Febrile seizure – Emergency management in children

Purpose

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 seizure 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.

Introduction

Febrile seizures are a frequent ED presentation and the most common seizure disorder in children.¹ They occur in 3% of healthy children, mostly between the ages of six months and six years. The peak incidence of febrile seizures is between 12-18 months of age.²

Most febrile seizures are brief, isolated, generalised tonic-clonic seizures that occur with an acute febrile illness in children with no history of afebrile seizures, known neurological abnormality, or evidence to suggest infection or metabolic disturbance.¹

Simple febrile seizures are not associated with an increased risk of neurological or cognitive impairments.³

Recurrent febrile seizures

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

Risk factors for recurrent febrile seizures include:

• first febrile seizure at less than 18 months of age – the younger the age of the child at the time of the first febrile seizure, the higher the risk of further febrile seizures.
• each additional febrile seizure increases the subsequent risk of recurrence
• family history of febrile seizures or epilepsy
• febrile status epilepticus

Febrile seizures and epilepsy

Most children who experience a febrile seizure will not develop epilepsy later in life.¹ 

Seizure risk factors for developing subsequent epilepsy include:

• family history of epilepsy
• complex febrile seizures
• Abnormal neurological or developmental status prior to first febrile seizure
• febrile status epilepticus

The number or type of risk factor increases the chance of developing epilepsy:

• No risk factors have a 0.9% risk,
• 1 risk factor has a 2.5% risk,
• 2 or more risk factors confers a 5-10% risk.
• If the febrile seizures are prolonged, lasting more than 30 minutes, approximately 9.4% of children may develop epilepsy⁶.

Classification

Assessment

The aim of the assessment is to:

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

Febrile seizures 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 seizures from other seizures should include:

• details preceding the seizure episode including:
  • prior events and behaviour of the child
  • signs or symptoms of illness
• details of the seizure 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 seizure
• any previous seizures (including afebrile)
• medical and surgical history including:
  • Immunization status especially for Haemophilus influenza type b and Streptococcus pneumoniae (unimmunised children have a higher risk of meningitis from these organisms)
  • prior intracranial infection
  • metabolic disturbance such as hypoglycaemia or electrolyte disturbance
  • progressive neurological conditions
  • Developmental delay or regression
  • 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

Investigations

Simple febrile seizures

Investigations are not routinely required for simple febrile seizures providing the child is aged between six months and six years, makes a full recovery to normal self and the focus of infection can be identified. Investigations in this group of children should be directed by the suspected underlying cause of infection (see Febrile illness guideline) rather than the febrile seizure 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 seizure or epilepsy risk)^11,12

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 seizure and are clinically well with no prior antibiotic treatment are at a very low risk of bacterial meningitis.^13,14

Atypical simple and other febrile seizures

Any febrile seizure 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

Seek senior emergency/paediatric advice for all children with a complex febrile seizure.

Management of children following a febrile seizure 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.  There is current research being conducted into antipyretics in the prevention of the recurrence of simple febrile seizures during the same fever episode but they have no role in preventing febrile seizure during distant fever episodes.¹⁷

Escalation and advice outside of ED

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 seizure lasting more than five minutes.

Inter-hospital transfers

Disposition

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 seizure.

Consider discharge for a child who meets the following criteria:

• suffered a simple febrile seizure
• 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 seizures
• first aid for a seizure

On discharge, parent/s should be provided with a Febrile seizures 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 seizures or status epilepticus will be made by the specialist referral team based on the further investigations and management required.

Consider consultation with inpatient team when:

• complex febrile seizure
• child does not return to neurological baseline within 1 hour
• child clinically unwell or ongoing concern about the nature of the febrile illness
• frequent seizures

Facilities with a Short Stay Unit (SSU)

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

Related documents

Guidelines

• Febrile illness
• Meningitis
• Sepsis

Factsheets

• Febrile seizures
• Fever in children
• Seizure first aid