This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with a suspected febrile convulsion in Queensland.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Paediatric Neurology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Febrile convulsions are a frequent ED presentation and the most common seizure disorder in children.1 Approximately 1 in 30 children will experience a febrile convulsion as a result of a fever, mostly between the ages of six months and six years.

Most febrile convulsions are brief, isolated generalised tonic-clonic seizures that occur with an acute febrile illness in children with no history of afebrile seizures, significant known neurological abnormality or current CNS infection.^1,2

There is no evidence to suggest any structural neurological damage or increased risk of cognitive decline in a child who experiences a simple febrile convulsion.³

Recurrent febrile convulsions

The estimated overall febrile convulsion recurrence rate is 30-35%⁴ with 10% of children experiencing three or more convulsions.⁵

Risk factors for recurrent febrile convulsions include:

• first febrile convulsion at less than 18 months of age
• family history of febrile convulsions or epilepsy

Febrile convulsions and epilepsy

Most children who experience a febrile convulsion will not develop epilepsy later in life.¹ Children who have multiple febrile convulsions starting less than one year of age are at the highest risk of developing afebrile seizures by 25 years of age.⁶ However, even in this group the risk is only 2.4% compared to the background 1% risk for the general population.^6-8

Classification

The aim of the assessment is to:

• differentiate simple febrile convulsion from other convulsions which require specialist referral
• identify and, if necessary, treat the source of the fever (refer to Febrile illness Guideline)

Febrile convulsions are extremely distressing to the care giver and other witnesses so be aware of the likely parental anxiety at the time of presentation.

History

Questioning to differentiate simple febrile convulsions from other convulsions should include:

• details preceding the convulsive episode including:
  • prior events and behaviour of the child
  • signs or symptoms of illness
• details of the convulsion including:
  • how it started
  • the exact movements of the eyes and limbs
  • symmetry of the movements
  • focal movements
  • estimated duration
• appearance/behaviour of the child post convulsion
• any previous convulsions (including a febrile)
• medical and surgical history including intracranial infection or severe metabolic disturbance such as hypoglycaemia or electrolyte disturbance, neurological damage, neurosurgical procedures (including the placement of ventriculo-peritoneal shunts)

Examination

The examination should be directed by the history, with particular emphasis on:

• localising a source for the fever
• assessing neurological status and return to normal level of alertness and activity

Simple febrile convulsions

Investigations are not routinely required for simple febrile convulsions providing the child is aged between six months and six years and makes a full recovery to normal self after a period of observation.² Investigations in this group of children should be directed by the suspected underlying cause of infection (see Febrile illness Guideline) rather than the febrile convulsion itself dictating investigation.

The following investigations are NOT routinely recommended if the child is otherwise well:

• bloods
• lumbar puncture (LP)
• imaging
• electroencephalogram (EEG) (not predictive of future febrile convulsion or epilepsy risk)^9,10

Refer to the Meningitis Guideline for the indications for a lumbar puncture in a child with suspected meningitis. Research has shown fully immunised children aged 6 to 18 months who present after a febrile convulsion and are clinically well with no prior antibiotic treatment are at a very low risk of bacterial meningitis.^11,12

Atypical simple and other febrile convulsions

Any febrile convulsion that has a focal component, is prolonged (more than 15 minutes), or results in a slow return to normal conscious state should prompt investigation into underlying infection. A focal component to the seizure, or any focal neurological findings, should prompt consideration of CNS infection or structural abnormality.

Management of children following a febrile convulsion will be dictated by the source of the fever. Refer to the Febrile illness Guideline for guidance on the management of febrile children with no focus of infection evident on initial assessment.

Ibuprofen and/or Paracetamol may alleviate discomfort in a febrile child.  Neither antipyretics or anticonvulsants prevent the recurrence of simple febrile convulsions.^13,14

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Refer to the Status epilepticus Guideline for the recommended management of child with a convulsion lasting more than five minutes.

Inter-hospital transfers

When to consider discharge from ED

Discharge will be based on the source of the infection and the management required. There is no evidence for a prescribed minimum duration of observation following a febrile convulsion.

Consider discharge for a child who meets the following criteria:

• suffered a simple febrile convulsion
• returned to their normal age appropriate baseline neurology
• has an infectious source identified that can be managed as an outpatient
• can be safely managed at home

Prior to discharge, parent/s should receive education regarding:

• the recurrence rate of febrile convulsions
• first aid for a convulsion

On discharge, parent/s should be provided with a Febrile convulsions Factsheet

Follow-up

• with General Practitioner within a week to ensure resolution of the instigating febrile illness.

When to consider admission

The requirement for admission will be based on the management of the underlying infectious disease.

The decision to admit a child with complex febrile convulsions or status epilepticus will be made by the specialist referral team based on the further investigations and management required.

Facilities with a Short Stay Unit (SSU)

Consider admission to an SSU for a child following a febrile convulsion for prolonged observation if ongoing parental anxiety or inappropriate community setting (i.e. middle of the night, transport not available).

Guidelines

• Febrile illness
• Meningitis
• Sepsis

Factsheets

• Febrile convulsions
• Fever in children

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2. Royal Childrens Melborne Febrile Convulsion Guideline. Available from: http://www.rch.org.au/clinicalguide/guideline_index/Febrile_Convulsion/
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