Art & science | | Theacutecaresynthesisofcareyoungofartandpeoplescience is lived by the nurse in the nursing act JOSEPHINE G PATERSON
MANAGEMENT OF FEBRILE
CONVULSION IN CHILDREN
Correspondence
siba_prosad@yahoo.co.uk
Siba Prosad Paul is a specialty
trainee year 8 in paediatrics at
Bristol Royal Hospital for
Children, part of University
Hospitals Bristol NHS
Foundation Trust
Eleanor Rogers is fourth-
year medical student at
the University of Bristol
Rachel Wilkinson is an advanced
paediatric nurse practitioner at St
Richard’s Hospital, Chichester,
part of Western Sussex Hospitals
NHS Foundation Trust
Biswajit Paul is a consultant
resident neurologist at
Gauhati Medical College and
Hospital, Guwahati, India
Date of submission
March 1 2015
Date of acceptance
April 14 2015
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
journals.rcni.com/r/
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Siba Prosad Paul and colleagues discuss the aetiology, clinical
presentation, diagnosis and management of the most common
type of seizure in children, and set out best practice for their care
Abstract
The causes of febrile convulsions are usually benign.
Such convulsions are common in children and their long-
term consequences are rare. However, other causes of
seizures, such as intracranial infections, must be
excluded before diagnosis, especially in infants and
younger children. Diagnosis is based mainly on history
taking, and further investigations into the condition are
not generally needed in fully immunised children
presenting with simple febrile convulsions. Treatment
involves symptom control and treating the cause of the
fever. Nevertheless, febrile convulsions in children can
be distressing for parents, who should
ONE DEFINITION OF febrile convulsion is an event
associated with fever, but with no evidence of
intracranial infection or acute electrolyte imbalance, that
occurs in an infant or child aged between
six months and six years (Sadleir and Scheffer 2007).
Such convulsions represent the most common type of
seizure in children and are one of the most frequent
presentations to emergency departments (EDs). They
are seen in between 3% and 4% of white children, but
are more common in children of some other ethnic
backgrounds: between 6% and 9% of Japanese
children,
for example, and between 5% and 10% of Indian
children (Mewasingh 2010).
Febrile convulsions are generally harmless to the
children concerned but can be extremely frightening for
their parents. It is therefore important that parents’
anxiety is addressed sensitively to help them to feel
calmer and to enable ED teams to treat
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be supported and kept informed by experienced
emergency department (ED) nurses. This article
discusses the aetiology, clinical presentation, diagnosis
and management of children with febrile convulsion,
and best practice for care in EDs. It also includes
a reflective case study to highlight the challenges
faced by healthcare professionals who manage
children who present with febrile convulsion.
Keywords
Children, paediatric, seizures, fever, high
temperature, febrile convulsions, epilepsy
children without repeated involvement of anxious
parents during resuscitation.
Aetiology and pathophysiology
The exact aetiology of febrile convulsion is
unknown, but it is considered to be the result of a
complex interplay between environmental and
genetic factors (Paul et al 2012, Chung 2014). Fever
in febrile convulsions is extra-cranial in origin and
the high temperature associated with it is a normal
physiological response to infection. Mechanisms that
could explain the process of such convulsions
include the release during fever of cytokines, which
cause temporary abnormal electrical activity in the
brain (Lux 2010a, NHS Choices 2014).
In the UK, the most common infections associated
with febrile convulsion (Paul and Eaton 2013, NHS
Choices 2014) are chickenpox, flu,
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Art & science | acutecareofcareyoung people
gastroenteritis, middle ear infections, respiratory
tract infections and tonsillitis.
The risk of febrile convulsion is increased
by positive family histories, with up to 40%
of children having such histories. Between 9% and
22% of children with siblings who have experienced
febrile convulsion experience it themselves, and the
likelihood that the other twin will experience febrile
convulsion is highest among monozygotic twins (Lux
2010a). Almost 50% of children in whom siblings
and one parent have experienced febrile convulsion
experience it too (Tejani 2015).
Pre-existing neurological conditions, such as
cerebral palsy, and iron and zinc deficiencies, are
also thought to increase the risk of febrile convulsion
(Paul et al 2012, Waqar Rabbani et al 2013).
Research demonstrates that the development
of febrile convulsion may be due mainly to
polygenetic inheritance (Paul and Chinthapalli
2013, Tejani 2015), although an autosomal
dominant pattern of inheritance known as a ‘febrile
seizure susceptibility trait’ has been identified in
a few families (Tejani 2015). Although the exact
molecular mechanisms are yet to be understood
fully, underlying mutations in genes encoding
sodium channels and the gamma-aminobutyric acid
A receptor have been identified in children with
febrile convulsions (Tejani 2015).
Clinical presentation
The peak age of onset of febrile convulsion is
18 months, with up to 50% of children having first
episodes aged between 12 and 30 months. First
presentations of febrile convulsions in children
aged over three years are rare (Sadleir and Scheffer
2007, Chung 2014).
Children with febrile convulsion usually have
a temperature of more than 38°C. Convulsions
can occur at any point during a febrile illness,
however, and children may not have a raised
temperature at the time of their seizures but may
subsequently develop one.
Signs and symptoms can include loss of
consciousness, global or focal twitching or jerking
of arms and legs, difficulty breathing, foaming at
the mouth, pallor or going blue, and eyes rolling
back in the head. After a seizure, children are often
drowsy and sometimes confused, and can take up to
30 minutes to wake properly (Department of Health
Australia 2010).
There are two types of febrile convulsion,
with 70% classified as simple and 30% as complex.
The characteristics of each are shown in Table 1.
Febrile status epilepticus, a severe form of complex
febrile convulsion lasting at least 30 minutes without
20 May 2015 | Volume 23 | Number 2
interim recovery, occurs in 5% of children with febrile
convulsion, and is more likely than other forms of
complex febrile convulsion to have focal features
(Sadleir and Scheffer 2007, Chung 2014, Tejani 2015).
Diagnosis
When children with febrile convulsion present
to EDs, healthcare professionals should take
detailed and accurate histories, and make physical
examinations, to rule out other diagnoses and to
identify the cause of fever. Differential diagnoses
of childhood seizures (Sadleir and Scheffer 2007,
Paul et al 2012) include:
■ Rigors with no loss of consciousness.
■ Febrile delirium, an acute and transient confused
state associated with fever.
■ Febrile syncope.
■ Breath-holding attacks, in which children
transiently lose consciousness due to voluntarily
holding their breath.
■ Reflex anoxic seizures, in which painful events or
shock causes children suddenly to become limp.
Such children may have low-grade pyrexia.
■ Evolving epilepsy syndrome.
■ Central nervous system (CNS) infections, such as
meningitis and encephalitis.
Histories are likely to come from children’s parents
or guardians, and healthcare professionals should be
careful to gather information on (Chung 2014):
■ The nature of the convulsion, for example
whether it is generalised or focal, and
its duration.
■ The duration of the post-ictal phase.
■ Recent illnesses or fever.
■ Recent antibiotic use.
■ Other symptoms, such as breathing difficulties
and diarrhoea.
■ Immunisation status.
■ Histories of febrile convulsions or previously
diagnosed neurological conditions.
■ Family histories of febrile convulsions, epilepsy
or sudden death.
■ Use of antipyretics.
■ Use of rescue anticonvulsants, such as diazepam
and midazolam, to terminate seizure. This
question may be asked of paramedic staff
rather than parents or guardians.
Examinations should include full neurological
assessments and healthcare professionals
should look for signs of meningeal irritation,
such as neck stiffness (Chung 2014). It is
therefore vital that they can recognise the signs
and symptoms of CNS infections, which can be
subtle in infants and young children (Paul and
Chinthapalli 2013).
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 Table 1 Characteristics of simple and complex febrile convulsions
Simple
■ Tonic-clonic activity is generalised and without the
features of a focal seizure.
■ Each convulsion lasts for less than ten minutes.
■ Convulsions resolve spontaneously.
■ There are no further convulsions within the next
24 hours.
(Adapted from Sadleir and Scheffer 2007, Mewasingh 2010, Paul and Eaton 2013, Chung 2014)
The seriousness of illness in children should
not be assessed solely on the height of their
temperatures, and healthcare professionals should
also record each child’s respiratory rate, oxygen
saturation, central capillary refill time, heart rate,
blood pressure, blood glucose level and paediatric
early warning score (PEWS) (Royal College of
Nursing 2013).
Clinicians should remember that children
who present during or immediately after febrile
convulsions will have a high PEWS and should be
reviewed urgently by a medical professional or
advanced emergency nurse practitioner. A high PEWS
is likely to persist for a short period of time due to
pyrexia and associated tachycardia and tachypnoea,
and ED nurses should continue to monitor the child
concerned until his or her transfer because a further
increase in PEWS should trigger a reassessment of
the child’s condition.
Investigations should also be carried out in
children who show signs and symptoms of serious
illness or intracranial infection, such as meningitis
or pneumonia. Investigations are rarely necessary
in children who are aged over one year, are fully
immunised, have a clear focus of infection and have
had simple febrile convulsions (Oluwabusi and Sood
2012). However, further investigations should usually
be carried out in children who are less than one
year old, who are presenting with complex febrile
convulsions for the first time or who may have
symptoms that suggest CNS infections (National
Institute for Health and Care Excellence (NICE) 2013a).
In such cases, healthcare professionals can
request full septic screens including:
■ Full blood count and tests of C-reactive
protein, calcium, glucose, magnesium, urea and
electrolytes, and, if bacterial sepsis is suspected,
blood culture.
■ Urine dipstick and culture tests.
■ Chest X-rays.
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Complex
■ Each convulsion lasts more than ten minutes.
■ A second convulsion may occur within 24 hours.
■ There is a focal seizure in which, for example,
convulsions occur on only one side of the body.
■ Full consciousness is not regained within one hour.
■ There are post-ictal neurological abnormalities.
■ There is a brief period of paralysis, known as
a Todd’s paresis, after the convulsion.
■ Febrile status epilepticus occurs.
■ Stool culture tests.
■ Lumbar puncture. However, because raised
intracranial pressure is difficult to assess in
the post-ictal period, this test should not be
undertaken immediately after a febrile convulsion.
In children with complex or recurrent febrile
convulsion, or those with neurological
abnormalities, magnetic resonance imaging,
computed tomography, electroencephalography
(EEG) or a combination of these can be considered
to rule out underlying or evolving neurological
problems. EEG is usually undertaken at least
48 hours after the febrile convulsion to prevent
post-ictal electrical activities being misinterpreted
as abnormal seizure activities (Paul et al 2012,
Shah et al 2014).
In children who have had recurrent episodes
of febrile convulsion and with clearly identified
sources of infection, repeat investigations
are not required. However, it is important
that healthcare professionals determine the
source of children’s infections and ensure
that they are managed appropriately (Paul and
Chinthapalli 2013).
A case study involving a young child with febrile
convulsion is shown on page 22.
Management
The first healthcare professionals to see children
with febrile convulsion are often emergency
nurses, who therefore have an important role
to play in managing the children’s condition.
Most such children present to EDs after their
episodes of convulsion are over, but a small
number present while still convulsing and must be
stabilised following the ABCDE approach. This is
generally done in a resuscitation room (Paul and
Chinthapalli 2013).
Witnessing convulsing children is distressing
for their parents. Such children appear pale,
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 Art & science | acutecareofcareyoung people
Case study
A paediatric medical team was ‘crash bleeped’
to attend resuscitation urgently after a three-
year-old boy was rushed with his parents by
ambulance to the emergency department (ED).
The boy’s parents said that, while at home about five
hours earlier, he had become febrile. His parents had
given him paracetamol, but he had suddenly become
‘floppy’ and unresponsive. Worried that their son had
sustained brain damage due to high fever or was about
to die, the parents had called for an ambulance. On the
way to the ED, the right side of the boy’s body had
begun to twitch and the twitching progressed to a
generalised tonic-clonic seizure.
On arriving at the ED, the parents were
extremely distressed and, while the team
stabilised the boy, made initial observations
and administered medications, his parents
were supported by a senior ED staff nurse.
The family is of an Indian ethnic background. History
taking from the parents revealed that there was no
family history of epilepsy, although the boy’s mother
reported that she had experienced recurrent febrile
convulsion early in her life and had been treated with
sodium valproate till her sixth birthday.
Initial observations showed that the boy had
a temperature of 39.3°C, a pulse rate of 166 beats
per minute, respiratory rate of 36 breaths per
minute, oxygen saturations of 91% in air and a
central capillary refill time of two seconds. His
bedside blood glucose level was 9.3mmol/L.
The boy was administered high-flow oxygen
through a face mask. An intravenous (IV)
cannula was inserted and the boy was
administered a dose of IV lorazepam 0.1mg/kg.
After 12 minutes, the boy’s seizure terminated
but he remained unresponsive and with a low
Glasgow Coma Scale score, of 10/15. He
remained unresponsive for a further 90 minutes.
During this period, laboratory results showed
he had a C-reactive protein level of 27 mg/L
and a white cell count of 14.8x109/L, but no
electrolyte abnormalities were detected.
On waking, the boy was confused and distressed,
and struggled to recognise his parents for another
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25 minutes. Clinical examination revealed he
had bilateral inflamed tympanic membranes
and right-sided inflamed enlarged tonsils.
The boy was given a provisional diagnosis of complex
febrile convulsion and was put under neurological
observation. The possibility that he had contracted
another serious infection, such as meningitis or
encephalitis, was considered and documented.
Because there had been a prolonged period of
unresponsiveness before and after his seizure, he was
administered IV ceftriaxone and acyclovir in case of
intracranial bacterial and herpes infections.
Over the next 36 hours, the boy’s fever settled and he
recovered completely. His detailed neurological
assessment produced normal results. The team
discussed with the boy’s parents whether he should
undergo lumbar puncture but, in light of the parents’
reluctance and the fact that the likelihood that
he had contracted an intracranial infection
was considered minimal, it was decided not
to carry out the procedure.
At 72 hours after admission, the boy’s blood
culture was reported to be negative and
IV medicines were discontinued. He was put
on a ten-day course of oral co-amoxiclav
and his discharge home was arranged.
At his discharge, his parents were given an
information leaflet on febrile convulsion.
A children’s nurse explained to them that, in
view of the boy’s complex febrile convulsion
and family history, he was at a high risk of
further febrile convulsions and gave them
advice about the use of antipyretics at home.
Two weeks later, the boy and his parents returned for
an electroencephalogram, which was subsequently
reported to be normal. After consulting a neurologist
while on holiday, his parents also organised
a magnetic resonance imaging scan of his
brain, which was also reported as normal.
The boy was discharged from the follow-up paediatric
clinic a year later, when the parents decided to move
the family to India. A summary of the boy’s medical
condition, including the investigations performed
and plan of management, was given to them. The boy
was reported to be developing normally and doing
well at school.
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cannot communicate, and can be frothing from
the mouth and actively fitting. Parents often
think their children are going to die because they
can appear lifeless during episodes. Baumer et al
(1981) interviewed 36 parents who had witnessed
their children’s first febrile convulsions and
reported that most thought that their children
were dying or were likely to die. It is therefore
vital that parents are adequately reassured and
that their concerns are addressed. It should be
acknowledged and explained that the experience
can be frightening, but they should be reassured
that their children will live.
If parents want to witness the resuscitation of
their children, appropriately trained healthcare
professionals should support them (Perry 2009).
The benefits of allowing parents to be present
(Maxton 2008, Keller 2011) include:
■ Giving them a sense of continual involvement in
their children’s care.
■ Giving children a sense of reassurance and safety
when they start to wake up and can see their
parents are present.
■ Helping parents to understand that their
children have received the best possible
care, and satisfying them that the healthcare
professionals have done everything they can to
make their children better.
■ Improving relationships between families and
healthcare professionals.
Healthcare professionals should also give parents
verbal and written advice about caring for their
children after febrile convulsions. This advice should
be based on (NICE 2013b):
■ Safe use of antipyretics.
■ Maintaining hydration, and identifying signs and
symptoms of dehydration.
■ Identifying non-blanching rash.
■ Checking children at night.
■ Seeking further help if children have further
seizures, if fevers last for more than five days or
if the children’s conditions deteriorate.
Resuscitation is also stressful for the staff supporting
the parents, especially if there is uncertainty about
when convulsing children will respond to medication.
Some children who have been given intravenous
(IV) lorazepam respond immediately, for example,
while others also need IV phenytoin or rapid sequence
induction by an anaesthetist before responding.
There is a risk in such cases that the information
staff provide to patients will distress them further
and staff need to judge what information to share on
a case-by-case basis.
Febrile convulsions are usually self-limiting but,
when they have lasted for more than five minutes,
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anticonvulsant medication, such as per rectal
diazepam or buccal midazolam, may be needed
to stop them (Chung 2014). A list of medicines
commonly used in children presenting with febrile
convulsion is shown in Table 2, page 24.
Children with simple febrile convulsions, a clear
focus of infection and who appear well do not
require admission and can be discharged after
a period of observation in the ED or a short-stay
ward, preferably six hours after the episode
(Shah et al 2014). However, admission for observation
is recommended (NICE 2013b) if:
■ The child is under 18 months of age.
■ The child is ill.
■ There has been a prolonged or complex
febrile convulsion.
■ There is a risk of recurrence.
■ Meningitis or encephalitis is suspected.
■ There is no clear source of infection.
■ The child shows developmental delay or
neurological abnormalities.
■ The parents cannot cope or clinicians
think the parents cannot provide regular
monitoring immediately after the child’s
febrile convulsion, or there are other
child-safeguarding concerns.
Treatment should be directed at treating the
source of infection and management of symptoms.
If bacterial infection is suspected, antibiotics may be
considered. Children should also be encouraged to
drink fluids to keep hydrated.
Parents and healthcare professionals often
assume that a raised temperature means an
increased risk of febrile convulsion, which often
leads to overuse of antipyretics (Banks et al
2013). However, research suggests that, although
antipyretics reduce body temperature, they do
not reduce febrile convulsion recurrence rates
(Strengell et al 2009, Lux 2010b, Banks et al 2013,
Chung 2014). Antipyretics should be administered
only to reduce discomfort, therefore, and to increase
the likelihood of drinking and thereby maintain
hydration (Banks et al 2013, Wragg et al 2014).
Paracetamol and ibuprofen can be administered,
unless they are contraindicated, although NICE
(2013b) recommends using only one because the
clinical benefit of using them together is small
and there is no evidence that the combination is
more effective than a single antipyretic agent in
reducing distress. Administering combinations of
antipyretics is common practice in hospitals but
provides no added benefit, increases the risk of
drug administration errors and overdoses, and gives
an incorrect message to parents (Banks et al 2013,
NICE 2013b, Wragg et al 2014).
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Art & science | acutecareofcareyoung people

Children with fever should not be under- or Prognosis

overdressed, and infants’ heads should be left uncovered
(NICE 2013b). The temperature of the room can be
reduced, but it is not advisable to blow air from a fan
directly towards children or to give them a sponge bath
as these techniques can lead to peripheral
vasoconstriction, and raise body temperature even further
through shivering (NICE 2013b).
Long-term anticonvulsant medication is not
usually prescribed as prophylaxis for febrile
convulsions because trials have shown they do not
reduce the chance of developing epilepsy and their
potential side effects outweigh their potential benefits
(Strengell et al 2009, Lux 2010a, Paul and
Chinthapalli 2013, Shah et al 2014).
In specific circumstances, however, the benefits can
outweigh the risks and children are prescribed
benzodiazepines, such as rectal diazepam or buccal
midazolam, for use at home as a ‘rescue therapy’ to stop
a seizure (Chung 2014). Benzodiazepines to be
administered by parents at home can be prescribed for
children who have frequent febrile convulsions in short
periods or convulsions that last more than 15 minutes, as
long as anticonvulsants have been required previously to
stop seizures, or the children and their families live in
geographically isolated areas where they cannot receive
immediate medical assistance (Sadleir and Scheffer 2007,
Lux 2010a, Paul and Chinthapalli 2013).
Healthcare professionals and parents are usually most
concerned about the risk of seizure recurrence of
febrile convulsions and the risk of epilepsy. For most
children, however, febrile convulsions have no long-
term consequences,
and do not affect behaviour, learning or intelligence
(Chung 2014). It is important to emphasise that febrile
convulsions are not epileptic in origin and children who
have simple febrile convulsions are at no greater risk of
developing epilepsy than other children (Mewasingh
2010).
One third of children who have one febrile
convulsion will have a second during a later febrile
illness. Healthcare professionals should be aware of
the risk factors for recurrence, therefore, because
they may need to counsel the children’s parents
accordingly and some children may need ‘rescue’
anticonvulsants. Risk factors for recurrence of
febrile convulsions (Waruiru and Appleton 2004,
Sadleir and Scheffer 2007, Mewasingh 2010,
Chung 2014) include:
■ A strong family history of febrile convulsion.
■ Onset of first episode before 18 months of age.
■ Less than one hour of fever before onset of first
febrile convulsion.
■ Body temperature of less than 38°C at the onset of
febrile convulsion.

Table 2 Medicines commonly used for children with febrile convulsion who present to emergency departments

Name Dosage Administration route Frequency Maximum dosage When used

Paracetamol 15mg/kg Oral or rectal, Between four Four within 24 hours For pyrexia in
or intravenous (IV) and six hourly children with febrile
during resuscitation convulsion (FC)

Ibuprofen 5mg/kg Oral Between six Three within 24 hours For pyrexia in children
and eight hourly with FC unless they
are dehydrated

Diazepam 0.25mg/kg IV or intraosseous Second dose Only two doses of For an actively

ten minutes benzodiazepines are to convulsing child whose

0.5mg/kg Rectal
after the first be used irrespective of seizure have lasted

the agents and whether more than five minutes

Lorazepam 0.1mg/kg IV
they are administered
Midazolam 0.15-0.2mg/kg IV singly or in combination

0.5mg/kg Buccal

0.9% sodium 20ml/kg IV During resuscitation More than two doses are In children with shock,
chloride solution rarely required for example during
febrile illness due
to gastroenteritis
 (Adapted from Advanced Life Support Group 2011, British National Formulary for Children 2015)

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Febrile convulsion will recur in 4% of children for
whom no risk factor applies but in 75% of those for
Implications for practice
whom all four apply (Waruiru and Appleton 2004, Healthcare professionals can:
Sadleir and Scheffer 2007). It is important that ■ Raise suspicion of any serious pathology such
healthcare professionals provide a realistic view of the as intracranial infection.
chances of recurrence depending on the relevance of ■ Provide urgent clinical care for convulsing children.
these risk factors so that parents are fully informed and ■ Provide care for children, including monitoring
can act appropriately. their temperature and other parameters, and
make them as comfortable as possible.
Summary ■ Instigate investigations and ensure children’s airways
Febrile convulsion is the most common type of are safe if they are being moved to other parts of
childhood seizure and most children with the a hospital, such as the radiology department
condition have good prognoses, with few going on to for computed tomography scans, when they
develop long-term health problems. The diagnosis is may not have regained consciousness fully.
clinical and it is important to exclude serious ■ Reassure parents and advise them verbally and in
intracranial infections, especially after a complex information leaflets before discharge on, for example, the
febrile convulsion. Management involves symptom use of single antipyretics, fluid management and what to Online archive
control and treating the cause of the fever. do if their children have further convulsions. For related information, visit
■ Identify children who have missed immunisations and our online archive and
Healthcare professionals need to support parents, search using the keywords
encourage parents to ensure they are immunised.
who are likely to be distressed and frightened after ■ Address parental concerns if febrile convulsions
convulsions have occurred. It is essential that they have occurred after vaccinations because they may be Conflict of interest
provide guidance on, and dispel myths about, fever None declared
reluctant to immunise their children again.
management.

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