Febrile seizures
History/questionnaire:
Simple febrile seizure with usually generalised tonic-clonic features (< 15 minutes, only one seizure in 24 hours)?
Complex febrile seizures (30-35%) either focal, prolonged (> 15 minutes) or multiple (> 1 in 24 hours)?
Febrile status epilepticus (5%) with seizure > 30 minutes (or recurrent seizures without full recovery of consciousness)?
Red flags that may indicate CNS infection?
- History of irritability, decreased feeding, lethargy?
- Prolonged post-ictal phase (> 1 hour)?
- Incomplete vaccinations (HIB and strep pneumonia)?
- Signs of meningitis/encephalitis?
------ Bulging fontanelle?
------ Neck stiffness?
------ Photophobia?
------ Focal neurological deficit?
(Note: Be aware if < 2 years old, as signs of meningeal irritation may be absent)
Infective cause?
- URTI/pneumonia?
- Otitis media?
- Gastroenteritis?
- Urine culture if no cause found?
(Note: in children with a first seizure the diagnosis of febrile seizure will not be definitive even if there is a fever present)
Examination:
Temperature at end of seizure < 38?
If yes, consider non-febrile cause
Management:
Spontaneous resolve over a few minutes (most febrile seizures)?
Generalised seizure persisting for > 5 minutes?
If yes, offer anticonvulsant treatment
First seizure?
- Checked airway – opened if necessary?
- High flow oxygen?
- Protected child from injury?
- Recovery position once seizure stopped?
As seizure lasted > 5 minutes:
- Rectal diazepam (< 1 month: 1.25-2.5 mg, 1 month – 1 year: 5 mg, 2-11 years: 5-10 mg)
- Buccal midazolam (< 6 months: 300 mcg/kg (max. 2.5 mg), 6-11 months: 2.5 mg, 1-4 years: 5 mg, 5-9 years: 7.5 mg)
As ongoing seizure 10 minutes after a dose of diazepam or midazolam called 999 ambulance
Admitted as:
- First febrile seizure or child < 18 months of age
- Diagnostic uncertainty about the cause of the seizure or no clear focus of infection
- Focal seizure or incomplete recovery after one hour
- Current or recent antibiotics (can mask CNS infection)
- Parents are anxious and feel that they cannot cope
- Suspected serious cause for the fever (e.g. pneumonia)
Recurrent seizure?
- Checked airway – opened if necessary?
- High flow oxygen?
- Protected child from injury?
- Recovery position once seizure stopped?
Benzodiazepine rescue medication only on specialist advice depending on?
- Frequency and pattern of febrile illnesses
- Type of febrile seizures
- Parent/carer wishes
- Individualised risk-benefit assessment
Post-seizure care/information for parents given?
Reassurance given?
- Simple febrile seizures are benign
- Low risk (1:40) of developing epilepsy
- Even with recurrent febrile seizures there is no association with behavioural problems or levels of function, but there may be a small risk of language delay
- Risk of recurrence (1:3); higher risk of recurrence if:
--- Age <18 months at first onset
--- History of febrile seizure in a relative
--- Fever < 39°C associated with febrile fit
--- Short duration of fever before seizure (<1 hour)
--- History of complex febrile seizure
--- Prolonged seizure (>15 minutes)
--- Multiple seizures in 24 hours/within the same febrile episode
--- Day nursery attendance
Advice given to parents on what to do in the event of further seizures?
- Prophylactic use of antipyretics does not reduce recurrence risk
- Tepid sponging is no longer recommended for febrile children
- Children should not be under or overdressed
- Currently no evidence to support the use of prophylactic anticonvulsant medication
- Further information available at www.nhs.uk
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