This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with a suspected febrile seizure in Queensland.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Paediatric Neurology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Febrile seizures are a frequent ED presentation and the most common seizure disorder in children.1 They occur in 3% of healthy children, mostly between the ages of six months and six years. The peak incidence of febrile seizures is between 12-18 months of age.2
Most febrile seizures are brief, isolated, generalised tonic-clonic seizures that occur with an acute febrile illness in children with no history of afebrile seizures, known neurological abnormality, or evidence to suggest infection or metabolic disturbance.1
Simple febrile seizures are not associated with an increased risk of neurological or cognitive impairments.3
The estimated overall febrile seizure recurrence rate is 30-35%4 with 10% of children experiencing three or more seizures.5
Risk factors for recurrent febrile seizures include:
Most children who experience a febrile seizure will not develop epilepsy later in life.1
Seizure risk factors for developing subsequent epilepsy include:
The number or type of risk factor increases the chance of developing epilepsy:
| Simple febrile seizure | Complex febrile seizure | Febrile Status Epilepticus | Benign seizure associated with gastroenteritis7 |
|---|---|---|---|
Fever and ALL of the following:
|
Fever and ANY of the following:
|
Fever and All of the following:
|
A febrile seizure in the following:
|
The aim of the assessment is to:
Prior to diagnosing a simple febrile seizure in a child aged outside of six months to six years, carefully consider and exclude alternative diagnoses.
Febrile seizures are extremely distressing to the care giver and other witnesses so be aware of the likely parental anxiety at the time of presentation.
Questioning to differentiate simple febrile seizures from other seizures should include:
The examination should be directed by the history, with particular emphasis on:
Investigations are not routinely required for simple febrile seizures providing the child is aged between six months and six years, makes a full recovery to normal self and the focus of infection can be identified. Investigations in this group of children should be directed by the suspected underlying cause of infection (see Febrile illness guideline) rather than the febrile seizure itself dictating investigation.
The following investigations are NOT routinely recommended if the child is otherwise well:
Refer to the Meningitis guideline for the indications for a lumbar puncture in a child with suspected meningitis. Research has shown fully immunised children aged 6 to 18 months who present after a febrile seizure and are clinically well with no prior antibiotic treatment are at a very low risk of bacterial meningitis.13,14
Any febrile seizure that has a focal component, is prolonged (more than 15 minutes), or results in a slow return to normal conscious state should prompt investigation into underlying infection. A focal component to the seizure, or any focal neurological findings, should prompt consideration of CNS infection or structural abnormality.
| Investigation type | Indications |
|---|---|
| Full blood count (FBC) |
|
| Serum biochemistry |
|
| Urine MCS |
|
| Lumbar puncture (LP) |
|
| EEG |
|
| Neuroimaging |
|
A seizure for longer than five minutes is a medical emergency. Refer to the Status epilepticus guideline for management.
Seek senior emergency/paediatric advice for all children with a complex febrile seizure.
Management of children following a febrile seizure will be dictated by the source of the fever. Refer to the Febrile illness guideline for guidance on the management of febrile children with no focus of infection evident on initial assessment.
Ibuprofen and/or Paracetamol may alleviate discomfort in a febrile child. There is current research being conducted into antipyretics in the prevention of the recurrence of simple febrile seizures during the same fever episode but they have no role in preventing febrile seizure during distant fever episodes.17
Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.
Refer to the Status epilepticus guideline for the recommended management of child with a seizure lasting more than five minutes.
| Advice may be required for the following children: |
|---|
|
| Reason for contact | Who to contact |
|---|---|
Advice | Follow local practices. Options:
|
| Referral | First point of call is the onsite/local paediatric service |
| Do I need a critical transfer? |
|
| Request a non-critical inter-hospital transfer |
|
| Non-critical transfer forms |
|
Discharge will be based on the source of the infection and the management required. There is no evidence for a prescribed minimum duration of observation following a febrile seizure.
Consider discharge for a child who meets the following criteria:
Prior to discharge, parent/s should receive education regarding:
On discharge, parent/s should be provided with a Febrile seizures factsheet
The requirement for admission will be based on the management of the underlying infectious disease.
The decision to admit a child with complex febrile seizures or status epilepticus will be made by the specialist referral team based on the further investigations and management required.
Consider consultation with inpatient team when:
Consider admission to an SSU for a child following a febrile seizure for prolonged observation if ongoing parental anxiety or inappropriate community setting (i.e. middle of the night, transport not available).