Febrile children are a common presentation to health-care services with febrile convulsions being a relatively frequent call to the ambulance service. Traditionally paramedics have felt less comfortable in the assessment and management of paediatrics, especially in nonconveyances and discharging on scene.
Febrile convulsions are convulsions occurring in children aged six months to six years presenting with a fever above 38oC but without any signs of central nervous system infection (AAoP, 2011). Most commonly they occur between six months and three years of age with a peak occurrence of 18 months (Paul et al, 2015). Any diagnosis of a febrile convulsion made in a child aged over six years old should be made with extreme caution. Febrile convulsions are the most common cause of convulsion within paediatrics (Paul et al, 2012).
Febrile convulsions occur within all ethnicities; within the Caucasian population 2–5% of children will suffer from a febrile convulsion. Other ethnic groups have an increased risk compared to Caucasians with 5–10% of Indian children and 14% of children from Guam suffering febrile convulsions (Paul et al, 2015).
There is a strong familial link with 25–40% of children presenting with febrile convulsions having a family history of febrile convulsions. A family history of epilepsy also increases the risk (Paul et al, 2012; Paul et al, 2015). The presence of anaemia or neurological conditions, such as cerebral palsy, also increases the risk of febrile convulsions. However it should be noted that around 50% of children presenting with febrile convulsions do not have any risk factors (Paul et al, 2012).
Types of febrile convulsions
There are two types of febrile convulsions:
When assessing the child it is important to ascertain the nature, length and presentation of the convulsion as this enables the classification of febrile convulsion to be made (Table 1). The type of convulsion the child presented with dictates the clinical pathway.
| Simple febrile convulsion | Complex febrile convulsion |
|---|---|
| Generalised tonic-clonic convulsion |
Focal convulsion |
The duration of a simple febrile convulsion within the literature varies between ten minutes (Paul et al, 2015) to 20 minutes (Trainor et al, 2001). The guidelines by the American Academy of Pediatricians (2011) and NICE (2013a) suggest 15 minutes as the cut-off time, which is more accepted.
Simple febrile convulsions are the most common form, making up approximately 70% of diagnoses (Paul et al, 2015). Of the complex convulsions 67% of children have multiple convulsions within 24 hours with 16% having focal convulsions and 35% having prolonged convulsions (Seltz et al, 2009).
Assessment
The goal of assessing a child post suspected febrile convulsion is to determine the possible source of infection (NICE, 2013a). It's important to undertake a thorough history taking and physical examination.
Within the history taking it is important to ascertain the type of febrile convulsion that the patient presented with as well as any fever trajectory and symptoms reported. The presence of any fever, parental perception of fever and previous administration of antipyretics (paracetamol and ibuprofen) should be noted. The patient may have been given antipyretics prior to ambulance arrival and therefore be apyrexic on examination. The majority of children will have a history of fever before or shortly after the febrile convulsion (Paul et al, 2015).
Any febrile child should receive a holistic assessment utilising the ABCDE approach, supported by a full set of observations. Within the observations it is important to remember that the pulse rate increases by 10 beats per minute per 1oC temperature increase, so a pyrexic child may be slightly tachycardic (AACE, 2013). It is essential to record blood sugar and assess the child using the traffic light system within ‘Fever in under 5s: assessment and initial Management’(NICE, 2013b) to identify any amber or red flags.
The systematic physical examination, including exposure to skin, also enables the identification of red flags and elimination of more serious causes. The absence of meningeal signs, neck stiffness, non-blanching rashes and bulging fontanelles are important to exclude central nervous system infections as the cause (NICE, 2013a).
Simple infections (Table 2) are the major causes of febrile convulsions. The two most common causative infections are otitis media (34%) and Upper Respiratory Tract Infection (URTI) (12%). Within 34% of patients no cause is identified (Trainor et al, 2001). In the case of some common causes such as otitis media, URTI and urinary tract infection the assessment techniques such as otoscopy, throat examination and urinalysis fall outside the standard paramedic scope of practice (Mason et al, 2008). Where the clinician does not have the competencies they should be referred to other health care professionals or specialist paramedics for further assessment.
| Common causes of febrile convulsions |
|---|
| Middle ear infection – otitis media (34%) |
Diagnosis & differential diagnoses
When formulating a working diagnosis it is important to exclude the differential diagnoses for the convulsion. The most common differentials causing convulsions are meningitis, encephalitis, metabolic disorders (including hypoglycaemia), neurological and afebrile causes (Seltz et al, 2009; NICE, 2013a). Other differentials include rigors, febrile syncope, breath holding attacks, evolving epilepsy syndrome and febrile delirium (Paul et al, 2015). The majority of these differentials can again be excluded through a thorough history taking and physical examination.
In most cases the history may indicate a febrile convulsion and when combined with a systematic assessment, the diagnosis can be confirmed.
Trainor et al (2001) and Guedj et al (2015) showed the risk of children who present with simple febrile convulsions having meningitis as the cause, is low without the presence of meningococcal signs and symptoms. Within children presenting with complex febrile convulsions the risk of meningitis is also low at 1.5% (Seltz et al, 2009). Where patients have had a diagnosis of meningitis or encephalitis, they presented with the signs and symptoms of these illnesses in addition to any febrile convulsions (Trainor et al, 2001; Guedj et al, 2015).
Management
The management of children presenting with febrile convulsions is based upon the classification of the febrile convulsion in addition to the presence of any red flags (NICE, 2013a). To aid the pre-hospital management of these patients the author developed the following pre-hospital management flowchart (Figure 1) to aid clinical decision making.
Child still fitting
With the child who is still fitting it is important to utilise an ABCDE approach and manage the child accordingly. Any child fitting for longer than five minutes should be treated with diazepam (AACE, 2013).
Hospital-based assessment
Within the pre-hospital environment, traditionally patients presenting with a febrile convulsion were taken into hospital. It is however unusual for patients presenting with a simple febrile convulsion to be admitted into the hospital (Paul et al, 2015). As such only patients presenting with certain red flags (Table 3) need to be assessed within the hospital.
| First febrile convulsion or second convulsion where the patient was not assessed by a health-care professional on initial convulsion |
Where a patient has had a simple febrile convulsion and previously suffered from them, unless there has been a febrile convulsion within the previous 24 hours there is no requirement for hospital assessment.
Therefore paramedics do not necessarily need to take all febrile convulsions into hospital and some can be managed within the community. As long as the patient has a simple febrile convulsion, has recovered to their normal self and there are no indicators for hospital assessment (Table 3) then the patient can be managed at home within the community.
When a patient does not necessarily require hospital admission (NICE, 2013a), a holistic assessment should still take priority. The presence of multiple amber or any red flags suggest the child is acutely unwell and should still be assessed within the hospital (NICE, 2013b).
In children who require hospital assessment but have fully recovered from a febrile convulsion, they do not necessarily require paramedic conveyance (Brodsky et al, 2009). In these cases alternative conveyances could be utilised, such as being transported by parents where the parents are safe to drive and not too distressed. If they require an ambulance conveyance as parental conveyance is not appropriate or possible the patient could be safely conveyed to hospital by a technician crew with appropriate worsening advice.
Discharging on scene
Where a child is diagnosed with a simple febrile convulsion and does not require hospital admission it is safe and appropriate to discharge on scene. When a child is being discharged on scene it is important to make direct onward referral to specialist paramedics or GPs where appropriate. This needs to be a clinician to clinician discussion rather than asking parents to contact them. In the case of a further referral and examination not being required it is advisable to inform the GP through the local alerting system of the febrile convulsion so they are aware.
Parents are often very distressed following a febrile convulsion as many thought that their child was going to die and therefore it is important to have an empathetic approach to the discharge (Paul et al, 2015). It is essential when discharged on scene that parents are given written advice as they are unlikely to retain all aspects of verbal information received.
Thorough and comprehensive worsening advice for parents around keeping the patient hydrated, appropriate use of paracetamol and ibuprofen and what to do in the case of further convulsions is essential in community management (NICE 2013a; 2013b;Paul et al, 2015).
Writing ‘if child worsens dial 999’ or something to that effect is not acceptable. The worsening advice needs to be explicit with clear signs to look out for and an expected trajectory.
For example, if a fever lasts more than five consecutive days they need to see the GP (suspected Kawasaki disease) (NICE, 2013b). Key aspects of the worsening advice include:
| Red flags to be given to parents | |
|---|---|
|
999
|
GP
|
It is important to explain to the parents that while routine use of paracetamol and ibuprofen does not prevent further febrile convulsions, their use should be encouraged if the child is distressed or unwell child who is not appearing their normal self (NICE, 2013b). Ibuprofen should be avoided in cases of suspected dehydration. The use of cold sponging or placing a fan on the child should also be avoided (Woollard and Pitt, 2003; NICE, 2013a; Paul et al, 2015). Despite this the routine use of paracetamol and ibuprofen to relieve temperature still occurs within healthcare.
Many parents will be worried that their child is going to develop epilepsy as they have had a convulsion. This is an area where the paramedic is able to provide education and reassure the parents. The prognosis for children with febrile convulsions is good; the majority only have one self-limiting convulsion with no significant neurological impairment. A third of children will have a further febrile convulsion during their childhood (Paul et al, 2015). Following a simple convulsion there is a 6.7% risk of developing epilepsy compared to a 1.2% background risk (Neligan et al, 2012). With a complex convulsion this risk increases to 10–20% (Paul et al, 2015).
Conclusion
Febrile convulsions are relatively common and the majority of children suffering from them will have simple febrile convulsions and no long term neurological deficit. These patients do not necessarily need transporting to the hospital and can be safely managed within the community. These patients have a very small risk of having a serious bacterial infection and the chance of developing epilepsy is only slightly higher than the background population.