Abnormal behavior in children with fever are very frightening to the parents, challenging to treating doctors and can be life threatening to the child. Majority of these abnormal behaviors are benign. But because parents are so worried that such kids are exposed to unnecessary investigations and over treatment. In hurry, while rushing them to the hospital, they are prone for accident.
Fever is the commonest cause of headache in childhood, but since small children cannot explain, so they are irritable, do not eat, continuously crying and their sleep is disturbed. Parents are worried. But what they need to do is to give antipyretics and plenty of oral fluids. Paracetamol is safe and few doses can be given even without prescription. The dose is 10mg to 15 mg /kg/dose, 3 to 4 times in 24 hours.
Common abnormal neurological behaviors during fever in children are febrile seizures, febrile syncope, febrile myoclonus and febrile delirium. Vomiting is a common association with fever and these children are invariable given anti emetics. One of the common toxicity of antiemetic is encephalopathy. Such children are agitated, restless, disoriented, hallucinated and irrelevant in their talk. Such problems are more common in combination drugs like paracetamol and domperidone, where parents are not aware of the contents. These drugs can also cause extrapyramidal symptoms. Such symptoms can be scary to parents. Single parental dose of diazepam or diphenhydramine can relieve these symptoms.
The incidence of febrile seizure in India is around 3% in children younger than 5 years of age. Common age group is 6 months to 5 years. The cause of fever is not CNS infection and is usually viral upper respiratory tract infection. Majority (85%) are typical and are generalized, usually once in a febrile episode and last less than 15 min. treatment is antipyretics and plenty of fluids. EEG and neuro imaging are not required. Short term preventive treatment with clobazam 5mg up to 10 kg weight, 7.5mg up to 15 kg weight and 10 mg up to 20 kg weight per day for 3 days, started at onset of fever can be given in worried parents.
Delirium is seen at peak of fever, child is agitated, restless, disoriented and talks irrelevant. There can be marked tachycardia with sweating. Once the fever comes down, child becomes normal. Only treatment advised is to lower the temperature with cold sponging and antipyretics. Avoid giving feeds during that time.
In febrile syncope, child becomes unresponsive, pale and limp. This is due to vasodilatation and pooling of blood at peripheries leading to decreased intracranial blood flow. Nothing to panic. Put the child on flat hard surface. Give cold liquids to drink and antipyretics to lower the fever.
Some children start jerking their whole body for hours together and do not respond to benzodiazepines and other anticonvulsants. These are known as febrile myoclonia and are supposed to be due to the release of cytokines during fever. These cytokines stimulate hypothalamus causing myoclonus.
CNS infection should always be kept in mind when a child presents with abnormal neurological behavior and fever. In meningitis, child will be sick looking and may have neck rigidity. Observation in majority of the case will resolve the issue and few may require CSF analysis to exclude CNS infection.
Written By: Dr (Brig) K S Rana (Venkateshwar Hospital, Dwarka)
Senior Consultant Pediatric Neurology