Kejang Pada Anak

sumber : http://www.pediatrik.com/isi03.php?page=html&hkategori=Tips%20-%20Tips&direktori=tips&filepdf=0&pdf=&html=20060220-r9k8mu-tips.htm

Kejang disebabkan oleh pelepasan hantaran listrik yang abnormal di otak. Gejala-gejala yang timbul dapat bermacam-macam tergantung pada bagian otak yang terpengaruh, tetapi umumnya kejang berkaitan dengan suatu sensasi aneh, kekakuan otot yang tidak terkendali, dan hilangnya kesadaran.

Kejang dapat terjadi akibat adanya kelainan medis. Rendahnya kadar gula darah, infeksi, cedera kepala, keracunan, atau overdosis obat-obatan dapat menyebabkan kejang. Selain itu, kejang juga dapat disebabkan oleh tumor otak atau kelainan saraf lainnya. Kurangnya oksigen ke otak juga dapat menyebabkan kejang. Pada beberapa kasus, penyebab kejang mungkin tidak diketahui. Kejang yang terjadi berulang mungkin merupakan suatu indikasi akan adanya suatu kondisi kronik yang dikenal sebagai epilepsi.

Kejang demam merupakan kejang yang cukup sering dijumpai pada anak-anak yang berusia dibawah 5 tahun. Kejang demam dapat timbul bila seorang anak mengalami demam tinggi, biasanya suhu tubuh meningkat dengan cepat mencapai 39 derajat Celsius atau lebih. Walaupun hal ini sangat mengkhawatirkan bagi orang tua, kejang seperti ini umumnya terjadi singkat dan jarang menimbulkan masalah, kecuali bila demam yang terjadi berkaitan dengan infeksi serius seperti meningitis. Anak yang mengalami kejang demam tidak mempunyai kecenderungan untuk mengalami epilepsi.

Apa Yang harus Dilakukan

Anak yang mengalami kejang harus dibaringkan di tempat yang aman agar tidak ada kemungkinan jatuh. Jauhkan benda-benda disekitarnya agar tidak mengganggu. Longgarkan pakaiannya di sekitar kepala dan leher.Hati-hati bila memasukkan benda-benda di antara gigi anak karena benda tersebut dapat masuk dan membuntu jalan nafas anak. Jangan menahan gerakan-gerakan anak seperti memegangi tangan atau kakinya. Segera miringkan anak apabila kejang telah berhenti.

Selain itu segera hubungi dokter terutama bila:

– anak tampak kesulitan bernafas
– anak tampak berwarna kebiruan
– anak mengalami cedera pada kepalanya
– anak tampak sakit
– anak memiliki suatu penyakit bawaan yang mungkin membahayakan seperti kelainan jantung
– anak sebelumnya dicurigai telah menelan zat-zat tertentu yang dapat menyebabkan keracunan

Jika anak tampak bernafas dengan normal dan kejang hanya terjadi beberapa menit saja, anda dapat menghubungi dokter setelah kejang selesai. Jika seorang anak baru sekali mengalami kejang, segera hubungi dokter bila hal ini terjadi. Sedangkan bila seorang anak sebelumnya pernah mengalami kejang, hubingi dokter bila kejang terjadi lebih dari 5 menit, atau bila kejang yang timbul lain dari kejang yang biasanya timbul.

Umumnya setelah kejang, anak akan tidur dengan nyenyak. Periode ini merupakan suatu periode yang dikenal sebagai periode postictal. Hal ini merupakan hal yang normal, dan sebaiknya anak tidak usah berusaha dibangunkan. Jangan memberikan makan atau minum kepada anak bila anak belum benar-benar terbangun dan sadar.

Bila anak memang dinyatakan mengalami kejang demam oleh dokter, umumnya dokter akan menyarankan agar anak diberi obat penurun panas bila anak demam agar demam dapat terkendali sehingga kejang dapat dicegah. Selain itu, dokter juga akan menyarankan untuk mengkompres anak dengan kain basah untuk membantu mendinginkan anak.

(cfs/kidshealth.org)

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Febrile Seizure

Q. My 2-year-old daughter had a seizure and a fever and she was sent to the ER. They sent us home, but now I’m wondering if she’s going to have another one or how should she feel now because she is so fussy. She only wants to be carried by me and cries all day long. What do I do? Elizabeth, San Bernardino, CA

A. Since your child is still so fussy, you likely should seek further medical attention.

Although scary for parents, febrile seizures (a seizure that is caused by a fever) are usually not serious.

They usually occur in young children, during a viral illness in which their fever spikes up high all of a sudden. About 2% to 5% of children have febrile seizures.

Children who have febrile seizures have a very small risk of later developing regular seizures, but according to the National Institute of Neurological Disorders and Stroke, ‘between 95% to 98% of children who have experienced febrile seizures do not go on to develop epilepsy.’

These children are at risk for having more febrile seizures though. In fact, about one=third of children who have febrile seizures go on to have another one later on. Fortunately, most children outgrow having febrile seizures by the time they are about 5 years old.

Remember that febrile seizures are not harmful though and they do not cause brain damage.

First Aid for Febrile Seizures
If your child is having a febrile seizure, according to the National Institute of Neurological Disorders and Stroke, you should “stay calm and carefully observe the child. To prevent accidental injury, the child should be placed on a protected surface such as the floor or ground. The child should not be held or restrained during a convulsion. To prevent choking, the child should be placed on his or her side or stomach. When possible, the parent should gently remove all objects in the child’s mouth. The parent should never place anything in the child’s mouth during a convulsion. Objects placed in the mouth can be broken and obstruct the child’s airway. If the seizure lasts longer than 10 minutes, the child should be taken immediately to the nearest medical facility for further treatment. Once the seizure has ended, the child should be taken to his doctor to check for the source of the fever. This is especially urgent if the child shows symptoms of stiff neck, extreme lethargy, or abundant vomiting.”
Medical Treatment for Febrile Seizures
Although febrile seizures are not harmful and usually don’t require any treatment, the concern comes when your Pediatrician is not sure that your child is in fact having a simple febrile seizures. Although a child has both a fever and a seizure, it is sometimes possible that a child has something else, like meningitis, causing both and that the fever didn’t trigger the seizure. In this case, further testing, like a spinal tap, might be done, especially in children younger than 12 to 18 months old. Blood and urine tests may also be done in some situations.

Most children with simple febrile seizures, who aren’t too fussy and appear well after the seizure, don’t require any testing though. In fact, that American Academy of Pediatrics recommends that other tests, like an EEG, CT, or MRI, not routinely be done in children with a first simple seizure.
Preventing Febrile Seizures
The only real way to prevent febrile seizures is to try and avoid allowing your child to get sick, which might lead to a fever, in the first place. Giving a fever reducer, such as Tylenol (acetaminophen) or Motrin (ibuprofen), at the first sign of a fever is often recommended, but likely won’t prevent a febrile seizure.

Some children who have a lot of febrile seizures are treated with Diazepam at the first sign that they have a fever, but this usually isn’t necessary. A pediatric neurologist can be helpful if you think your child needs treatment for her febrile seizures.

Febrile Seizures

source : http://www.ninds.nih.gov/disorders/febrile_seizures/detail_febrile_seizures.htm#120793111

What are febrile seizures?

Febrile seizures are convulsions brought on by a fever in infants or small children. During a febrile seizure, a child often loses consciousness and shakes, moving limbs on both sides of the body. Less commonly, the child becomes rigid or has twitches in only a portion of the body, such as an arm or a leg, or on the right or the left side only. Most febrile seizures last a minute or two, although some can be as brief as a few seconds while others last for more than 15 minutes.

The majority of children with febrile seizures have rectal temperatures greater than 102 degrees F. Most febrile seizures occur during the first day of a child’s fever. Children prone to febrile seizures are not considered to have epilepsy, since epilepsy is characterized by recurrent seizures that are not triggered by fever.
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How common are febrile seizures?

Approximately one in every 25 children will have at least one febrile seizure, and more than one-third of these children will have additional febrile seizures before they outgrow the tendency to have them. Febrile seizures usually occur in children between the ages of 6 months and 5 years and are particularly common in toddlers. Children rarely develop their first febrile seizure before the age of 6 months or after 3 years of age. The older a child is when the first febrile seizure occurs, the less likely that child is to have more.
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What makes a child prone to recurrent febrile seizures?

A few factors appear to boost a child’s risk of having recurrent febrile seizures, including young age (less than 15 months) during the first seizure, frequent fevers, and having immediate family members with a history of febrile seizures. If the seizure occurs soon after a fever has begun or when the temperature is relatively low, the risk of recurrence is higher. A long initial febrile seizure does not substantially boost the risk of recurrent febrile seizures, either brief or long.
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Are febrile seizures harmful?

Although they can be frightening to parents, the vast majority of febrile seizures are harmless. During a seizure, there is a small chance that the child may be injured by falling or may choke from food or saliva in the mouth. Using proper first aid for seizures can help avoid these hazards (see section entitled “What should be done for a child having a febrile seizure?”).

There is no evidence that febrile seizures cause brain damage. Large studies have found that children with febrile seizures have normal school achievement and perform as well on intellectual tests as their siblings who don’t have seizures. Even in the rare instances of very prolonged seizures (more than 1 hour), most children recover completely.

Between 95 and 98 percent of children who have experienced febrile seizures do not go on to develop epilepsy. However, although the absolute risk remains very small, certain children who have febrile seizures face an increased risk of developing epilepsy. These children include those who have febrile seizures that are lengthy, that affect only part of the body, or that recur within 24 hours, and children with cerebral palsy, delayed development, or other neurological abnormalities. Among children who don’t have any of these risk factors, only one in 100 develops epilepsy after a febrile seizure.
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What should be done for a child having a febrile seizure?

Parents and caregivers should stay calm and carefully observe the child. To prevent accidental injury, the child should be placed on a protected surface such as the floor or ground. The child should not be held or restrained during a convulsion. To prevent choking, the child should be placed on his or her side or stomach. When possible, the parent should gently remove all objects in the child’s mouth. The parent should never place anything in the child’s mouth during a convulsion. Objects placed in the mouth can be broken and obstruct the child’s airway. If the seizure lasts longer than 10 minutes, the child should be taken immediately to the nearest medical facility. Once the seizure has ended, the child should be taken to his or her doctor to check for the source of the fever. This is especially urgent if the child shows symptoms of stiff neck, extreme lethargy, or abundant vomiting.
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How are febrile seizures diagnosed and treated?

Before diagnosing febrile seizures in infants and children, doctors sometimes perform tests to be sure that seizures are not caused by something other than simply the fever itself. For example, if a doctor suspects the child has meningitis (an infection of the membranes surrounding the brain), a spinal tap may be needed to check for signs of the infection in the cerebrospinal fluid (fluid that bathes the brain and spinal cord). If there has been severe diarrhea or vomiting, dehydration could be responsible for seizures. Also, doctors often perform other tests such as examining the blood and urine to pinpoint the cause of the child’s fever.

A child who has a febrile seizure usually doesn’t need to be hospitalized. If the seizure is prolonged or is accompanied by a serious infection, or if the source of the infection cannot be determined, a doctor may recommend that the child be hospitalized for observation.
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How are febrile seizures prevented?

If a child has a fever most parents will use fever-lowering drugs such as acetominophen or ibuprofen to make the child more comfortable, although there are no studies that prove that this will reduce the risk of a seizure. One preventive measure would be to try to reduce the number of febrile illnesses, although this is often not a practical possibility.

Prolonged daily use of oral anticonvulsants, such as phenobarbital or valproate, to prevent febrile seizures is usually not recommended because of their potential for side effects and questionable effectiveness for preventing such seizures.

Children especially prone to febrile seizures may be treated with the drug diazepam orally or rectally, whenever they have a fever. The majority of children with febrile seizures do not need to be treated with medication, but in some cases a doctor may decide that medicine given only while the child has a fever may be the best alternative. This medication may lower the risk of having another febrile seizure. It is usually well tolerated, although it occasionally can cause drowsiness, a lack of coordination, or hyperactivity. Children vary widely in their susceptibility to such side effects.
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What research is being done on febrile seizures?

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health (NIH), sponsors research on all forms of febrile seizures in medical centers throughout the country. NINDS-supported scientists are exploring what environmental and genetic risk factors make children susceptible to febrile seizures. Some studies suggest that women who smoke or drink alcohol during their pregnancies are more likely to have children with febrile seizures, but more research needs to be done before this link can be clearly established. Scientists are also working to pinpoint factors that can help predict which children are likely to have recurrent or long-lasting febrile seizures.

Investigators continue to monitor the long-term impact that febrile seizures might have on intelligence, behavior, school achievement, and the development of epilepsy. For example, scientists conducting studies in animals are assessing the effects of seizures and anticonvulsant drugs on brain development.

Investigators also continue to explore which drugs can effectively treat or prevent febrile seizures and to check for side effects of these medicines.

Can Febrile Seizures Be Prevented?

slource : http://www.drgreene.org/body.cfm?id=21&action=detail&ref=28

My 18-month-old son recently had a simple febrile seizure. I had no idea what was happening. It was terrifying! His doctor says that he’s all right now, but I’m still worried about lasting brain damage. I also feel guilty for not noticing his fever. How can I prevent this terror from happening again? Anonymous

Some children have seizures or convulsions when they have fevers. Although febrile seizures are fairly common, many parents have never seen one until it happens to their child. Febrile seizures occur in 3% to 5% of otherwise healthy children between the ages of 6 months and 5 years. Toddlers are the most commonly affected.

The seizure begins with the sudden sustained contraction of muscles on both sides of a child’s body — usually the muscles of the face, the trunk, the arms and the legs. Often a haunting, involuntary cry or moan emerges from the child, from the force of the muscle contraction. The contraction continues for seemingly endless seconds, or tens of seconds. The child will fall, if standing, and may pass urine. He may vomit. He may bite his tongue. The child will not be breathing, and may begin to turn blue. Finally, the sustained contraction is broken by repeated brief moments of relaxation — the child’s body begins to jerk rhythmically. The child is unresponsive to the parent’s screams.

This is usually one of lifetime’s most frightening moments for the parents. Most parents are afraid that their child will die or will have brain damage. Thankfully, simple febrile seizures are harmless.

Febrile seizures are brought on by the sudden stimulation of many brain cells at once. Experts argue over whether febrile seizures are triggered by the height of the fever or by the rate of rise. I suspect that both play a role. Most febrile seizures occur well within the first 24 hours of an illness, not necessarily when the fever is highest. Often the seizure is the first sign of a fever, making febrile seizures hard to prevent.

A simple febrile seizure stops by itself within a few seconds to 10 minutes, sometimes followed by a brief period of drowsiness or confusion. Anticonvulsant medicines are generally not needed.

A complex febrile seizure is one that lasts longer than 15 minutes, occurs in an isolated part of the body, or recurs during the same illness.

During the seizure leave your child on the floor, although you may want to slide a blanket under him if the floor is hard. Move him only if he is in a dangerous location. Loosen any tight clothing, especially around the neck. If possible, open or remove clothes from the waist up. If he vomits, or if saliva and mucus build up in the mouth, turn him on his side or stomach. Don’t try to restrain your son, or stop the seizure movements. Don’t try to force anything into his mouth to prevent him from biting his tongue, as this increases the risk of injury and choking. Be sure that your child is breathing during the seizure. If he appears blue around his lips, you should call 911 immediately.

Focus your attention on bringing the fever down. Inserting rectal acetaminophen (Tylenol) is a great first step — if you happen to have some. Don’t try to give him anything by mouth.

Apply cool washcloths to the forehead and neck. Sponge the rest of his body with lukewarm (not cold) water. (Cold water or alcohol may make him shiver and make the fever worse). After the seizure is over and your son is awake, give him the normal dose of ibuprofen (Motrin or Advil) or acetaminophen (Tylenol). Children should see a doctor as soon as possible after their first febrile seizure. If the seizure ends quickly, drive him to an emergency room when it is over. If the seizure is lasting several minutes, call 911 to have an ambulance bring him to the hospital.

After the seizure, the most important step is to identify the cause of the fever. Most febrile seizures are brought on by fevers arising from viral upper respiratory infections, ear infections, or roseola. Meningitis causes less than 0.1% of febrile seizures but should always be considered, especially in children less than one year old or who still look ill when the fever drops.

About one third of the children who have had a febrile seizure will have another one with a subsequent fever (about 2/3 won’t). Of those who do, about half will have a third seizure. Few have more than three. Sometimes febrile seizures run in families. If there is a family history, if the first seizure happened before 12 months of age, or if the seizure happened with a fever of <102, a child is more likely to fall in the group that has more than one febrile seizure.

To try to prevent future febrile seizures, many health care providers recommend using acetaminophen (Tylenol) and/or ibuprofen (Motrin or Advil) at the first sign of a fever. However, researchers have found that these medications may not necessarily prevent febrile seizures. Despite the question of their utility in preventing febrile seizures, these medications can make children more comfortable when they are feverish and are worth trying for that reason(Eur J Pediatr (2008) 167:17–27).

Other things to try include sponging your child with lukewarm water. Also give him cool liquids to drink — both to lower the temperature and to keep him well hydrated. Since febrile seizures can occur as the first sign of illness, prevention is often not possible. Neither an initial nor a recurrent febrile seizure suggests second-rate care of your child.

Sometimes children who have had a febrile seizure are subsequently treated by their parents as weak or vulnerable children. This does not help anyone. Simple febrile seizures should not hold a child back from his normal activities.

There is no evidence that febrile seizures cause death, brain damage, epilepsy, mental retardation, a decrease in IQ, or learning difficulties.

A small number of children who have had a febrile seizure do go on to develop epilepsy, but not because of the febrile seizures. Children who would develop epilepsy anyway will sometimes have their first seizures during fevers. These are usually prolonged, complex seizures. Previous neurologic problems and a family history of epilepsy also make future epilepsy more common (about 2% of these high risk children will develop epilepsy, compared to about 1% in the general population). The number of febrile seizures has no correlation with future epilepsy.

I have no doubt that your son's febrile seizure was a moment of terror for you. For many families, these seizures shake more than the children's bodies. The seizure can shake up the routine of being a parent. For parents of toddlers, the battles of the wills can get exasperating. The work can be exhausting. The seizure can shake off the layers of weariness and frustration to reveal the intense love you have for each other.

Alan Greene MD FAAP

Reviewed by: Khanh-Van Le-Bucklin MD & Liat Simkhay Snyder M.D.
Originally published: March 10, 1997
Last reviewed and updated: April 2009

Febrile Seizure

source : http://www.nlm.nih.gov/medlineplus/ency/article/000980.htm

A febrile seizure is a convulsion in a child triggered by a fever. These convulsions occur without any brain or spinal cord infection or other nervous system (neurologic) cause.
Causes

About 3% – 5% of otherwise healthy children between ages 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected. Febrile seizures often run in families.

Most febrile seizures occur in the first 24 hours of an illness, and not necessarily when the fever is highest. The seizure is often the first sign of a fever.

Febrile seizures are usually triggered by fevers from:

* Ear infections
* Roseola
* Upper respiratory infections caused by a virus

Meningitis causes less than 0.1% of febrile seizures but should ALWAYS be considered, especially in children less than 1 year old, or those who still look ill when the fever comes down.

A child is likely to have more than one febrile seizure if:

* There is a family history of febrile seizures
* The first seizure happened before age 12 months
* The seizure occurred with a fever below 102 degrees Fahrenheit

Symptoms

A febrile seizure may be as mild as the child’s eyes rolling or limbs stiffening. Often a fever triggers a full-blown convulsion that involves the whole body.

Febrile seizures may begin with the sudden contraction of muscles on both sides of a child’s body — usually the muscles of the face, trunk, arms, and legs. The child may cry or moan from the force of the muscle contraction. The contraction continues for several seconds, or tens of seconds. The child will fall, if standing, and may pass urine.

The child may vomit or bite the tongue. Sometimes children do not breathe, and may begin to turn blue.

Finally, the contraction is broken by brief moments of relaxation. The child’s body begins to jerk rhythmically. The child does not respond to the parent’s voice.

A simple febrile seizure stops by itself within a few seconds to 10 minutes. It is usually followed by a brief period of drowsiness or confusion. A complex febrile seizure lasts longer than 15 minutes, is in just one part of the body, or occurs again during the same illness.

Febrile seizures are different than tremors or disorientation that can also occur with fevers. The movements are the same as in a grand mal seizure.
Exams and Tests

The health care provider may diagnose febrile seizure if the child has a grand mal seizure but does not have a history of seizure disorders (epilepsy). In infants and young children, it is important to rule out other causes of a first-time seizure, especially meningitis.

In a typical febrile seizure, the examination usually shows no abnormalities other than the illness causing the fever. Typically, the child will not need a full seizure workup (which includes an EEG, head CT, and lumbar puncture (spinal tap)).

To avoid having to undergo a seizure workup:

* The child must be developmentally normal.
* The child must have had a generalized seizure, meaning that the seizure was in more than one part of the child’s body, and not confined to one part of the body.
* The seizure must not have lasted longer than 15 minutes.
* The child must not have had more than one febrile seizure in 24 hours.
* The child must have a normal neurologic exam performed by a health care provider.

Treatment

During the seizure, leave your child on the floor.

* You may want to slide a blanket under the child if the floor is hard.
* Move him only if he is in a dangerous location.
* Remove objects that may injure him.
* Loosen any tight clothing, especially around the neck. If possible, open or remove clothes from the waist up.
* If he vomits, or if saliva and mucus build up in the mouth, turn him on his side or stomach. This is also important if it looks like the tongue is getting in the way of breathing.

DO NOT try to force anything into his mouth to prevent him from biting the tongue, as this increases the risk of injury. DO NOT try to restrain your child or try to stop the seizure movements.

Focus your attention on bringing the fever down:

* Insert an acetaminophen suppository (if you have some) into the child’s rectum.
* DO NOT try to give anything by mouth.
* Apply cool washcloths to the forehead and neck. Sponge the rest of the body with lukewarm (not cold) water. Cold water or alcohol may make the fever worse.
* After the seizure is over and your child is awake, give the normal dose of ibuprofen or acetaminophen.

After the seizure, the most important step is to identify the cause of the fever.
Outlook (Prognosis)

The first febrile seizure is a frightening moment for parents. Most parents are afraid that their child will die or have brain damage. However, simple febrile seizures are harmless. There is no evidence that they cause death, brain damage, epilepsy, mental retardation, a decrease in IQ, or learning difficulties.

A small number of children who have had a febrile seizure do go on to develop epilepsy, but not because of the febrile seizures. Children who would develop epilepsy anyway will sometimes have their first seizures during fevers. These are usually prolonged, complex seizures.

Nervous system (neurologic) problems and a family history of epilepsy make it more likely that the child will develop epilepsy. The number of febrile seizures is not related to future epilepsy.

About a third of children who have had a febrile seizure will have another one with a fever. Of those who do have a second seizure, about half will have a third seizure. Few children have more than three febrile seizures in their lifetime.

Most children outgrow febrile seizures by age 5.
Possible Complications

* Biting oneself
* Breathing fluid into the lungs, pneumonia
* Complications if a serious infection, such as meningitis, caused the fever
* Injury from falling down or bumping into objects
* Injury from long or complicated seizures
* Seizures not caused by fever
* Side effects of medications used to treat and prevent seizures (if prescribed)

When to Contact a Medical Professional

Children should see a doctor as soon as possible after their first febrile seizure.

If the seizure is lasting several minutes, call 911 to have an ambulance bring your child to the hospital.

If the seizure ends quickly, drive the child to an emergency room when it is over.

Take your child to the doctor if repeated seizures occur during the same illness, or if this looks like a new type of seizure for your child.

Call or see the health care provider if other symptoms occur before or after the seizure, such as:

* Abnormal movements
* Agitation
* Confusion
* Drowsiness
* Nausea
* Problems with coordination
* Rash
* Sedation
* Tremors

It is normal for children to sleep or be briefly drowsy or confused right after a seizure.
Prevention

Because febrile seizures can be the first sign of illness, it is often not possible to prevent them. A febrile seizure does not mean that your child is not getting the proper care.

Occasionally, a health care provider will prescribe diazepam to prevent or treat febrile seizures that occur more than once. However, no medication is completely effective in preventing febrile seizures.
Alternative Names

Seizure – fever induced
References

Johnston MV. Seizures in Childhood. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 593.

Leung AK, Robson WL. Febrile seizures. J Pediatr Health Care. 2007 Jul-Aug;21(4):250-5.

Warren CR. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003; 41(2): 215-222.
Update Date: 8/2/2008

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.