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, Lady Cilento Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Statewide Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Division.

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 6 months and 6 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

The estimated overall febrile convulsion recurrence rate is 30-35%⁴ with 10% of children experiencing ≥ 3 convulsions.⁵

Risk factors for recurrent febrile convulsions include:

• first febrile convulsion < 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 < 1 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

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 – Emergency management in children guideline)

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

Differentiating simple febrile convulsions from other convulsions will require specific questioning on:

• 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 afebrile)
• 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 6 months and 6 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 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}

If the source of infection is not identified on initial assessment consider the role of sterile urine collection to exclude urinary tract infection. Refer to the Febrile Illness – Emergency Management in Children Guideline for further information on the recommended approach to investigations for febrile children with no identified focus of infection.

Refer to the Meningitis – Emergency Management in Children Guideline for the indications for LP 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

Any febrile convulsion that has a focal component, is prolonged (> 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.

Acute treatment is indicated for prolonged convulsions > 5 minutes (refer to Status epilepticus – Emergency management in children guideline). Earlier onset of treatment results in shorter duration of complex febrile convulsions.¹³

Management will be dictated by the source of the fever. Refer to the Fever Guideline for guidance on 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.^14,15

Follow your local facility escalation protocols for children of concern. Transfer is recommended if the child requires care beyond the level of comfort of the treating hospital. Clinicians can contact the services outlined below to escalate the care of a paediatric patient.

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 is appropriate for outpatient treatment
• 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 (with recommendation to complete a formal first aid course)

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

Follow-up

• with GP 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 a 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).

Statewide Emergency Guidelines

• Fever
• Meningitis
• Sepsis

Factsheets

• Febrile convulsions
• Fever

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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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11. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. 2009.
12. Amir A. Kimia, Andrew J. Capraro et al, Utility of lumbar puncture for first simple febrile seizure among 6 to 18 months of age; Pediatrics Vol. 123 No. 1. January 1, 2009, pp. 6-12.
13. Seinfeld S, Shinnar Sm Sun S et al. Emergency Management of Febrile Status Epileptiucs: Results of the FEBSTAT study
14. Camfield PR, Camfield CS, Shapiro SH, Cummings C. The first febrile seizure: antipyretic instruction plus either phenobarbital or placebo to prevent recurrence. J Pediatr. 1980;97:16–21
15. Uhari M, Rantala, H, Vainionpaa L, Kurttila R. Effect of acetaminophen and of low intermittent doses of diazepam on prevention of recurrence of febrile seizures. J Pediatr. 1995;126:991–995