3 years ago

Republication de : Évaluation d’un enfant après une crise fébrile : focus sur trois problèmes de pratique clinique

S. Auvin, M. Antonios, G. Benoist, M.-a. Dommergues, F. Corrard, V. Gajdos, C. Gras Leguen, E. Launay, A. Salaün, L. Titomanlio, L. Vallée, M. Milh

Publication date: October 2018

Source: Journal Européen des Urgences et de Réanimation, Volume 30, Issue 3

Author(s): S. Auvin, M. Antonios, G. Benoist, M.-A. Dommergues, F. Corrard, V. Gajdos, C. Gras Leguen, E. Launay, A. Salaün, L. Titomanlio, L. Vallée, M. Milh

Résumé

Les crises fébriles (CF) concernent 2 à 5 % des enfants de moins de 5 ans et sont la cause la plus fréquente de crise épileptique chez l’enfant. Il s’agit donc d’une situation fréquente en pratique clinique. Les connaissances et les recommandations ont évolué aux cours des vingt dernières années. Cinq critères sont enseignés et utilisés en pratique courante pour classer les CF en CF simples et complexes. Il semble toutefois que l’ambiguïté de certains critères rende inopérante leur utilisation en pratique, en particulier pour l’indication d’une ponction lombaire. De plus, les études épidémiologiques ont montré que les critères prédictifs de récidive des CF étaient différents de ceux associés à un risque d’épilepsie, augmentant la confusion sur le rôle de chacun de ces critères. C’est dans ce contexte qu’un groupe de travail s’est mis en place pour essayer de formuler des réponses à trois questions cliniques se posant face à un enfant ayant présenté une CF : quand réaliser une ponction lombaire, faut-il prescrire un traitement antiépileptique d’urgence en cas de récidive se prolongeant, chez quel enfant demander un avis neurologique (risque d’épilepsie) ? Un travail de bibliographie a été réalisé suivi d’une journée de travail de discussion et de synthèse des données disponibles. Nous présentons dans cette étude les données de la littérature ainsi que les conclusions des experts.

Abstract

Febrile seizures (FS) are the most common seizures seen in the paediatric population in the out-of-hospital and emergency department settings, and they account for the majority of seizures seen in children younger than 5 years old. An FS is a seizure accompanied by fever, without central nervous system infection, occurring in children between 6 months and 5 years old. Five criteria have been used and taught to classify any FS as simple or complex FS. These factors do not bear the same significance for clinical practice, in particular, the decision to perform a lumbar puncture for cerebrospinal fluid analysis to rule out an intracranial infection. Moreover, epidemiological studies have illustrated that some factors are predictive of febrile seizure recurrence while others are predictive of epilepsy occurrence. On this basis, a workshop was organized to provide an answer to three clinical practice questions: when should a lumbar puncture be performed in a child who has experienced a seizure during a fever episode, is the prescription of a rescue drug required with a risk of a prolonged febrile seizure recurrence, when should a neurological consultation be requested (risk of later epilepsy)? Based on a review of the literature and on a 1-day workshop, we report here the conclusion of the working group. A lumbar puncture is required in any child with meningitis symptoms or septic signs or behaviour disturbance. A lumbar puncture should be discussed based on the clinical symptoms and their progression over time when a child has experienced a focal FS or repetitive FSs without signs of meningitis or sepsis or behaviour disturbance. The lumbar puncture is not necessary in case of simple FS without signs of meningitis, including in infants between 6 and 12 months old. An early clinical evaluation (at least 4 h after the first clinical assessment) could be helpful, in particular in infants younger than 12 months of age. A rescue drug might be prescribed when there is a high risk of prolonged FS (i.e., risk higher than 20 %): age at FS < 12 months OR a history of a previous febrile status epilepticus OR if the first FS was a focal seizure OR abnormal development/neurological exam/MRI OR a family history of nonfebrile seizure. A neurological consultation should be requested for any child who has experienced a prolonged FS before the age of 1 year, for children who have experienced prolonged and focal FS or repetitive (within 24 h) focal FS, for children who have experienced multiple complex (focal or prolonged or repetitive) FS, for children with an abnormal neurological exam or abnormal development experiencing a FS. Although childhood febrile seizures in most cases are benign, witnessing such seizures is always a terrifying experience for the child's parents. Most parents feel that their child is dying or could have severe brain injury related to the episode. Therefore, the group also suggests a post-FS visit with the primary care physician.

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