See also

Convulsions
Febrile Child  

The approach to febrile convulsions requires dealing with
- the convulsion
- the illness causing the fever.

Background to condition

Convulsions, in a child between 6 months and 6 years of age, in the setting of an acute febrile illness, without previous afebrile seizures, significant prior neurological abnormality, and no CNS infection.

They

• occur in 3% of health children
• are normally associated with simple viral infection
• are benign
• Simple febrile convulsions:

Simple febrile convulsions

These are generalised, tonic-clonic seizures lasting less than 15 minutes that do not recur within the same febrile illness.

Complex febrile convulsions

These have one or more of the following:

- focal features at onset or during the seizure
- Duration of more than 15 minutes
- Recurrence within the same febrile illness
- Incomplete recovery within 1 hour.

Febrile status epilepticus

This is a febrile convulsion lasting for longer than 30 minutes.

Note:
It is now recognised that some children can have a presentation with convulsions and an acute infectious illness (particularly gastroenteritis) without documented fever. This is sometimes referred to as " afebrile febrile convulsions". The management and prognosis is the same as for classical febrile convulsions.

Acute Management

Treat the convulsion when necessary as per  Convulsions guidelines.

* Reassurance is important in simple febrile convulsions. The onset of the convulsion may be sudden with little evidence of preceding illness. The convulsion may be terrifying for the parents to observe they frequently believe that their child is dying and may attempt CPR or other resuscitative measures.

Fever control

•  Paracetamol has NOT been shown to reduce the risk of further febrile convulsions. It may be used for pain / discomfort associated with febrile illnesses such as otitis media. The parents should understand the reasons for its use and be discouraged from using it solely to reduce their child's fever.

Assessment

In a simple febrile convulsion once the convulsion has terminated, the aim of the assessment is to determine the cause of the fever.

History and examination as per Febrile child guidelines.

In addition, look for the following risk factors which make simple febrile convulsion unlikely:

- previous afebrile seizures
- progressive neurological conditions
- signs of CNS infection

Investigations

In a simple febrile convulsion, where the focus of infection can be identified, blood tests and invasive investigations are often NOT indicated.

In a child less than 6 months of age reconsider your diagnosis, especially the possibility of CNS infection ( meningitis guideline).

Consider LP if the child is less than 12 months and not up to date with immunisations (especially Hib and pneumococcal), if they are clinically unwell, or if they are already on oral antibiotics that may mask meningitis. Discuss these children with a senior clinician. If there is a genuine  contraindication then antibiotic cover appropriate for  meningitis should be commenced.

Consider consultation with local paediatric team when:

-  Complex febrile convulsion.
- Seizures unable to be controlled.
- Child does not return to normal mental state within 1 hour
- Child clinically unwell.
- Ongoing concern regarding the nature of the febrile illness. ( febrile child guideline)

Consider transfer when:

- Respiratory or haemodynamic compromise.
- Children requiring care above the level of comfort of the local hospital.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Discharge requirements

- Return to normal neurological state following simple febrile convulsion
- Serious bacterial infection excluded or adequately treated
- Parental education regarding febrile convulsions

If discharging a patient home following a febrile convulsion, it is important to give the family advice regarding what to do in the event of a future convulsion.
- Verbal advice should be reinforced with written advice (give Parent Information Sheet - see below).
- Follow-up during as appropriate for the underlying illness.

Parent information sheet:

Additional notes

Long term issues with febrile convulsions.

• Recurrence rate depends on the age of the child; the younger the child at the time of the initial convulsion, the greater the risk a further febrile convulsion (1 year old 50%; 2 years old 30%).
• Risk of future afebrile convulsions (epilepsy) is increased by family history of epilepsy, any neurodevelopmental problem, atypical febrile convulsions (prolonged or focal).
  • No risk factors: risk of subsequent epilepsy approx. 1% (similar to population risk).
  • 1 risk factor: 2%.
  • More than 1 risk factor: 10%.
• Long term anticonvulsants are not indicated except in rare situations with frequent recurrences.
• It may be appropriate to offer a review appointment with a general paediatrician, especially in the case of  complex febrile convulsions.

Last updated April 2011