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Primary care emergencies - febrile convulsions

In the fourth part of our series on common emergencies in primary care, GPs Dr Chantal Simon, Dr Karen O’Reilly, Dr Robin Proctor and Dr John Buckmaster advise on how cases should be managed by GPs and which require referral

In the fourth part of our series on common emergencies in primary care, GPs Dr Chantal Simon, Dr Karen O'Reilly, Dr Robin Proctor and Dr John Buckmaster advise on how cases should be managed by GPs and which require referral

Some 2% to 4% of all children have a febrile convulsion. They occur among children aged between six months and five years, with the peak age being 18 months.

Classification

• Simple febrile convulsions: isolated, generalised, tonic-clonic seizures lasting <10-15 minutes.
• Complex febrile convulsions: last 15 to 30 minutes, or are focal, or recur during the febrile illness, or are not followed by full consciousness within one hour.

Causes

In decreasing order of frequency:

• viral infections
• otitis media
• tonsillitis
• UTI
• gastroenteritis
• lower respiratory tract infection
• meningitis
• post-immunisation.

Assessment

By the time the GP arrives, the febrile convulsion is usually over, so diagnosis is based on a history of short, generalised tonic-clonic seizure in a febrile child.

Examination and investigation

The main concern when assessing children who have had a febrile convulsion is to detect and manage bacterial meningitis. Check temperature, assess level of consciousness and examine for a source of infection (see causes above).

If there is no obvious cause and the child is not being admitted, check an MSU for urinary tract infection. Note that complex are more likely than simple febrile convulsions to be provoked by a serious condition. Suspect serious pathology if a child has:

• had a prolonged febrile convulsion
• had a focal febrile convulsion, or
• not recovered within an hour of a febrile convulsion.

Differential diagnosis

• Epilepsy
• Any other cause of convulsion:
– meningitis or encephalitis
– cerebral palsy with intercurrent infection
– hypoglycaemia
– neurodegenerative disorders
– poisoning (such as inadvertent drug ingestion)
– NAI

Box 1 below contains answers to some frequently asked questions.

Management

Most children do not need admission.
Admit if:
• child was drowsy before the seizure
• child is irritable, systemically unwell or ‘toxic' and/or the cause of the fever is unclear
• petechial rash
• symptoms or signs of meningitis
• recent or current treatment with antibiotics (may mask symptoms or signs of meningitis)
• age under 18 months (meningitis may present with non-specific signs)
• the cause of the fever requires hospital management in its own right
• complex convulsion
• early review by a doctor is not possible
• inadequate home circumstances
• carer anxious or unable to cope.

For children not being admitted

• Reassure parents/carers that febrile convulsions do not harm the child.
• Advise on controlling fever in the future: an antipyretic, for example paracetamol or ibuprofen syrup, cool clothing. If not managing to lower temperature, fan the child or sponge with lukewarm water.
• Teach parents to manage a recurrent convulsion: recovery position, nothing forced into mouth.
• Recommend that immunisation schedules be completed.
• Advise the parents/carers to seek urgent medical help if the child deteriorates in any way, fits again or they are worried.
• Arrange early review, for example later the same day or the following morning.

Consider referral to paediatrics or paediatric neurology if:

• Diagnosis of febrile convulsion is in doubt.
• Febrile convulsions have been frequent, severe and/or complex and prophylactic treatment might be indicated.
• The child is at increased risk of epilepsy, for example co-existent neurological or developmental conditions; history of epilepsy in first-degree relative.
• The parents/carers are still anxious despite reassurance or request a specialist opinion.

Prophylactic measures: prescribe under consultant direction only.

• Rectal diazepam: may prevent febrile convulsions in subsequent illness if given at the onset of a febrile episode. Rectal diazepam is safe for home use provided parents are properly educated about its use.
• Continuous prophylaxis: use of anticonvulsants on a regular basis to prevent frequent febrile convulsions is controversial. In general benefits are outweighed by risks.

Box 2 below answers common questions from parents.

1. FAQs on febrile convulsions

Q What is the risk of recurrence after a febrile convulsion?
A Febrile convulsions recur in subsequent febrile illnesses in about 30% of children – 9% have fewer than seizures. Recurrence is most common in the year following the first febrile convulsion. Recurrence is more likely if:
• first febrile convulsion aged under 15 months
• first febrile convulsion is complex
• family history of febrile convulsions or epilepsy in a
first-degree relative
• child attends day nursery (increases frequency of febrile illnesses).

Q Is there an increased risk of epilepsy after febrile convulsion?
A Rarely – 1% of children having a febrile convulsion go on to develop epilepsy (compared with 0.4% of children who have not had a febrile convulsion). Risk increases if any of the following features are present:
• neurological abnormalities or developmental delay before the onset of febrile convulsions
• atypical seizures
• family history of epilepsy
• complex convulsions.

Q Are there long-term complications after febrile convulsions?
A Long-term adverse effects are rare. There is no evidence of subsequent impaired intelligence or poorer academic achievement, but there is a slightly increased risk of epilepsy.

Q Is immunisation contraindicated after febrile convulsion?
A There is evidence to suggest immunisations do not increase risk of recurrent febrile convulsions. Immunisation is not contraindicated.

2. Information for parents

What are febrile convulsions?
A febrile convulsion or fit happens when normal brain activity is disturbed when a child has a fever. It usually occurs without warning. During the fit, your child may:
• become stiff or floppy
• become unconscious or unaware of their surroundings
• display jerking or twitching movements
• have difficulty breathing.
Febrile convulsions are frightening to watch, but they are not harmful to your child, don't cause brain damage, and will not cause your child to die.

What happens after a febrile convulsion?
Your child will become tired for up to an hour after the fit. If your child remains sleepy or is difficult to rouse after sleep, seek medical attention.

Will my child have another febrile convulsion?
Possibly – febrile convulsions may recur. About one in three children who have had a febrile convulsion will have another. The risk of another febrile convulsion decreases with time as the child gets older. Immunisation is still advised after a febrile convulsion, even if, as rarely happens, the febrile convulsion followed an immunisation.

Are febrile convulsions the same as epilepsy?
No – febrile convulsions are not epilepsy. Rarely, in about one in 100 children who have had more than one febrile convulsion, epilepsy can develop later.

How can I prevent fevers that cause convulsions?
Controlling fever eases symptoms. It does not prevent febrile convulsions. A high temperature can be reduced by:
• giving paracetamol or ibuprofen – read the instructions on the packet carefully and only give your child the recommended dose for their age
• removing excessive clothing or bedding – in the home this usually means stripping your child down to underwear or nappy.

What should I do if my child has another convulsion?
• Stay calm. Remember, most fits stop within a couple of minutes without treatment.
• Look at your watch or a clock and time the convulsion.
• Don't try to restrain your child or put anything in their mouth.
• Stay with your child and lie them on their side.
• Loosen tight clothing from around their neck and move objects away that may cause injury.
• Ring your GP or NHS Direct after the convulsion has stopped.

Call an ambulance if:
• the fit lasts for more than five minutes
• another fit starts up after the first one stops
• your child has difficulty breathing or looks particularly unwell.

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