Febrile convulsion
If the child is still fitting at the time of presentation, initial management is directed towards resuscitation and stopping the convulsion in accordance with APLS guidelines on the management of status epilepticus.
Management is directed towards identifying the cause and excluding serious infection.
Information
- A febrile fit is a tonic / tonic clonic convulsion in a
child
- aged between 6 months to 6 years
- precipitated by fever, arising from infection outside the CNS
- in a child who is otherwise developmentally normal.
- Febrile fits affect approximately 4% of children under 5 years of age
- Male to female ratio being 2:1
- Positive family history up to one third of cases
- Mean age of first presentation is 20 months
- 80% "simple", 20% "complex".
- A simple febrile fit is one that lasts for less than 15
minutes.
- It is not repeated in the same episode
- There are no focal features
- Recovery is complete within 1 hour.
- A complex fit is either
- prolonged (over 15 minutes)
- focal
- or with incomplete recovery, (for example Todd's paresis).
- Status epilepticus is a single convulsion lasting for more than
30 minutes
- or a series of convulsions during which the patient does not regain full consciousness
- A rapid rise in temperature is said to be
important,
- At the time of the fit 75% of children have a temperature > 390.
- Aetiology. The most common cause is viral illness (80-90%). Identifiable causes include upper respiratory tract infection, otitis media, lower respiratory tract infection, urinary tract infection and gastro-enteritis. Fever following immunisation can lead to a febrile convulsion.
Diagnostic approach
- Resuscitation. The priority is to stop the fit and to stabilise the patient following standard APLS guidelines.
- Don't ever forget Glucose (DEFG !) - check BM in ALL.
History
- The state of health prior to the fit
- typically the child is a little off colour or well prior to the fit).
- Features of the fit
- Obtain an accurate description of the fit if at all possible
- Importantly - whether consciousness was lost.
- The eyes may roll up, the limbs may stiffen, there may by cyanosis, there may be generalised movements of either upper and/or lower limbs.
- Previous medical history.
- Particularly any previous history of fits
- Contact with infectious diseases
- Foreign travel.
- Family history of epilepsy or of febrile convulsions.
- Medication.
Assessment
- The unconscious child should be assessed in accordance with APLS guidelines
- Primary survey of ABCD, before a secondary survey general examination.
- Ix - Continuous pulse
oxymetry
- Specific investigation depends on three factors
- Clinical findings
- Age of patient
- Type of fit.
- Specific investigation depends on three factors
Children less that 6 months old
- Treat with caution (Any child under 6 months old with a high fever)
- By definition this is not a febrile convulsion 9< 6/12 old)
- Considered as a sign of CNS infection until proven otherwise.
- All are treated as for meningitis.
- Antibiotic therapy must be commenced
- Urgent discussion with the ED Duty doctor and on call paediatrician
- Antibiotic treatment should not be delayed whilst the septic screen samples are collected.
Age 6 - 18 months
- Treated with extreme caution
- signs of serious infection are few
- If severely unwell a full septic screen should be carried out after appropriate resuscitative measures have been taken.
- Antibiotic therapy should not be delayed if obtaining these samples proves difficult.
- If mildly or moderately unwell, the child should be observed closely and the following
investigations should be performed
- Urine microscopy
- Full blood count
- C Reactive Protein
- Electrolytes and Glucose
- Calcium and Magnesium
Further investigation should be guided by continuing clinical review. A full septic screen should be considered if the child fails to show clinical improvement after appropriate healing measures, particularly if any of the following features are present;
- The child looks toxic or is irritable
- The child shows any sign of meningism
- The child shows signs of drowsiness or delayed recovery from the fit
- The fit is complex.
Age over 18 months
Other children are easier to assess clinically.
- If the child is severely unwell, investigations should be carried out as for the severely unwell child under 18 months of age.
- If mildly or moderately unwell, clinical assessment is of the greatest importance.
- Where there is an obvious source of infection, after thorough clinical assessment, no further investigations are required.
- Where the source of infection is not
obvious or the fit was complex then the following investigations
should be performed
- Urine microscopy
- Full blood count
- C reactive Protein
- Urea and electrolytes
- Calcium and magnesium.
Management & Referral
Following a febrile fit, it may be reasonable to send the child home if the following criteria are met;
- Age > 1 year
- The fit was simple
- The child has fully recovered
- There is an obvious source of infection
- The child is not severely unwell
- The parents are not unduly anxious
- The child has had a previous febrile convulsion or there is a family history of febrile convulsions.
As a general rule, cases involving first febrile fits should be discussed with Senior ED staff or with the duty paediatrician.
All children presenting with a febrile convulsion who are less than 1 year of age should be admitted
Between 1 year and 18 months of age cases should be discussed with the duty admitting paediatrician
Differential paediatric fitting
| First day of life | Second- Third day of life | Day 4 to 6 months of age |
|---|---|---|
|
|
|
Discharge checklist
If the child is to be discharged from the Emergency department check:
- Appropriate treatment for the infection (if any)?
- Advice about keeping the child comfortable (remove clothing, Paracetamol 15mg per kg every 4-6 hours orally and/or Ibuprofen syrup 5mg per kg every 8 hours).
- An advice sheet should be given about febrile convulsions.
- Follow-up - should be arranged within 24-48 hours (normally with the General Practitioner but occasionally by return for ED senior review).
Outcome & Prognosis
The parents should be counselled
fully (nearly all parents think that their child is dying during the
first febrile fit).
The recurrence risk is
less than 30% (1 in 6 have three fits or more).
Most recurrences
occur within one year of the first convulsion.
Often a
strong family history, so siblings should be kept cool during
illnesses.
Simple febrile fits have no relationship to the
development of epilepsy (if the convulsion was complex then
outpatient follow-up with an EEG and/or CT scan is indicated).
From a health prevention perspective, it is important to emphasise that the immunisation schedule should not be changed because of a simple febrile convulsion.
Links
Reference. The handbook of Paediatric Accident and Emergency Medicine by Caphorn, Swain and Goldsworthy.
