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.
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Aim
To guide Emergency Department (ED) staff with the assessment and management of febrile convulsions.
Background
Febrile convulsions are seizures that occur in children aged between 6 months and 5 years that result from a sudden rise in temperature associated with an acute febrile (usually viral) illness.
1,2
- 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.
- Occur between 6 months and 5 years, 90% occurring between 6 months and 3 years.1,2
- Peak incidence is at 18 months of age.1,2
- 5% of children present with febrile status epilepticus.1,2
Febrile convulsions can be divided into
Simple (80%) and
Complex (20%).
1,2
Febrile Convulsions Flowchart
Simple Febrile Convulsions
- Duration less than 15 minutes (usually less than 15 minutes)1,2
- Generalised (not focal)
- Only 1 seizure in 24 hours
- Occur in developmentally normal children
- No neurological abnormalities post seizure
Complex Febrile Convulsions
- Prolonged (> 15 minutes)
- Recur (> 1 seizure in 24 hours)1,2
- Focal onset 1,2
Recurrence rate3
- 30% of children who have had a febrile convulsion will have a recurrence.
- Of those that have a recurrence 50% will occur within the first year, 90% within 2 years.
Increased risk of recurrence
- Multiple initial seizures (occurs in 10-15% of febrile seizures)
- < 12 months
- Seizure with low grade fever
- Family history of febrile seizures
- Brief duration between fever onset and the febrile seizure
- Developmental delay
Future risk of epilepsy
- Complex febrile convulsions
- Family history of epilepsy
- Any neuro-developmental problem in the child
If there is one risk factor, the chance of epilepsy is 2% (which is double the background population risk). If there are two or more risk factors, the chance of epilepsy is 10%.2,3
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
Investigations
- Usually no investigations are required for a simple febrile convulsion and obvious focus of fever
- For complex febrile convulsions consider blood tests including blood glucose levels (BGL), full blood count, urine microculture and sensitivities (MC&S), lumbar puncture (LP) and chest X-ray (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 the fever if appropriate
- Antipyretics such as paracetamol - PCH Medications Manual (internal WA Health only) 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 convulsion 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:
Nursing
- For seizures in progress commence high flow oxygen and turn the patient on their side.
- Continuous oxygen saturation monitoring is required while the patient has a reduced level of consciousness.
- Complete and record a full set of observations on the observation and response tool and record additional information on the Clinical Comments chart. Minimum of hourly observations whilst in ED.
- Complete a full set of neurological observations if clinically indicated.
- See ED guideline: Status epilepticus.
- Protect the patient from falls and from potentially harmful objects in their surroundings.
- Undertake a Falls Risk Assessment and implement risk reduction strategies as soon as possible.
- Parental reassurance and education
References
- Millichap JJ. Clinical features and evaluation of febrile seizures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. 2021. Accessed at www.uptodate.com
- Kliegman RM. Nelson Textbook of Pediatrics, 21st Ed. Elsevier, Philadelphia. 2020.
- Millichap JJ Treatment and prognosis of febrile seizures. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. 2021. Accessed at www.uptodate.com
- Cameron P et al Textbook Of Paediatric Emergency Medicine. 3rd Ed. Elsevier, Edinburgh. 2018.
| Endorsed by: |
Co-Director Nursing, Surgical Services |
Date: |
Jun 2022 |
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