Art & science paediatric nursing
Recognition and management
of febrile convulsion in children
Paul SP et al (2015) Recognition and management of febrile convulsion in children.
Nursing Standard. 29, 52, 36-43. Date of submission: January 20 2015; date of acceptance: March 7 2015.
Abstract
Febrile convulsion is characterised by convulsion associated with
fever in an infant or child aged between six months and six years.
The febrile illness causing the convulsion should not be secondary
to an intracranial infection (meningitis or encephalitis) or acute
electrolyte imbalance. Most cases of febrile convulsion are short
lived and self-terminating. However, a few cases of prolonged febrile
convulsion may need anticonvulsant medication to stop the seizure.
Management is mainly symptomatic, although anticonvulsants may
have a role in a small number of children with complex or recurrent
febrile convulsion. Referral to paediatric neurologists may be
necessary in cases of complex or recurrent febrile convulsion, or in
those where a pre-existing neurological disorder exists. One third of
children will develop a further febrile convulsion during subsequent
febrile illness. Nurses have a vital role in managing children with
febrile convulsion, educating parents about the condition and
dispelling myths. This article outlines the presentation, management,
investigations and prognosis for febrile convulsion, indicating how
nurses working in different clinical areas can help to manage this
common childhood condition.
Authors
Siba Prosad Paul Specialty trainee in paediatrics, year 8, Bristol Royal
Hospital for Children, Bristol, England.
Emily Natasha Kirkham Fourth-year medical student, University of
Bristol, Bristol, England.
Bethany Shirt Senior staff nurse, paediatric emergency department,
Bristol Royal Hospital for Children, Bristol, England.
Correspondence to: siba.paul@nhs.net
Keywords
Anticonvulsants, antipyretics, children, epilepsy, febrile convulsion,
febrile illness, febrile seizures, fever phobia, infants, paediatric nursing
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A FEBRILE CONVULSION is an event
(convulsion) occurring in an infant or a child aged
between six months and six years. It is associated
with fever that is not a result of an intracranial
infection such as meningitis or encephalitis,
and where there is no evidence of hypoglycaemia
or acute electrolyte imbalance, for example low
sodium or calcium levels (Lux 2010a, Paul and
Chinthapalli 2013, Paul and Eaton 2013). Seizures
occurring in individuals over six years of age are
classified as epileptic seizures. However, discussion
of this type of convulsion is outside the scope of
this article. The concept of febrile convulsion is
not new. In 1684, Thomas Willis described febrile
convulsion in his work entitled Of Convulsive
Diseases, suggesting an association between febrile
convulsion and teething (Lux 2010a).
Febrile convulsion is the most common seizure
disorder in children, and most children do not
experience any long-term consequences (Paul
et al 2012). Febrile convulsion is a common
presentation to the emergency department (ED)
and other health professionals will encounter it in
a number of children in different clinical settings
(Paul et al 2015). The presentation of febrile
convulsion can be a distressing and frightening
experience for parents. It is, therefore, important
that health professionals remain empathetic and
address parental anxiety in a sensitive manner
(Paul et al 2015).
There are two types of febrile convulsion –
simple and complex. Management depends on
the type of febrile convulsion and the aetiology
associated with the febrile illness.
Causes of febrile convulsion
The cause of a febrile convulsion is unknown, but is
thought to be multi-factorial in origin. Both genetic
and environmental factors are considered to
contribute to its occurrence (Waruiru and Appleton
2004, Paul and Chinthapalli 2013). Fever is a
normal physiological phenomenon in response to
infection and is beneficial in combating infections
(Banks et al 2013, Paul et al 2015). High levels
of cytokines released during fever are considered
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to cause abnormal electrical activity in the brain
temporarily, potentially triggering febrile convulsion
(Lux 2010b, NHS Choices 2014). Pre-existent iron
and zinc deficiencies are considered to increase
risk of febrile convulsion (National Institute for
Health and Care Excellence (NICE) 2013a,
Waqar Rabbani et al 2013). The most common
infections in children associated with febrile
convulsion are (NICE 2013a, NHS Choices 2014):
 Chickenpox and influenza.
 Middle ear infection.
 Tonsillitis.
 Respiratory tract infection (for example,
pneumonia, sinusitis).
 Tooth infection.
 Gastroenteritis.
 Bronchitis.
Epidemiology
Febrile convulsion has a prevalence of 2-5%
in children from Western Europe and the
United States (Waruiru and Appleton 2004,
NICE 2013a). The peak age of onset is 18 months.
Almost 50% will occur in children aged between
12 and 30 months of age (Waruiru and Appleton
2004, NICE 2013a). The first episode of febrile
convulsion occurs in a small proportion (6-15%)
of children after four years of age and all children
grow out of these episodes by the age of six
years. They occur in all ethnic groups, although
certain ethic groups are known to have a higher
prevalence, for example Guamese 14%, Japanese
6-9% and Indian 5-10% (Waruiru and Appleton
2004, Paul et al 2012). Family history of febrile
convulsion is a strong risk factor for developing
febrile convulsion in children. Twenty-five to 40%
of children with febrile convulsion have a positive
family history. Frequency in siblings ranges from
9% to 22%, with an increased prevalence in
monozygotic twins. Children with pre-existing
neurological conditions, for example cerebral
palsy, are also at higher risk. However, 50%
of children presenting with febrile convulsion have
no identifiable risk factors (Paul et al 2012).
Clinical presentation
Simple febrile convulsion makes up 70% of
all cases. Generally, this has no long-term adverse
neuro-developmental effects. Febrile convulsion
is a clinical diagnosis. Features suggestive of
both types of febrile convulsion are described in
Table 1. Febrile convulsion lasting longer than
20 minutes is termed febrile status epilepticus
and anticonvulsants may be required to
terminate the event.
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A raised temperature is a common symptom in
young children. It can be associated with seizures
when the temperature exceeds 38°C, although
convulsions can occur before the onset of feverish
symptoms (Royal College of Nursing (RCN) 2013).
NICE (2013b) outlines the general signs associated
with fever, including pallor, general malaise,
decreased social cues, increased respiratory rate,
tachycardia, dry mucous membranes, poor feeding,
reduced urine output and sometimes rigors and
rash. The child may complain of feeling cold,
may shiver and have cold peripheries, but the body
is usually warm (NICE 2013b).
The signs and symptoms of febrile convulsion
usually include loss of consciousness, twitching or
jerking of the limbs, difficulty in breathing (parents
may report the child stopped breathing), foaming
at the mouth, going pale or blue in colour and
the eyes rolling back in the head (Paul et al 2012).
After the seizure, the child may be irritable and/or
drowsy, may appear confused and may fail to
recognise the people around them. Differential
diagnoses should be considered when a child
presents with features suggestive of febrile
convulsion (Box 1).
Diagnosis
It is important to differentiate febrile convulsion from
acute symptomatic seizures secondary to central
nervous system infection, or seizures triggered by
fever in a child with previously diagnosed epilepsy
(Paul et al 2012). In most cases the illness is a result of
a self-limiting viral infection, but more serious causes
should be ruled out (NICE 2013b).
TABLE 1
Features suggestive of the types of febrile convulsion
Simple febrile convulsion Complex febrile convulsion
 Generalised tonic-clonic seizure  Duration of seizure more than
without focal features lasting ten minutes.
less than ten minutes.  Two or more seizures within
 Resolved spontaneously 24 hours, irrespective of duration
without administration of of seizures.
anti-epileptics.  Child does not regain full
 No recurrence of febrile consciousness within one hour after
convulsion in the next onset of seizures.
24 hours.  Focal features, such as seizures in
one side of the body.
 Anticonvulsant medicines may be
necessary to terminate the event.
 Todd’s paralysis: a brief period
of paralysis after the episode of
febrile convulsion.
(Sadleir and Scheffer 2007, Mewasingh 2010, Paul et al 2012, Paul and Chinthapalli
2013, Shah et al 2013)
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The first step in making the diagnosis is to
obtain a focused but detailed history (Paul et al
2012, Paul and Eaton 2013). The history should
include the nature and duration of the seizure,
previous developmental delay, any neurological
conditions previously diagnosed or under
BOX 1
Differential diagnoses for a child with febrile convulsion
 Rigors (shaking with no loss of consciousness).
 Febrile delirium: acute and transient confusional state associated with
high fever.
 Febrile syncope.
 Breath holding attacks: child voluntarily holds breath and may lose
consciousness transiently.
 Evolving epilepsy syndrome: fever triggers seizure episodes.
 Central nervous system infections: meningitis and/or encephalitis.
(Waruiru and Appleton 2004, Sadleir and Scheffer 2007, Paul et al 2012, National
Institute for Health and Care Excellence 2013a)
BOX 2
Case study
A previously healthy, Afro-Caribbean girl aged four years and three
months presented to the emergency department (ED) after an episode
of being floppy and unresponsive for five minutes. She was incontinent
of urine during the episode. On arrival to the ED, she experienced a
three-minute episode of generalised tonic-clonic seizure, which initially
started on the right side. The temperature recorded after the seizure was
38.9°C, heart rate was 140 beats per minute, respiratory rate was 28
breaths per minute and central capillary refill time (checked by pressure
on the forehead or sternum) was two seconds, which indicates normal
circulation. The bedside blood glucose was 8.9 mmol/L. She remained
post-ictal for one hour, with a Glasgow Coma Scale (GCS) score of 11/15.
On waking, she remained confused and struggled to identify her mother.
Her tonsils were inflamed and enlarged.
A provisional diagnosis of complex febrile convulsion (Table 1) was made
although the possibility of intracranial infection and space occupying
lesion were documented. She was admitted for hourly neurological
observations and monitoring of vital parameters. Intravenous ceftriaxone
and acyclovir were started in the ED. There was a strong family history of
febrile convulsion in both parents.
Blood investigations were carried out in view of the presentation, which
revealed white cell count 12.8x109/L, platelets 312x109/L, C-reactive
protein 11mg/L. Electrolytes were within normal limits. A computed
tomography (CT) scan was carried out in view of focal symptoms
and recurrence of seizures. The CT scan did not reveal any evidence
of intracranial bleeds, space occupying lesions or encephalitis. Herpes
and meningococcal polymerase chain reaction and blood culture were
reported as negative. Her parents declined lumbar puncture for the child.
The child recovered completely and ‘became her normal self’ in three
hours. Nurses conducted regular observation of vital signs. The Paediatric
Early Warning Score (PEWS) and GCS score remained stable and the fever
settled in 24 hours. In view of negative results, the antibiotics were changed
to oral penicillin after 48 hours and the patient was discharged home.
An outpatient electroencephalogram was carried out 15 days later in view
of focal symptoms, which did not reveal any epileptic activity. She remains
under the care of a paediatric consultant. The family has been prescribed
buccal midazolam in view of the higher risk of recurrent febrile convulsion.
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investigation and any family history of febrile
convulsions, epilepsy or sudden death (Waruiru
and Appleton 2004). If the paramedic team
used medication to terminate the seizure,
this should be noted.
A physical examination should be performed
to identify the focus of infection causing the
fever. A child presenting with febrile convulsion
may need emergency stabilisation if still
convulsing using the ABCDE (airway, breathing,
circulation, disability [plus blood glucose
check] and exposure/examination) approach
(Paul and Chinthapalli 2013, Paul et al 2015).
It is important to record the vital parameters,
including temperature, heart rate, respiratory
rate, capillary refill time and blood glucose
(NICE 2013b, RCN 2013). Possible intracranial
infections, such as meningitis or encephalitis,
should be ruled out since the signs and symptoms
can be subtle, especially in younger children
(Lux 2010b, Oluwabusi and Sood 2012,
Paul et al 2012, Paul and Chinthapalli 2013).
It is important to differentiate the first episode
of febrile convulsion from the first episode
of an epileptic or afebrile seizure. A clear
history of fever either before, or soon after
the febrile convulsion is necessary (Paul and
Chinthapalli 2013).
Investigations may not be necessary in a fully
immunised child with a definite history of simple
febrile convulsion with a clear focus for febrile
illness. In cases where the focus may not be
clear, or where there is a suspicion of intracranial
infection, investigations such as blood tests (full
blood count including urea and electrolytes,
calcium, magnesium and C-reactive protein
levels), urine analysis and lumbar puncture will
be indicated (NICE 2013b). Computed
tomography (CT) scan, magnetic resonance
imaging (MRI) and electroencephalography
(EEG) may be necessary in children with complex
febrile convulsion, or in cases of recurrent febrile
convulsion where an underlying neurological
problem is suspected (Paul and Chinthapalli
2013, Shah et al 2013). When a diagnosis of
febrile convulsion is established, recurrent
episodes of simple febrile seizure do not require
repeat investigations, but require review by a
health professional to confirm the history of
febrile convulsion and to determine the focus
for infection and initiation of appropriate
management (Paul and Chinthapalli 2013).
The case study in Box 2 demonstrates the
challenges in clinical practice during management
of a child presenting with complex febrile
convulsion and that investigation may be necessary
in such cases.
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Management
A child with simple febrile convulsion is not
usually hospitalised, as long as the focus for
infection is clear and the child is judged to be well
(Shah et al 2013). Most often episodes of febrile
convulsion are short lived and self-terminating,
meaning treatment with long-term anticonvulsant
medicines is not required. It is important to remain
aware of red flag features (Box 3) while assessing
a child presenting with febrile convulsion, since
these will help in deciding further management.
The NICE (2013b) traffic-light system should be
used while assessing children with febrile illness,
and febrile convulsion, for the presence or absence
of symptoms and signs that can be used to predict
the risk of serious illness.
An episode of febrile convulsion is a distressing
experience for parents (NICE 2013a). In a study
of 50 parents, of 36 children, who had witnessed
their child’s first febrile convulsion, most of them
responded that they thought their child was
dying or was likely to die (Baumer et al 1981).
It is imperative that health professionals adopt
an empathetic approach while dealing with
parents. Most cases of simple febrile convulsion
can be managed with reassurance, explanation
and advice on symptomatic management of
fever and associated illness (Paul et al 2015).
Some considerations that nurses may find useful
while reassuring or counselling parents, derived
from the available literature and the authors’
experience in managing children with febrile
convulsion, are provided in Box 4.
Hospitalisation for observation is suggested
when (NICE 2013a, Paul et al 2013):
 The child has red flag signs and symptoms.
 The seizure is prolonged, or after an episode of
complex febrile convulsion.
 There are residual neurological findings,
for example Todd’s paresis (focal weakness
post seizure).
 There is suspicion of serious infection.
 The source of infection cannot be determined
clearly.
 The child is aged less than one year.
Treatment in the acute phase is mainly directed
at the underlying cause of fever and is generally
aimed at symptomatic management of fever.
It is essential that adequate hydration be
maintained by encouraging the child to drink.
Paracetamol or ibuprofen can be prescribed to
help relieve the discomfort of a febrile child,
but ibuprofen should be avoided if the child is
dehydrated. It should be explained to parents
that administration of paracetamol or ibuprofen
will not prevent recurrence of febrile convulsion
(Paul et al 2012, NICE 2013b). The immediate
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actions that may be taken by parents or nurses
following an episode of febrile convulsion are
outlined in Box 5.
Trials have shown that giving antipyretic drugs
to children with fever does not reduce the risk
of recurrence of febrile convulsion; therefore,
rigorous attempts to decrease temperature are
BOX 3
Red flag signs and symptoms in a child presenting with
febrile convulsion
 Child presenting with complex febrile convulsion.
 Presence of meningeal signs: positive Kernig’s sign (patient supine, hips
and knees in flexion, pain when extending patient’s knees beyond 135°
constitutes a positive test for Kernig’s sign); and/or positive Brudzinski’s
sign (with the patient supine, physician places one hand behind the
patient’s head and the other hand on the patient’s chest. The physician
then raises the patient’s head while the hand on the chest restrains the
patient and prevents the patient from rising. Flexion of the patient’s lower
extremities constitutes a positive sign).
 Altered level of consciousness more than one hour after cessation of
febrile convulsion.
 Evolving non-blanching rashes in an unwell child.
 Neck stiffness.
 Bulging anterior fontanelle.
 Presence of tachycardia out of proportion to the body temperature, or
persistence of tachycardia even after body temperature normalises.
 Signs of moderate to severe respiratory distress, such as tachypnoea,
grunting, low oxygen saturation (<92% on air), chest wall recessions.
(Waruiru and Appleton 2004, Lux 2010b, National Institute for Health and Care
Excellence 2013a, 2013b)
BOX 4
Issues to discuss with parents after an episode of febrile convulsion
 Provide reassurance to parents that their child will not die.
 Provide verbal and written information about the favorable outcome of
febrile convulsion, which can alleviate anxiety and let the family return
to their usual life.
 Give advice to parents on what to do if their child has another febrile
convulsion – ensure child is in a safe place, loosen clothes, place in
recovery position after seizure stops, do not insert finger or objects
inside the child’s mouth and call an ambulance if seizure lasts more
than five minutes.
 Provide advice on safe use of antipyretics: dispel fever phobia and explain
that antipyretics do not prevent febrile convulsion.
 Provide advice to seek specialist help if child has another febrile
convulsion, if the fever lasts for more than five days (suspect Kawasaki
disease) or if the child deteriorates post discharge.
 Explain to parents that children who have experienced an episode
of febrile convulsion following immunisation are no more likely to
have subsequent seizures than other children who experience febrile
convulsion not associated with immunisation. This may improve uptake
of further immunisations.
 Provide guidance on identifying signs of dehydration and measures to
maintain hydration at home.
(Barlow et al 2001, Paul et al 2012, 2013, 2015, National Institute for Health and
Care Excellence 2013a, Royal College of Nursing 2013, Paul and Eaton 2013)
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not recommended (Waruiru and Appleton 2004,
Lux 2010a, 2010b, Paul et al 2012, NICE 2013b,
RCN 2013). A recent meta-analysis did not find
any clinically important benefits for children
with febrile convulsion when treated with
intermittent ibuprofen, diclofenac or paracetamol
when compared with placebo (Offringa
and Newton 2013).
Parents should be made aware of the evidence
against prophylactic antipyretic treatment in
children with febrile convulsion during subsequent
febrile episodes. This will enable them to
understand that the rationale for administration of
antipyretics is to make the child more comfortable
and should not be considered a preventive measure
for febrile convulsion. Sponge bathing of the child
or putting a fan directly on the child to decrease
their temperature is not recommended and the
child should not be underdressed or overwrapped
(Strengell et al 2009, NICE 2013a, RCN 2013).
Peripheral cooling of the body temperature
without a decrease of the core temperature will
BOX 5
Useful actions during or after an episode of febrile convulsion
 Note the time of onset of febrile convulsion.
 Note whether the convulsion is generalised or one-sided.
 Do not insert finger or other objects inside child’s mouth to prevent
tongue biting.
 Administer rescue anticonvulsants (per rectal or buccal route) where it
has been recommended for the child with recurrent febrile convulsion.
 Put the child in the recovery position when the convulsion has stopped.
 Paramedic staff may be summoned after the first episode of febrile
convulsion or during subsequent episodes if it was an episode of complex
febrile convulsion, or the child is unwell.
(National Institute for Health and Care Excellence 2013a)
TABLE 2
Presentations where anti-epileptic drugs may be useful in
febrile convulsion
Rescue anticonvulsants Long-term prophylactic
(benzodiazepines, such as buccal anticonvulsants (sodium
midazolam or rectal diazepam) valproate)
 Frequent febrile convulsions over  Children with febrile status
a short period of time (three or epilepticus, complex or recurrent
more febrile convulsions in febrile convulsion (more than six
six months). episodes of febrile convulsion per
 Febrile convulsion lasting year in spite of use of intermittent
more than 15 minutes or rescue anticonvulsant therapy).
anticonvulsant therapy required
to stop the seizure.
 Child living in a remote area
geographically.
 Poor access to medical care.
(Scott et al 1999, Lux 2010b, Mewasingh 2010, Paul et al 2012, Paul and
Chinthapalli 2013, Shah et al 2013)
lead to shivering, generating a further increase in
body temperature.
In cases of bacterial febrile illness, for example,
tonsillitis, otitis media or pneumonia, prescription
of antibiotics is necessary. Rescue anticonvulsant
medications such as benzodiazepines may
be administered to children with prolonged
febrile convulsion.
Long-term strategies for children with recurrent
febrile convulsion may include the administration
of rescue anticonvulsants, for example buccal
midazolam, during an episode (Camfield and
Camfield 2014). Trials of prophylactic treatment
with regular anti-epileptic drugs including
carbamazepine, diazepam, phenobarbital,
phenytoin and sodium valproate did not reduce the
risk of developing epilepsy in the future, were not
successful in preventing the recurrence of febrile
convulsion in all participants and the side effects
outweighed any potential benefits (Strengell et al
2009, Lux 2010b, Offringa and Newton 2013,
Shah et al 2013).
There is a limited role for long-term
prophylaxis (antipyretic or anti-epileptic
medicines) in children with febrile convulsion
and this is generally not prescribed for children
in the UK (Paul and Chinthapalli 2012, Offringa
and Newton 2013).The need for long-term
prophylactic anticonvulsants should be decided
after the advantages and disadvantages have
been evaluated by a paediatrician with an
interest in epilepsy or a paediatric neurologist.
Cases where this may be considered necessary
are identified in Table 2. There is no consensus
regarding the duration of long-term prophylactic
anticonvulsant therapy and duration depends on
the discretion of the clinician. It is either given
for two years after the last episode of febrile
convulsion or continued until the child reaches six
years of age, by which time they are expected to
grow out of the condition (Paul and Chinthapalli
2013, Camfield and Camfield 2014).
Two drugs that may be used for long-term
prophylaxis are sodium valproate and
phenobarbitone. Previous studies support the
use of sodium valproate, since it is better at
controlling recurrence of febrile convulsion
and the side effects are less in comparison to
phenobarbitone (Paul and Chinthapalli 2013).
Prognosis
Febrile convulsion is common and subsequent
risks of serious adverse outcomes are rare. Febrile
convulsion is not epileptic in origin and most
children do not progress to develop epilepsy.
The background risk for developing epilepsy is

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the same as the background population risk in
the absence of pre-existing risk factors (Box 6).
The risk after a complex febrile convulsion is
10-20% (NICE 2013a). The risk of developing
epilepsy increases with each additional risk
factor (2.5% with one risk factor, 5-10%
with two to three risk factors) (Paul et al 2012,
Paul and Eaton 2013).
One third of children develop a further febrile
convulsion during subsequent episodes of
febrile illness (Lux 2010b). It is important that
health professionals remain aware of the risk
factors for recurrence (Box 7). If a child has all
the risk factors for recurrence as described in
Box 7, the risk of experiencing another febrile
convulsion is as high as 76% in comparison
to 4% when no risk factors for recurrence are
present (Sadleir and Scheffer 2007, Mewasingh
2010, Paul et al 2012, Paul and Eaton 2013).
Children usually have fewer febrile convulsions
as they grow older and these stop completely by
six years of age (Paul et al 2012). It is important
to reassure parents that there is no increased
risk of intellectual delay, school difficulties or
behavioural problems in most children who
have had febrile convulsions (Verity et al 1998).
Parents need to be counselled about their child’s
risk, so that they can appropriately manage
another episode of febrile convulsion at home.
Role of the nurse in different settings
Nurses are often the first health professional to
come across a child after an episode of febrile
convulsion. They have a vital role in managing
and supporting children and their families
(Paul et al 2013).
School and nursery nurses
School and nursery nurses often have the most
contact as a health professional with a child and,
therefore, are in a good position to detect any signs
of fever or changes in behaviour. They should
emphasise their concerns to parents or consider
referring the child to paediatric services if they
remain uncertain about the diagnosis, or another
serious pathology is suspected (Paul and Eaton
2013). If a child experiences febrile convulsion in
the school premises, it is important that a finger or
spoon is not inserted in the child’s mouth, that the
child is kept safe during the seizure activity,
for example, not in a high place and away from
electrical appliances or radiators. The child must
be placed in the recovery position after the seizure
has terminated. An ambulance should be called
and the nurse should assist the paramedic team by
providing details about preceding fever, infections,
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and the onset, duration and nature (generalised,
focal) of the febrile convulsion. This first-hand
version of the event will enable the hospital team
to categorise the febrile convulsion and decide on
appropriate management for the child once they
are in the ED.
Practice nurses
Nurses working in primary care regularly
encounter febrile children in their clinical practice.
Although most cases are a result of relatively minor
childhood infections, it is important to remain
vigilant to detect early signs of potentially more
serious illnesses (NICE 2013b). Practice nurses
have a vital role in managing a child who might
be brought to the GP surgery for consultation after
a febrile convulsion.
While some nurses have limited knowledge
of managing sick children, it is important that
they improve their skills in assessing children,
keep themselves updated about NICE and Scottish
Intercollegiate Guidelines Network (SIGN)
guidelines on managing children’s conditions,
and remain aware of the red flag signs and
symptoms (Box 3) while assessing a febrile child.
Further education and training in managing
sick children may be required, and guidance is
BOX 6
Risk factors for developing epilepsy after febrile convulsion
 Neurological symptoms or signs of developmental delay before the onset
of febrile convulsion.
 Complex febrile convulsion (prolonged, focal features).
 Multiple episodes of febrile convulsion over a short time period (more
than three episodes of febrile convulsion in six months).
 History of epilepsy in first-degree relatives.
 Low APGAR* scores.
 Fever of short duration (of less than one hour) before the episode of
febrile convulsion.
* APGAR = Appearance (skin colour), Pulse, Grimace (reflex irritability), Activity
(muscle tone), Respiration (rate and effort) observed at one and five minutes
after birth (Lux 2010b, Mewasingh 2010, National Institute for Health and Care
Excellence 2013a, Paul and Eaton 2013)
BOX 7
Risk factors for recurrence of febrile convulsion
 Onset of first febrile convulsion before 18 months of age.
 History of febrile convulsion in one or both parents.
 Family history of epilepsy.
 Lower body temperature at the onset of febrile convulsion (<38°C).
 Short duration of fever (less than one hour) before onset of seizure.
 Children who have experienced a complex febrile convulsion.
 Multiple seizures occurring during the same febrile episode.
 Attendance at a day care nursery.
(Lux 2010b, Paul and Eaton 2013)
26 other
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Art & science paediatric nursing
available from the RCN and the Royal College
of General Practitioners. Attending shifts and
shadowing nurses caring for children who are ill in
the ED at the local hospital may help in enhancing
skills in assessing children and improve nurses’
decision-making processes when presented with
a febrile child.
A thorough assessment should include
detection of the infection causing the febrile
illness and recording vital parameters and signs
of dehydration. Suspicion of a serious illness or
an intracranial infection should lead to an urgent
review by a medical professional or referral to
hospital. Practice nurses can provide education,
support and counsel families, provide information
leaflets about febrile convulsion and provide
appropriate information on the use of single
antipyretic therapy (Banks et al 2013). Parents and
carers can be educated on what to do if their child
has another febrile convulsion. Children who need
follow-up appointments and investigations with
specialists after complex febrile convulsion should
be encouraged to attend these appointments.
New or immigrant children registering with the
GP surgery who have had previous complex febrile
convulsion should be identified and supported
(Paul et al 2012, 2013, Paul and Eaton 2013).
Emergency department nurses
Nurses in EDs have a crucial role in raising the
suspicion of serious pathology following an
episode of febrile convulsion (Paul et al 2015).
They should triage patients according to their
clinical status, identify any red flag features
(Box 3) and take seriously any fever reported by
parents, even if the child is apyrexial at the time
of triage (Paul et al 2015). A blood glucose test
should be included at triage following a reported or
witnessed febrile convulsion (Glasper et al 2007).
It is beneficial for the triage nurse to ask parents
to obtain a urine sample from their child while
waiting for medical review and encourage the child
to drink oral fluids (NICE 2013b). Antipyretics
can be considered where a child over three months
old with a fever appears distressed or in discomfort
at triage, however, they should not be used with
a sole purpose of reducing the body temperature
(Glasper et al 2007, Paul et al 2015).
In some cases emergency nurse practitioners
manage the patient alone and decide on the need
for admission or discharge. Commonly, the child
presents after termination of the seizure, but in
some cases the child may be still convulsing (Paul
et al 2015). If convulsing, the child should be
managed with an ABCDE approach, urgent
medical assistance should be summoned and the
parents should be supported by the provision of
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information about the management of their child.
In the few cases where the child requires transfer to
the paediatric intensive care unit, or is undergoing
a CT scan, ED nurses should support the process
(Paul et al 2015).
Children’s nurses
Children who may have experienced a complex
febrile convulsion, infants (less than one year)
with febrile convulsion, or where the focus for febrile
illness is not clear are often admitted for observation
and further management. Children’s nurses arrange
monitoring in the ward, record Paediatric Early
Warning Score (PEWS), identify any new or evolving
red flag features (Box 3), administer medications and
provide support to the family. The patient’s clinical
observations should be assessed regularly, including
their neurological signs, particularly after any
anticonvulsant medication has been administered
(Paul et al 2013). They should alert the doctors to
any deterioration and treat accordingly (Hawes
et al 2013). Use of the PEWS will help alert the team
to the possibility of early deterioration and need
for intervention. If the child experiences another
febrile convulsion during the hospital stay, nurses
should support stabilisation (ABCDE approach)
and management of the child. Similarly, the use of
a recognised pain score increases understanding
of the effectiveness of the analgesia given to ensure
the child is as comfortable as possible (Hawes et al
2013). The nurse should also ensure that the child
is as comfortable as possible, by controlling their
temperature and encouraging adequate fluid intake
(Hawes et al 2013, Paul et al 2013).
The nurse is likely to be asked many
questions about the child’s condition, diagnosis,
management and prognosis (Paul et al 2013). It is,
therefore, important that educational programmes
targeting practice change are theoretically based
and target knowledge, attitudes and barriers to
change (Edwards et al 2007). This will ensure
that nurses are well informed about the condition,
enabling them to reassure parents appropriately,
provide relevant appropriate information and
dispel any myths regarding fever phobia and
febrile convulsion. Nurses, in their holistic role,
are best placed to provide families with emotional
support and ensure that they are kept up-to-date
with the patient’s clinical progress (Hawes et al
2013). Nurses can allay parents’ fever phobia and
explain the rationale for using single antipyretic
agents while reiterating that the antipyretic
administration will not prevent recurrence of
febrile convulsion (Banks et al 2013, NICE 2013b,
RCN 2013). A clear discharge and follow-up plan
should be explained to the parents and nurses can
emphasise the need to monitor the child at home
STANDARD
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(Paul et al 2013). Appropriate supporting leaflets
should be offered to parents.
Conclusion
Although febrile convulsion is common,
most cases are benign, with low risk for
progression to any long-term adverse effects.
However, witnessing the child’s febrile convulsion
is a distressing experience for parents and carers
necessitating nursing support. There are certain
high-risk groups of children in which febrile
convulsion occurs more frequently. Febrile
convulsions are not epileptic fits and the baseline
risk for developing epilepsy following simple
febrile convulsion remains the same as for the rest
of the population in the absence of any increased
risk factors. Management of febrile convulsion is
mainly symptomatic and investigations are only
necessary in a small number of children. Single
antipyretic agents should be prescribed to keep
the child comfortable, but this does not prevent
recurrence of febrile convulsion. Reassurance
and appropriate information will allay parents’
fear and anxiety and help to dispel myths about
febrile convulsion in children NS

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