Seizures - febrile
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An epileptic seizure that presents in the context of a fever can be:
- A febrile seizure
- An acute symptomatic epileptic seizure (e.g. in a child with meningitis or encephalitis)
- An epileptic seizure in an individual with epilepsy in whom the seizure is triggered by a fever or illness
Febrile Seizure is a diagnosis given to children who have epileptic seizures only with fever between the age of six months and six years. This has previously been referred to as Febrile Convulsions. A child presenting with a febrile epileptic seizure has the same risk for serious sepsis as a child presenting with fever alone.
Seizures occurring within the context of a gastrointestinal illness (regardless of temperature during the seizure) should be conceptualised and managed in the same way as febrile seizures.
A child who has had an epileptic seizure with a fever should be investigated according to the same criteria used for other children presenting with a febrile illness.
See guideline for the febrile child.
Check blood sugar.
Perform lumbar puncture in all children less than six months of age who have a fever and an epileptic seizure, or in any age if there is concern about meningitis, unless contraindicated. Contraindications include:
- GCS 8 or less (P on AVPU scale)
- Persistent focal neurological signs
- Child shows signs of clinical deterioration in conscious level or perfusion during period of observation
If meningitis cannot be excluded clinically and a lumbar puncture is contraindicated, the child should be admitted and started on appropriate therapy for bacterial meningitis. In addition, IV Acyclovir should be started in those children who have had contact with herpes simplex, or who have focal neurology or had focal seizures.
Most febrile seizures are brief (1-2 minutes) and do not require any specific treatment. If the seziure is prolonged (>5 minutes):
- Position child to prevent aspiration of any vomitus
- Give O2 via face mask
- Monitor airway carefully and manage as necessary
- Check blood glucose (if not already checked)
Follow guideline for Status epilepticus.
Acute neuro-imaging (CT or MRI)
Consider acute neuro-imaging if:
- There are new focal neurological deficits
- First episode of status epilepticus
- There is concern about intracranial disease requiring acute surgical intervention
Observation, admission, and discharge
Children who remain drowsy (GCS 13 or less) after a febrile seizure should be observed in hospital. Use 30 minute neurological observations on the standard observation chart. Post-ictal drowsiness is usually brief (1-2 hours). Children who regain normal conscious level and appear well may be able to be discharged with appropriate advice to parents and no specific investigations.
Some children will require admission due to the nature of their illness or other factors.
Repeated seizures during the same illness occur in about 10-15% of children with febrile seizures. If a child has repeated seizures:
- Arrange medical reassessment
- Consider a longer period of observation or admission to clarify progress of the illness
Children with a diagnosis of Febrile seizure do not require follow up unless they have features of concern which include any of the following:
- >3 seizures
- under six months or over six years of age
- seizures longer than 30 minutes
- seizures that have focal signs
- seizures that are not tonic clonic
Best practice recommends that a child with any features of concern should see a paediatrician within two weeks.
Children with recurrent febrile seizures (particularly if prolonged) may benefit from having emergency medication available. The medication of choice is buccal midazolam if needed, or rectal diazepam if buccal midazolam not appropriate. Provide advice, prescription, and information sheets as follows:
- Buccal midazolam (for intranasal
administration use local protocol with an atomiser):
3 - 11 months 2.5mg 1 - 4 years 5mg 5 - 9 years 7.5mg 10 - 18 years 10mg
- Prescribe plastic ampoules 15mg/3ml
- Info sheets
OR (if buccal midazolam not appropriate for child)
- Rectal diazepam:
- 0.3-0.5mg/kg/dose (max dose usually 10mg)
- Dose may only be repeated under medical supervision
- Delayed respiratory depression may occur after rectal administration
- Info sheet: Emergency Management of Seizures using rectal diazepam (Stesolid)
Information for Families
Explain expected clinical progress and what to do in the event of a future seizure. Provide written advice:
Answers to some common questions
- Antipyretics (paracetamol, ibuprofen) do not prevent febrile seizures. They are sometimes given to help a child feel less miserable
- Use simple cooling cares (undress to a single layer, avoid sponging or baths)
- There is about a 1 in 3 chance of the child having a seizure with a future febrile illness
- Long term anticonvulsant use is not indicated in children with febrile seizures
Did you find this information helpful?
- Date last published: 20 September 2018
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department, Paediatric Neurology, General Paediatrics
- Author(s): Greg Williams, Sarah Jamison, Suzanne Davis
- Editor: Greg Williams
- Review frequency: 2 years
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