CKS Clinical solutions - Febrile seizures

THE CASE - You are on call when a frightened mother calls to say that her two-year-old daughter is 'fitting'. She had been hot and coughing overnight. As you are nearby, you make an emergency visit. When you arrive, the seizure has stopped and the girl is drowsy.

Was this a febrile seizure?
Typically, febrile seizures last three to six minutes, do not recur within 24 hours or within the same febrile illness, and occur in children aged six months to five years old.

A fever is characteristic, but the seizure may be the presenting feature or occur early in the illness.

How should you manage?

Urgent hospital assessment should be sought in the following circumstances:

  • Meningococcal disease is suspected (give a single parenteral dose of benzylpenicillin or cefotaxime while waiting for an ambulance).
  • Children with a first febrile seizure.
  • Children previously diagnosed with a febrile seizure if:
  • there is diagnostic uncertainty about the underlying cause.
  • the child has had a complex seizure (>15 minutes, focal features, repeated in the same episode of illness, or there is incomplete recovery within one hour).
  • there is a suspected serious cause (e.g. pneumonia) or the child appears unwell.
  • the child is younger than 18 months old.
  • the child is currently or has recently taken antibiotics.
  • early review by a doctor is not possible.
  • home circumstances are unsuitable, or parents are particularly anxious.
  • Consider urgent assessment for a short period of observation if the child has no apparent focus of infection.

The 'traffic light system' recommended by NICE can help identify serious illness.1

Consider non-urgent referral if the child is at increased risk of epilepsy or if she has a low threshold for seizures during febrile illness.

Prophylaxis with rectal diazepam during febrile episodes may be considered. Parents may ask for a specialist opinion.

What advice should you give?
Reassure parents that febrile seizures are common and, if short, are not harmful. The chance of developing epilepsy is low.

Advise when to seek further medical advice and on the management of fever. Explain that febrile seizures recur in about a third of children, and how to manage this. Future immunisation is still advised if a febrile seizure follows an immunisation.

Arrange follow up and have a low threshold for early review if there is no focus of infection.

Evidence

CKS have based these recommendations on a guideline,1 a consensus report,2 and expert opinion.3,4

The recommendation to offer reassurance that short-lasting febrile seizures are not harmful is based on evidence from a population study.5 The risk of recurrence is derived from a pooled analysis of five studies.6

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. See www.cks.nhs.uk

References

1. NICE Clinical Guideline 47. Feverish illness in children. London: NICE, 2007. www.nice.org.uk

2. Armon K, Stephenson T, Hemingway P et al. Emerg Med J 2003; 20: 13-20.

3. Offringa M, Moyer V A. BMJ 2001; 323: 1,111-4.

4. Waruiru C, Appleton R. Arch Dis Child 2004; 89: 751-6.

5. Verity CM, Greenwood R, Golding J. N Engl J Med 1998; 338: 1,723-8.

6. Offringa M, Bossuyt P M, Lubsen J et al. J Pediatr 1994; 124: 574-84.

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