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CLINICAL REVIEW: Lynette G Sadleir and Ingrid E Scheffer Febrile seizures BMJ 2007; 334: 307-311 [Full text]

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Time of occurrence of febrile seizures

Roberto Manfredini, Benedetta Boari, Gianluca Vergine, Elisa Fiumana, and Caterina Borgna-Pignatti   (14 February 2007)

“Febrile convulsion-parental perspective”

Pratima Jain, Pir Shah, SHO; Sam Ramaiah, Medical Director   (17 February 2007)

Cerebral Malaria should not be overlooked as a differential diagnosis to febrile convulsions in Tropics.

Neeru Gupta   (16 April 2007)

Time of occurrence of febrile seizures 14 February 2007
Roberto Manfredini, assistant professor University of Ferrara, 44100 Ferrara, Italy, Benedetta Boari, Gianluca Vergine, Elisa Fiumana, and Caterina Borgna-Pignatti Send response to journal: Re: Time of occurrence of febrile seizures	EDITOR – We read with interest the very informative review article from Dr Sadler and Dr Scheffer (1) and would like to suggest that a useful piece of information could be added, regarding the time of occurrence of febrile seizures. In fact, a seasonal variation characterized by a winter peak has been reported (2), with a possible association with influenza (3). Moreover, first febrile seizures exhibit a circadian variation, with a significant peak in the evening, between 4 to 8 PM (2). As appropriately stated (1), it is of limited importance whether febrile seizures are more likely to occur with the maximal rate of temperature rise or before the fever is apparent. A close relationship between circadian rhythms of physiological functions and diseases exists, such as that between blood pressure rhythm and time of onset of cardiovascular events (4-5). Also body temperature exhibits a well-known endogenous circadian rhythm, characterized by a physiological increase during the afternoon – evening hours and an estimated variation in amplitude up to 0.8°C (6). Thus, in some children, an even mild increase may reach the threshold that triggers convulsions. Although febrile seizures are a benign disorder with an excellent outcome (1), they are particularly stressful for parents, who often develop a high level of anxiety in the fear of recurrence. Since education and reassurance are the mainstay of management, parents of children should be informed about the clustering of events during winter and in the evening. References 1) Sadler LG, Scheffer IE. Febrile seizures. BMJ 2007;334:307-311. 2) Manfredini R, Vergine G, Boari B, Faggioli R, Borgna-Pignatti C. Circadian and seasonal variation of first febrile seizures. J Pediatr 2004;145:838-839. 3) van Zeijl JH, Mullaart RA, Borm GF, Galama JMD. Recurrence of febrile seizures in the respiratory season is associated with influenza A. J Pediatr 2004;145:800-805. 4) Manfredini R, Gallerani M, Portaluppi F, Fersini C. Relationships of the circadian rhythms of thrombotic, ischemic, and arrhythmic events to blood pressure rhythms. Ann N Y Acad Sci 1996;783:141-158. 5) Portaluppi F, Manfredini R, Fersini C. From a static to a dynamic concept of risk: the circadian epidemiology of cardiovascular events. Chronobiol Int 1999;16:33-49. 6) Reilly T. Circadian rhythms in muscular activity. In: Komi PV, Marconnet P, Saltin B, Sejersted OM, eds. Muscle Fatigue Mechanisms in Exercise and Training (Switzerland): Karger;1992;218-222. Competing interests: None declared
“Febrile convulsion-parental perspective” 17 February 2007
Pratima Jain, FY2-SHO-Public Health Medicine Jubilee house, bloxwich lane, Walsall, WS2 7JL, Pir Shah, SHO; Sam Ramaiah, Medical Director Send response to journal: Re: “Febrile convulsion-parental perspective”	Lynette G Sadlier et al 1 present an excellent clinical review on febrile seizures. The article very effectively highlights all the major areas of concerns.However we believe, providing information on the risk factors associated with febrile seizures is particularly important to relieve parental anxiety and apprehension related to fever and febrile seizures . Indeed emphasising on good parental education coupled with the possible etiological factors for febrile seizures would be invaluable. Studies have shown significant genetic predisposition to the development of febrile seizures. One such study revealed 2 that low birth weight, repeated episodes of respiratory infections in early childhood and or a positive family history for febrile seizure were all significant risk factors. Also, positive family history is associated with earlier age of onset and simple type convulsions. Studies have also identified the environment as a risk factor but the specific components within the environment have not been elucidated.Some of this work has also looked at the association between prenatal exposure to cigarette, alcohol & coffee and the risk of febrile seizures. Data from these studies suggest that prenatal exposure to low to moderate levels of alcohol and coffee has negligible influence on the risk of febrile seizures, whereas effect of moderate smoking cannot be ruled out3. While febrile seizures are mostly benign, there is no doubt that parents experiencing their child having a febrile seizure is indeed a frightening experience. So we believe that raising awareness about the disorder, allaying parental fears, anxieties and addressing their concerns about recurrence and long term consequences will be of significant value. References: 1.Lynette G Sadlier, Ingrid E Scheffer. Febrile Seizures. BMJ 2007:334:307 -311 2.Bener-A, Al-Suweidi-E-E-K, Bessisso-M, Al-Gazali, Al-Khider-A:J- PEDIATR-NEURO: Genetics and environmental risk factors associated with febrile convulsion 2006:4:4:239-243 3.Vestergaard M, Wisborg K, Henriksen TB, Secher NJ. Ostergaard JR, Olsen J: Paediatrics: Prenatal exposure to cigarette, alcohol, and coffee and the risk for febrile seizures: 2005:116(5):1089-94 Competing interests: None declared
Cerebral Malaria should not be overlooked as a differential diagnosis to febrile convulsions in Tropics. 16 April 2007
Neeru Gupta, Assistant Director General Indian Council of Medical Research, Ansari Nagar, New Delhi-110029 Send response to journal: Re: Cerebral Malaria should not be overlooked as a differential diagnosis to febrile convulsions in Tropics.	Editor- Sir, it is surprising to note in this, very informative clinical review by Lynette GS and Ingrid ES that they did not mention Cerebral Malaria as a differential diagnosis to febrile convulsions1. In places where malaria transmission is intense, malaria can be both a cause of febrile seizures as well as may present as convulsions with fever in cerebral malaria caused by Plasmodium falciparum2,3,4. So appropriate tests and treatment should be considered in countries (mainly tropical) where malaria is endemic. A thin and thick blood film and hematocrit are easy investigations and can be done in resource constraint settings too. References: 1) Sadler LG, Scheffer IE. Febrile seizures. BMJ 2007;334:307-311. 2) Akpede GO, Sykes RM, Abiodun PO. Convulsions with malaria: febrile or indicative of cerebral involvement?J Trop Pediatr.1993;39(6):350-5. 3) Osuntokun BO Malaria and the nervous system. Afr J Med Med Sci.1983;12(3-4):165-72. 4) Phillips RE, Solomon T Cerebral malaria in children. Lancet. 1990 Dec 1;336(8727):1355-60 Competing interests: None declared