Paediatrics - Febrile convulsions Assessment, treatment and education

            
Raftery, Sara, Febrile Convulsions: Assessment, Treatment and education, World of Irish Nursing 10 (3), March 2002 pp 27-
28.

Part 3, This month in part three of the Continuing Education module on Paediatrics, we tackle the issue of febrile
convulsions. Previously in this module, part one dealt with assessment and intervention for gastroenteritis in children and
part two dealt with juvenile arthritis.Subsequent articles will deal with a range of common paediatric illnesses and
conditions including diagnosis and management of type 1 diabetes in children; the asthma emergency; treatment of UTIs;
palliative care of the dying child; epilepsy in children; severe constipation in infants and young children; febrile convulsions;
eating disorders; and the management of burns in children.Module co-ordinator: Moira Cassidy, RGN, staff writer with the
World of Irish Nursing

By:   Sara Raftery

Febrile convulsion, or febrile seizure, is broadly defined as ‘a seizure accompanied by fever, without
central nervous system infection, occurring in infants and children between six months and five
years’.1 It is important to note that this definition excludes fever which occurs in conjunction with
neurological disease such as meningitis and encephalitis. There is some variation within the
literature as to the exact range of ‘normal temperature’, with some studies suggesting it may be as
wide as 35.6C – 38.2C. 2

Febrile convulsions occur in 2%-5% of all children, making them the most common convulsive event
in children less than five years old. They can be classified as simple or complex:

simple – a single generalised seizure which lasts less than 15 minutes

complex – a seizure lasting longer than 15-20 minutes with focal features.1 The complex
febrile convulsion often recurs within a 24-hour period.

Causes and risk factors

It is not clear why some children experience febrile convulsions. Specific risk factors include:

genetic propensity, particularly first-degree family history

rapid elevations of temperature
a temperature of less than 40C at the initial convulsion
one or more previous occurrences;3 the risk of a second convulsion occurring is approximately
30%. Of the children who experience a second event 50% will have at least one additional
recurrence.

Children with simple febrile convulsions are slightly more at risk (approximately 1%) of developing
epilepsy.1

Nursing management

It is likely that children suffering a first febrile convulsion will present either to a paediatric A&E
department or to their GP surgery.4 It is essential that the attending nurse be alert to the traumatic
effect such an event will have on the child’s parents.5

On presentation, initial nursing assessment and management is aimed at maintaining oxygenation

and minimising the risk of complications. The nurse must remain with the child and family and
ensure that oxygen, suction and resuscitation equipment are readily accessible.

The child should be placed in a semi-prone position and protected from any additional injury. It is
imperative that the nurse observe, assess and document the presenting characteristics of the febrile
convulsion (see Table 1).

Table (1) Nursing Assessment during a febrile convulsion

Assess the child’s colour

Continuous assessment of vital signs including pulse oxymetry

Accurate timing of the febrile convulsion

Note for alterations in consciousness and document motor sensory and autonomic
function 4

A soon as is appropriate record the child’s temperature

Assess family coping and offer brief explanations at this time

If possible remove warm clothing

The medical treatment of febrile convulsion is much debated within the literature and local hospital
protocols may differ.6 By the time the child presents to the A&E department it is likely that the febrile
convulsion will have begun several minutes previously. Therefore anticonvulsant medication is often
prescribed immediately. This tends to be administered either per rectum or intravenously.

Following the administration of anticonvulsant drugs the nurse must continue to assess the child
carefully and note for the cessation of the convulsion. Should it continue, medical reassessment and
further administration of anticonvulsant medication is warranted. It is essential that the nurse offers
ongoing advice, explanation and support for the family during the event, as many parents report
fears that their child is going to die or to become ‘brain damaged’. 4,5

Antipyretic therapy

As soon as is appropriate, antipyretic medication should be administered to reduce the child’s

temperature and thus the risk of subsequent febrile convulsions. Antipyretics are usually
administered rectally, but if the child regains consciousness rapidly they may be taken orally. Both
paracetamol and the non-steroidal anti-inflammatory drugs have anti-pyretic actions.7

Warm clothes should also be removed and fluids should be introduced orally if tolerated, to prevent
dehydration. Intravenous fluids may be warranted if the child is slow to recover from the febrile
convulsion. Rapid cooling measures such as tepid sponging and fanning are no longer advocated in
children.7

In order to determine and treat the underlying cause – usually a bacterial or viral infection – many
children will be admitted to hospital following the initial febrile convulsion. There are no routine
investigations indicated following such convulsions. Instead, investigations are conducted
individually in order to ascertain each child’s diagnosis.

Ears, nose and throat should be carefully assessed and a chest x-ray may be ordered. It is likely that
blood and urine samples will be obtained and a lumbar puncture may be indicated if meningitis is
suspected. This period of hospitalisation also provides the nurse with a valuable opportunity to
educate parents regarding detection of infection, temperature control, and measures to take should
the child experience another febrile convulsion.

Key responsibilities

The key responsibilities of the nurse while the child is hospitalised involve:

temperature monitoring
pharmacological and non-pharmacological methods of temperature regulation
maintaining child comfort
ensuring adequate hydration
assisting in the treatment of the underlying cause
family education.

Family education

It is essential that the nurse provides confident and honest information to parents following their
child’s convulsion. This information should be both written and verbal and must include the causes
of febrile convulsion and the risk of subsequent events. It would be helpful for written information to
be available in a number of languages in A&E departments. It is essential to stress the prognosis so
that parents are fully aware that their child is likely to outgrow the risk of experiencing febrile
convulsions.

Parents should be informed that fever is a sign of infection. While it is useful to advise parents to
purchase a thermometer, it is equally important that they learn to trust their own judgement. If fever
is present, the child will feel hot, look flushed and may be listless or irritable.

In addition, there may be signs of a specific associated infection such as:

cough
sore throat or ears
pain passing urine.

Parents should be advised to dress the child in light cotton clothing and to encourage frequent oral
fluids. Antipyretics should be administered as soon as parents become aware of the increase in
temperature. As stated, paracetamol tends to be the most commonly used drug and this is available
in many forms. Parents may have personal preferences as to the route they choose to administer the
antipyretic.

Information families will require prior to discharge

Nature of febrile convulsions

Causes of febrile convulsions

 Risk of recurrence

Whether the child suffers pain or discomfort during the convulsion

How to manage a high temperature in a child

How to deal with another convulsion in the home

Prognosis

Further Convulsions

If the child has a further febrile convulsion parents should be advised to lie their child in semi-prone
position.   A prescription for rectal diazepam is often given to parents on discharge from hospital
and the nurse is responsible for ensuring that they are confident and competent in its
administration.  An educational video is available and can be given to carers to view at home. 
Parents should be advised exactly when to administer anticonvulsant medication.  They should also
be asked to bring their child to a doctor following a convulsion in order to determine and address the
underlying cause.

Family Trauma

Witnessing a febrile convulsion is a terrifying experience for a family.  Studies have shown that
parents imagine that their child is dying or in great pain.  The nursing management of the child
focuses upon the immediate care of the child in the A & E Department and temperature
management.  In addition, a significant emphasis by the nurse must placed on education of the
family so that fever can be detected and treated, potentially preventing another febrile convulsion.

Sara Raftery is a nurse teacher in the Children’s Hospital, Temple Street, Dublin 1

References

1.    American Academy of Pediatrics.  Provisional Committee Quality Improvement, Subcommittee

on Febrile Seizures.  Practice parameter: the neurodiagnostic evaluation of the child with a first
simple febrile seizure.  Pediatrics 1996; 97 (5): 769-772.

2.    Purssell E.  The use of antipyretic medications in the prevention of febrile convulsions in
children. J. Clinical Nursing 2000, 9: 473-480.

3.    Boschert S.  High Fever Raises Risk of Multiple Febrile Seizures.  Paediatric News 1999; 33(2):
20.

4.    Rogers M, Febrile Convulsions. Paediatric Nursing 1995; 7 (5): 33-37.

5.    Miller R. The effect on parents of febrile convulsions.  Paediatric Nursing 1996; 8 (9): 28-31.

6.    Offringa M, Moyer VA. Evidence Based paediatrics: Evidence based Management of seizures
associated with fever.  BMJ 2001; 323 (7321): 1111-1114.

7.    Casey G. Fever Management in Children. Nursing Standard 2000; 14 (40): 36-40.

           

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