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of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON
MANAGEMENT OF FEBRILE
CONVULSION IN CHILDREN
Siba Prosad Paul and colleagues discuss the aetiology, clinical
presentation, diagnosis and management of the most common
type of seizure in children, and set out best practice for their care
Correspondence
siba_prosad@yahoo.co.uk Abstract
Siba Prosad Paul is a specialty The causes of febrile convulsions are usually benign. be supported and kept informed by experienced
trainee year 8 in paediatrics
at Bristol Royal Hospital for
Such convulsions are common in children and their emergency department (ED) nurses. This article
Children, part of University long-term consequences are rare. However, other discusses the aetiology, clinical presentation, diagnosis
Hospitals Bristol NHS causes of seizures, such as intracranial infections, and management of children with febrile convulsion,
Foundation Trust
must be excluded before diagnosis, especially in infants and best practice for care in EDs. It also includes
Eleanor Rogers is fourth-year and younger children. Diagnosis is based mainly on a reflective case study to highlight the challenges faced
medical student at the history taking, and further investigations into the by healthcare professionals who manage children who
University of Bristol
condition are not generally needed in fully immunised present with febrile convulsion.
Rachel Wilkinson is an advanced children presenting with simple febrile convulsions.
paediatric nurse practitioner at Treatment involves symptom control and treating the Keywords
St Richard’s Hospital, Chichester,
part of Western Sussex Hospitals
cause of the fever. Nevertheless, febrile convulsions Children, paediatric, seizures, fever, high temperature,
NHS Foundation Trust in children can be distressing for parents, who should febrile convulsions, epilepsy
gastroenteritis, middle ear infections, respiratory interim recovery, occurs in 5% of children with febrile
tract infections and tonsillitis. convulsion, and is more likely than other forms of
The risk of febrile convulsion is increased complex febrile convulsion to have focal features
by positive family histories, with up to 40% (Sadleir and Scheffer 2007, Chung 2014, Tejani 2015).
of children having such histories. Between 9% and
22% of children with siblings who have experienced Diagnosis
febrile convulsion experience it themselves, and the When children with febrile convulsion present
likelihood that the other twin will experience febrile to EDs, healthcare professionals should take
convulsion is highest among monozygotic twins (Lux detailed and accurate histories, and make physical
2010a). Almost 50% of children in whom siblings examinations, to rule out other diagnoses and to
and one parent have experienced febrile convulsion identify the cause of fever. Differential diagnoses
experience it too (Tejani 2015). of childhood seizures (Sadleir and Scheffer 2007,
Pre-existing neurological conditions, such as Paul et al 2012) include:
cerebral palsy, and iron and zinc deficiencies, are ■ Rigors with no loss of consciousness.
also thought to increase the risk of febrile convulsion ■ Febrile delirium, an acute and transient confused
(Paul et al 2012, Waqar Rabbani et al 2013). state associated with fever.
Research demonstrates that the development ■ Febrile syncope.
of febrile convulsion may be due mainly to ■ Breath-holding attacks, in which children
polygenetic inheritance (Paul and Chinthapalli transiently lose consciousness due to voluntarily
2013, Tejani 2015), although an autosomal holding their breath.
dominant pattern of inheritance known as a ‘febrile ■ Reflex anoxic seizures, in which painful events or
seizure susceptibility trait’ has been identified in shock causes children suddenly to become limp.
a few families (Tejani 2015). Although the exact Such children may have low-grade pyrexia.
molecular mechanisms are yet to be understood ■ Evolving epilepsy syndrome.
fully, underlying mutations in genes encoding ■ Central nervous system (CNS) infections, such as
sodium channels and the gamma-aminobutyric acid meningitis and encephalitis.
A receptor have been identified in children with Histories are likely to come from children’s parents
febrile convulsions (Tejani 2015). or guardians, and healthcare professionals should be
careful to gather information on (Chung 2014):
Clinical presentation ■ The nature of the convulsion, for example
The peak age of onset of febrile convulsion is whether it is generalised or focal, and
18 months, with up to 50% of children having first its duration.
episodes aged between 12 and 30 months. First ■ The duration of the post-ictal phase.
presentations of febrile convulsions in children ■ Recent illnesses or fever.
aged over three years are rare (Sadleir and Scheffer ■ Recent antibiotic use.
2007, Chung 2014). ■ Other symptoms, such as breathing difficulties
Children with febrile convulsion usually have and diarrhoea.
a temperature of more than 38°C. Convulsions ■ Immunisation status.
can occur at any point during a febrile illness, ■ Histories of febrile convulsions or previously
however, and children may not have a raised diagnosed neurological conditions.
temperature at the time of their seizures but may ■ Family histories of febrile convulsions, epilepsy
subsequently develop one. or sudden death.
Signs and symptoms can include loss of ■ Use of antipyretics.
consciousness, global or focal twitching or jerking ■ Use of rescue anticonvulsants, such as diazepam
of arms and legs, difficulty breathing, foaming at and midazolam, to terminate seizure. This
the mouth, pallor or going blue, and eyes rolling question may be asked of paramedic staff
back in the head. After a seizure, children are often rather than parents or guardians.
drowsy and sometimes confused, and can take up to Examinations should include full neurological
30 minutes to wake properly (Department of Health assessments and healthcare professionals
Australia 2010). should look for signs of meningeal irritation,
There are two types of febrile convulsion, such as neck stiffness (Chung 2014). It is
with 70% classified as simple and 30% as complex. therefore vital that they can recognise the signs
The characteristics of each are shown in Table 1. and symptoms of CNS infections, which can be
Febrile status epilepticus, a severe form of complex subtle in infants and young children (Paul and
febrile convulsion lasting at least 30 minutes without Chinthapalli 2013).
Simple Complex
■ Tonic-clonic activity is generalised and without the ■ Each convulsion lasts more than ten minutes.
features of a focal seizure. ■ A second convulsion may occur within 24 hours.
■ Each convulsion lasts for less than ten minutes. ■ There is a focal seizure in which, for example,
■ Convulsions resolve spontaneously. convulsions occur on only one side of the body.
■ There are no further convulsions within the next ■ Full consciousness is not regained within one hour.
24 hours. ■ There are post-ictal neurological abnormalities.
■ There is a brief period of paralysis, known as
a Todd’s paresis, after the convulsion.
■ Febrile status epilepticus occurs.
(Adapted from Sadleir and Scheffer 2007, Mewasingh 2010, Paul and Eaton 2013, Chung 2014)
Case study
A paediatric medical team was ‘crash bleeped’ 25 minutes. Clinical examination revealed he
to attend resuscitation urgently after a three-year-old had bilateral inflamed tympanic membranes and
boy was rushed with his parents by ambulance to the right-sided inflamed enlarged tonsils.
emergency department (ED).
The boy was given a provisional diagnosis of complex
The boy’s parents said that, while at home about five febrile convulsion and was put under neurological
hours earlier, he had become febrile. His parents had observation. The possibility that he had contracted
given him paracetamol, but he had suddenly become another serious infection, such as meningitis or
‘floppy’ and unresponsive. Worried that their son encephalitis, was considered and documented.
had sustained brain damage due to high fever or was Because there had been a prolonged period of
about to die, the parents had called for an ambulance. unresponsiveness before and after his seizure, he was
On the way to the ED, the right side of the boy’s body administered IV ceftriaxone and acyclovir in case of
had begun to twitch and the twitching progressed to intracranial bacterial and herpes infections.
a generalised tonic-clonic seizure.
Over the next 36 hours, the boy’s fever settled and
On arriving at the ED, the parents were extremely he recovered completely. His detailed neurological
distressed and, while the team stabilised the assessment produced normal results. The team
boy, made initial observations and administered discussed with the boy’s parents whether he should
medications, his parents were supported by a senior undergo lumbar puncture but, in light of the parents’
ED staff nurse. reluctance and the fact that the likelihood that
he had contracted an intracranial infection was
The family is of an Indian ethnic background. History considered minimal, it was decided not to carry out
taking from the parents revealed that there was no the procedure.
family history of epilepsy, although the boy’s mother
reported that she had experienced recurrent febrile At 72 hours after admission, the boy’s blood
convulsion early in her life and had been treated with culture was reported to be negative and
sodium valproate till her sixth birthday. IV medicines were discontinued. He was put
on a ten-day course of oral co-amoxiclav and his
Initial observations showed that the boy had discharge home was arranged.
a temperature of 39.3°C, a pulse rate of 166 beats
per minute, respiratory rate of 36 breaths per minute, At his discharge, his parents were given an
oxygen saturations of 91% in air and a central information leaflet on febrile convulsion.
capillary refill time of two seconds. His bedside blood A children’s nurse explained to them that, in view
glucose level was 9.3mmol/L. of the boy’s complex febrile convulsion and family
history, he was at a high risk of further febrile
The boy was administered high-flow oxygen through convulsions and gave them advice about the use of
a face mask. An intravenous (IV) cannula was antipyretics at home.
inserted and the boy was administered a dose of IV
lorazepam 0.1mg/kg. Two weeks later, the boy and his parents returned for
an electroencephalogram, which was subsequently
After 12 minutes, the boy’s seizure terminated but he reported to be normal. After consulting a neurologist
remained unresponsive and with a low Glasgow Coma while on holiday, his parents also organised
Scale score, of 10/15. He remained unresponsive for a magnetic resonance imaging scan of his brain,
a further 90 minutes. which was also reported as normal.
During this period, laboratory results showed he had The boy was discharged from the follow-up paediatric
a C-reactive protein level of 27 mg/L and a white cell clinic a year later, when the parents decided to move
count of 14.8x109/L, but no electrolyte abnormalities the family to India. A summary of the boy’s medical
were detected. condition, including the investigations performed
and plan of management, was given to them. The boy
On waking, the boy was confused and distressed, was reported to be developing normally and doing
and struggled to recognise his parents for another well at school.
Table 2 Medicines commonly used for children with febrile convulsion who present to emergency departments
Paracetamol 15mg/kg Oral or rectal, Between four Four within 24 hours For pyrexia in
or intravenous (IV) and six hourly children with febrile
during resuscitation convulsion (FC)
Ibuprofen 5mg/kg Oral Between six Three within 24 hours For pyrexia in children
and eight hourly with FC unless they
are dehydrated
Diazepam 0.25mg/kg IV or intraosseous Second dose Only two doses of For an actively
ten minutes benzodiazepines are to convulsing child whose
0.5mg/kg Rectal after the first be used irrespective of seizure have lasted
the agents and whether more than five minutes
Lorazepam 0.1mg/kg IV
they are administered
Midazolam 0.15-0.2mg/kg IV singly or in combination
0.5mg/kg Buccal
0.9% sodium 20ml/kg IV During resuscitation More than two doses are In children with shock,
chloride solution rarely required for example during
febrile illness due
to gastroenteritis
(Adapted from Advanced Life Support Group 2011, British National Formulary for Children 2015)
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