, distribution of the treatment of children with FCs by individual drugs is shown. Thus, most of the cases (n = 36) were under antipyretics, antibiotics and diazepam (30.0%), 20 cases from the total sample under antipyretics and antibiotic (16.7%). 12 cases were under anticonvulsants, 10 children were given antipyretic with normal saline. The other cases distributed with several different drugs such as antipyretics only, diazepam only, antibiotic only or salbutamol only as an adjunctive treatment. The distribution of the treatment in details which was administrated to the children (inpatient) is show in Table 4.
The prevalence of FCs in Beyda was increased and age has an influence on this approach to convulsion disorders. The highest prevalence was reported among 2 - 5 years old which was about half of the cases. On the other hand, the lowest prevalence was in a group of 8 - 12 years old. It has previously been reported that the heights peak occurs at 1 - 2 years old and low below 6 months or after 3 years of age [7, 11, 21]. Generally, FCs decrease after four years of age and rarely occur in children more than seven years . Although in another study, long term mortality study, is not increased in children with FCs, there were three death cases in this study, it seems to be a small excess mortality at age two years after complex seizure. Death of FCs is very rare even in a high risk children . Currently, the total number of the cases is low but the findings indicated that male is slightly more than female to FCs, however, a larger sample is needed to confirm this ratio. While, in a previous report of FC has shown more than two third of the cases were male which is also a small size sample study .
In current study, Libyan children with simple seizures was very high and the complex was found in about 20.0%. This is in line with the previous study . As regarding to children which they are diagnosed clearly with FCs in this study, it was found that there is half of the cases were given antibiotics which indicated that the cause of FCs is infection with bacteria, nevertheless, in other study children age between 2 - 24 months old with FCs are at a similar risk for occult bacteremia as those with fever alone . The admission has a deep excite, it is variable of admission, the highest prevalence was respiratory tract infections, then, pneumonia and acute gastrointestinal, meningitis's. In other study, it was found the most common cause of fever leading to FCs was respiratory tract infections, then most common being urinary tract and central nervous infections . With regard to the body temperature, the variable of the highest temperature level was among 37 - 40 °C which was and the lowest levels was between temperature less than 37 °C and greater than 40 °C. In a study of 344 children, the body temperature was recorded between 38 °C - 39 °C for majority of children and most of them had not used diazepam. The children with body temperature between 38 °C - 39 °C was at higher level, body temperature below 38 °C and between 39 °C - 40 °C were at next levels. Children with body temperature above 40 °C was reported at lower level . Thus, in the current study, fever (increase brain electricity, congestion, hypogly-cemia, convulsions and adenopathy) is two third fold while symptoms of hypoglycemia and adenopathy is low which is in line with the previous study . Other diagnosis was made as cerebral palsy (01.8%), tubercular meningitis (01.5%) and hypertensive encephalopathy (01.5%) . Many etiologies including electrolyte imbalance (hypoglycemia & hypocalcaemia), hydrocephalus, neurocutaneous syndrome, intracranial hemorr-hage, brain abscess, congenital malformations of central nervous system, hepatic and enteric encephalopathy accounted for remaining (06.0%) of cases . Data for the mortality rate during hospital stay is 02.5% and others discharged after completion of treatment 80.0% while the previous study reported that 04.4% of the children died in hospital, 04.0% had left against medical advice and 01.8% were referred to another center and the remaining were discharged after fully successful treatment .
Most of the patients that exist in the hospital, had given antipyretics, antibiotics and diazepam and about the third of the children under antibiotics and antipyretics while 10.0% under the anti-convulsant. Through in other study, most of the FCs controlled in the emergency department with medications and sponging, because of development of serious after effects prolong complex febrile fits such as saspiration, trauma, recurrent fist and progression to epilepsy. About half of the children controlled by medications alone. Immediate medications that are used include diazepam and non-steroidal anti-inflammatory drugs depending upon symptoms. Others are used in almost every patient to treat infection is ceftazidime, efotaxime and ampicillin. In this study of FCs, more than half of the children suffer from one attack with percentage and about third of children were exposed with two attacks with 05.0% was complex and suffer from several attacks. This is comparable to the previous reported study  that simple FCs was observed in most children but the several attacks that more than two and were complex cases. There is 20.0% of cases have family history of FCs and the rest without any family history which is in a good agreement with the study described that 340 children for whom information on family history was available, 76.1% without a family history . The frequency of recurrence factor is high, as one recurrent (63.3%) and low in more than four recurrents (08.0%) similar to the study of recurrent FCs .
Conclusion: The findings concluded that gender has no a major role in attack of febrile convulsions while family history and age play a role. Bacterial infections as respiratory tract infections is the predominance of febrile convulsions which were based on in- and out-prescriptions of antibiotics for most of febrile convulsions children in Libya.
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Majeed et al. (2023) Febrile convulsion in Libyan children. Mediterr J Pharm Pharm Sci. 3 (2): 19-25. https://doi.org/10.5281/zenodo.7869374.