Febrile convulsions

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of febrile convulsions.

Background

Febrile convulsions are seizures in children aged between 6 months and 5 years that result from a sudden rise in temperature associated with an acute febrile illness.
  • Febrile convulsions are common in childhood, and are common ED presentations.
  • Most are simple febrile convulsions which are benign.
  • Most occur on Day 1 of the illness

Key Points

Febrile convulsions occur in 2-4% of children
  • Between 6 months and 5 years.
  • 90% occurring between 6 months and 3 years.
  • The peak incidence is at 18 months of age.
  • Approximately 5% of children with febrile convulsions present with febrile status epilepticus.
Febrile convulsions can be divided into Simple and Complex.

Febrile convulsion management flowchart. Click to enlarge.

Simple Febrile Convulsions

  • Duration less than 15 minutes
  • Generalised in nature (not focal)
  • Only 1 seizure in 24 hours
  • Occur in developmentally normal children
  • No neurological abnormalities post seizure

Complex Febrile Convulsions

Either:

  • Prolonged (> 15 minutes)
  • > 1 seizure in 24 hours
  • Focal in nature

The risk of recurrent febrile convulsions is increased with:

  • Multiple initial seizures (occurs in 10-15% of febrile seizures)
  • < 12 months at first febrile convulsion
  • Low grade temperature at first seizure
  • Family history of febrile seizures
  • Brief duration between fever onset and febrile seizure
  • Developmental delay

Future risk of epilepsy

  • Complex febrile convulsions
  • Family history of epilepsy
  • Any neuro-developmental problem in the child

If one risk factor, chance of epilepsy is 2% (which is double the population risk). If two or more risk factors, chance of epilepsy is 10%. 

Assessment

  • A febrile convulsion can be the presenting complaint of an illness
  • It is important to identify the source of the fever
  • Most children with a simple febrile convulsion require no further investigation
  • Children with complex febrile convulsions may require admission and further investigations

History

  • Febrile seizure – make sure there is a history of fever at the time of seizure or documented fever in ambulance or ED
  • Determine if the child has had a vaccination in the past 14 days
    • If so, a WA Vaccine Safety Surveillance: Adverse Reaction Reporting Form WAVSS (external site) needs to be completed

Investigations

  • Usually no investigations are required for a simple febrile convulsion
  • For complex febrile convulsions consider blood tests, urine, lumbar puncture and CXR

Management

Initial management

  • Ensure high flow oxygen is provided whilst the child has a decreased level of consciousness or is still fitting
  • If the child is still fitting for more than 5 minutes proceed to ED Guideline: Status Epilepticus
  • Treat the underlying cause of fever if appropriate
  • Antipyretics such as paracetamol have not been shown to prevent convulsions but may be worth considering for symptomatic relief of discomfort and pain.

Discharge criteria

Children can be discharged who:

  • had a simple febrile convulsions and are fully recovered and parents are happy for discharge
  • have an obvious cause of fever and have been observed in ED for 2 hours post seizure

Discuss all other cases with a Senior ED Doctor regarding the need for admission.

Referrals and follow-up

  • For simple febrile convulsions, GP referral in next few days.

Health information (for carers)

At discharge provide parents with the following:

Facts for parents

  • Approximately 30% of children who have had a febrile convulsion will have a recurrence
  • Of those that have a reoccurrence 50% will occur within the first year, 90% within 2 years.

Nursing

  • For seizures in progress commence high flow oxygen and turn the patient on their side
  • Continuous SpO2 monitoring is required while the patient has a reduced level of consciousness
  • See ED guideline, Status epilepticus.

Bibliography

  1. John J Millichap, MD, FAAP Section Editors:Douglas R Nordli, Jr, MDDeputy Editor: John F Dashe, MD, PhD. Clinical features and evaluation of febrile seizures Literature review current through: Jan 2018. Jan 19, 2018. Accessed at Up to date 
  2. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 

Endorsed by:  Director, Emergency Department   Date:  Mar 2017


 Review date:   Feb 2021


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