Febrile_Convulsions_Flashcards
What are febrile convulsions?
Febrile convulsions are seizures provoked by fever in otherwise normal children between the ages of 6 months and 5 years.
What are typical clinical features of febrile convulsions?
Febrile convulsions usually occur early in a viral infection as the temperature rises rapidly, are brief (lasting less than 5 minutes), and are most commonly tonic-clonic.
What defines a simple febrile convulsion?
A simple febrile convulsion lasts less than 15 minutes, involves a generalised seizure, typically does not recur within 24 hours, and recovery occurs within an hour.
What defines a complex febrile convulsion?
A complex febrile convulsion lasts 15-30 minutes, may involve a focal seizure, and could have repeat seizures within 24 hours.
What is febrile status epilepticus?
Febrile status epilepticus is a febrile convulsion that lasts more than 30 minutes.
What is the management after a child experiences a febrile convulsion?
Children with a first seizure or features of a complex seizure should be admitted to paediatrics.
How should parents manage ongoing febrile convulsions?
Parents should call an ambulance if the seizure lasts more than 5 minutes. Antipyretics do not reduce the chance of a febrile seizure, and benzodiazepine rescue medication may be considered if recurrent.
What is the prognosis after a febrile convulsion?
The overall risk of further febrile convulsions is 1 in 3. Factors that increase the risk of developing epilepsy include a family history of epilepsy, having complex febrile seizures, and neurodevelopmental disorders.
summarise
Febrile convulsions
Febrile convulsions are seizures provoked by fever in otherwise normal children. They typically occur between the ages of 6 months and 5 years and are seen in 3% of children.
Clinical features
usually occur early in a viral infection as the temperature rises rapidly
seizures are usually brief, lasting less than 5 minutes
are most commonly tonic-clonic
Types of febrile convulsion:
Simple
< 15 minutes
Generalised seizure
Typically no recurrence within 24 hours
Should be complete recovery within an hour
Complex
15 - 30 minutes
Focal seizure
May have repeat seizures within 24 hours
Febrile status epilepticus
> 30 minutes
Management following a seizure
children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics
Ongoing management
parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes
regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring
if recurrent febrile convulsions occur then benzodiazepine rescue medication may be considered
this should only be started on the advice of a specialist (e.g. a paediatrician)
rectal diazepam or buccal midazolam may be used
Prognosis
the overall risk of further febrile convulsion = 1 in 3. This varies widely depending on risk factors for further seizure, including:
age of onset < 18 months
fever < 39ºC
shorter duration of fever before the seizure
a family history of febrile convulsions
link to epilepsy
risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder
children with no risk factors have a 2.5% risk of developing epilepsy
if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)
A 2-year-old boy is brought to the emergency department following a seizure. After a period of observation and several investigations, he is diagnosed with febrile convulsions and his parents are reassured that he is safe to return home.
What advice is it important to give the parents?
If he develops another fever, he should be placed in a cool bath
If the seizure lasts longer than 5 minutes, they should call an ambulance
Regular paracetamol will decrease his risk of further febrile convulsions
There is a 20% chance that he will go on to develop epilepsy
There is an 80% chance that he will have another febrile convulsion
If the seizure lasts longer than 5 minutes, they should call an ambulance
Parents should be advised to call an ambulance if a febrile convulsion lasts >5 minutes
Febrile convulsions are very scary for parents, so it is important to give them information regarding the condition so that they can safely manage their children at home. The majority of febrile convulsions last for less than 5 minutes, and these seizures do not require hospital admission. However, if the seizure lasts for longer than 5 minutes then the parents should call an ambulance.
To treat fever at home, parents should remove excessive clothing, give fluids and give antipyretics only if the child is uncomfortable. Active cooling is not advised.
Febrile convulsions recur in ~30% of children and there is a very slightly increased risk of developing epilepsy, but this is negligible. There is no evidence that paracetamol decreases the risk of further convulsions.
A 2-year-old boy is seen in seizure clinic after 3 episodes of febrile convulsions in the past 8 months. He has no past medical history. His seizures have all been associated with viral illness and his lumbar puncture, electroencephalogram, and MRI brain have all been reported as unremarkable. His mother is concerned about the recurrence of his seizures and asks if she can be given some medication ‘just in case’.
What is the most likely next step in management that the paediatric team will consider?
Buccal midazolam
Oral lamotrigine
Oral topiramate
Rectal diclofenac
Rectal lorazepam
Buccal midazolam
Specialists may consider prescribing benzodiazepine rescue medication for recurrent febrile seizures (rectal diazepam or buccal midazolam)
Buccal midazolam is correct. This has been shown to be effective in controlling febrile seizures. It is recommended as a rescue prescription for parents who have children with a history of recurrent febrile convulsions and who have been thoroughly investigated for other seizure causes. Buccal midazolam is preferred over rectal diazepam because it is easier to administer, has more predictable absorption, and does not require the child to be in the supine position.
Oral lamotrigine is an incorrect answer. This drug is recommended in the management of focal and generalised seizures in children over the age of 2 years. This patient is not noted to have a suspected diagnosis of epilepsy and is believed to suffer from recurrent febrile seizures, as such this is an incorrect answer.
Oral topiramate is an incorrect answer. Topiramate is recommended in the management of focal, general and myoclonic seizures in children over the age of 2 years. This patient has had normal investigations and is not believed to have epilepsy, therefore this answer is incorrect.
Rectal diclofenac is an incorrect answer as it is not associated with the termination of seizures. It is an NSAID that may have an antipyretic effect, however, it has no role in the termination of seizures as a rescue medication.
Rectal lorazepam is an incorrect answer. While lorazepam can be used to terminate seizures, it is not commonly administered rectally. As lorazepam is highly protein bound and poorly lipid soluble, it is not suitable for rectal administration and is absorbed relatively slowly when given orally.
A 1-year-old infant is brought in by ambulance after suffering from a seizure-like episode witnessed by his mother. She filmed the episode on her mobile phone, which lasted 40 seconds, and shows this to the paediatric team. He has never had a seizure before and has no medical history. His mother reports that for the past 3 days, he has had a cough and a runny nose. She also reports that he had poor sleep last night and needed paracetamol for a temperature of 39.5ºC. In the department, he is grizzly and coughing but he experiences no further seizures. The paediatric team inform his mother that this episode is not concerning and advise her that he should grow out of them.
By what age do children typically stop having these episodes?
3 years old
5 years old
7 years old
9 years old
11 years old
Febrile convulsion typically occur in children between the age of 6 months to 5 years
Important for meLess important
This infant has had an episode that is consistent with a febrile convulsion. These usually occur in children aged 6 months to 5 years. Children appear hot and flushed before losing consciousness during a febrile convulsion. Typically, these are tonic-clonic seizure-like episodes and there will be a post-ictal period. Parents should be informed that many children never have more than one episode. In children over 1-year-old experiencing their first febrile convulsion, there is a 1 in 3 chance of it happening again - this is higher in children under 1.
While most children experience their first febrile convulsion by 3 years, these can continue up to 5 years (especially in children who have had previous febrile convulsions).
Children over 5 years old are less likely to experience febrile convulsions - children aged 7, 9, or 11 years who are experiencing convulsions should be referred for neurological testing as this may indicate the child has epilepsy.
A 3-year-old boy is brought to his paediatrician by his parents. The child has experienced three febrile seizures in the past 6 months; two of which lasted over five minutes and required the child to be hospitalised.
His parents are very concerned about the risk of future seizures and are asking the paediatrician for medication to give to help if their child has any further seizures.
What medication, if any, can be offered in this scenario?
IM midazolam
No medication can be offered
Oral diazepam
Oral paracetamol
Rectal diazepam
Rectal diazepam
Specialists may consider prescribing benzodiazepine rescue medication for recurrent febrile seizures (rectal diazepam or buccal midazolam)
Rectal diazepam is correct. In cases of patients with recurrent febrile seizures, specialists may consider prescribing benzodiazepine rescue medication, to be administered during febrile episodes to abort or reduce the duration of seizures. Typically, either rectal diazepam or buccal midazolam will be offered.
IM midazolam is incorrect. Specialists can offer benzodiazepines to patients with recurrent febrile seizures. However, the forms offered are either rectal diazepam or buccal midazolam.
No medication can be offered is incorrect. Children with proven, recurrent febrile seizures may be offered ‘rescue’ benzodiazepines to abort or reduce the duration of future seizures. This patient has experienced 3 febrile seizures in the past 6 months, hence is experiencing recurrent febrile seizures. Therefore, he should be offered medication. This should only be offered by a specialist and should be either rectal or buccal in the administration route.
Oral diazepam is incorrect. Rescue medications for recurrent febrile seizures are rectal diazepam or buccal midazolam. Oral formulations are not recommended for this use. Instead, the buccal route is advised where the medication is given between the gum and the inner lining of the mouth, allowing it to diffuse through the oral mucosa.
Oral paracetamol is incorrect. While paracetamol is recommended for reducing the severity of fevers, they have no prophylactic role in managing febrile seizures and do not affect the risk or severity of seizures. Instead, rescue benzodiazepines should be offered, should as diazepam or midazolam.
buzz words
less than 5 years old
emergency department
seizure.
loss of consciousness and seizure activity.
filmed the episode on mobile phone
lasts less than 5 minutes if mild
never had a seizure before a
no medical history.
recent cough and a runny nose. - unwell recently
recent fever/viral illness
paracetamol
lumbar puncture, electroencephalogram, and MRI brain all reported as unremarkable
A 16-month-old girl is brought to the children’s emergency department by her parents who report loss of consciousness and seizure activity. Paramedics state that she was not seizing when they arrived. She has a temperature of 38.6ºC and has been unwell recently. Her other observations are normal. She has no known past medical history.
After investigations the child is diagnosed with a febrile convulsion.
What advice should you give her parents regarding this new diagnosis?
Call an ambulance only when a febrile convulsion lasts longer than 5 minutes
Call an ambulance only when a febrile convulsion lasts longer than 15 minutes
Call an ambulance when your child has a febrile convulsion
Febrile convulsions are not a risk factor for epilepsy
Regular paracetamol will reduce the risk of seizures
Call an ambulance only when a febrile convulsion lasts longer than 5 minutes
Parents should be advised to call an ambulance if a febrile convulsion lasts >5 minutes
The vast majority of febrile convulsions are short and do not cause any long-term damage. Parents should be advised to call an ambulance for any seizures lasting more than 5 minutes. This allows timely intervention if the child was to have a prolonged seizure (>10 minutes). Longer seizures mean there is a greater risk of harm to the child and also a greater risk of developing epilepsy later in life.
Waiting for 15 minutes would be too long and adds a degree of risk.
The current advice to parents is to place the child in the recovery position and to call an ambulance if the seizure lasts longer than 5 minutes. This is because the vast majority are short and self limiting. This is not to say that the parent can not seek advice from the GP and 111. If this is a child’s first febrile convulsion then parent’s are advised to call an ambulance. This is not the case.
Febrile convulsions are a risk factor for epilepsy. However, only 1-3% of children who have a febrile convulsion will go on to develop epilepsy. Other risk factors are a family history of febrile convulsions and background of neurodevelopmental disorder.
Regular antipyretics have not been shown to reduce the likelihood of febrile convulsions.
