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Febrile Convulsions
Synonyms: febrile seizure, febrile fit

Definition
Febrile convulsions are seizures (fits or convulsions) occurring in children aged 6 months to 5 years, associated
with fever, without other underlying cause such as CNS infection or electrolyte imbalance. [1] There are
uncommon atypical occurrences outside this age range which nonetheless otherwise fit the definition of a febrile
convulsion.

Consensus guidelines agree that: [2]

Axillary temperature should be >37.8C; or

There is a clinical history and examination indicative of febrile seizure.

Emergency treatment of febrile seizures [3]

If the child is still convulsing or not fully alert:
Recovery position, check and maintain Airway, Breathing, Circulation.
Check blood glucose.
If still seizing >5 minutes, give rectal diazepam (this may be repeated after five minutes if
the seizure has not stopped) OR a single dose of buccal midazolam (off-licence use).

Benzylpenicillin or cefotaxime if meningococcal disease is suspected:

Suspect meningitis in any child who is systemically unwell, irritable, or was drowsy before
the seizure.
Important signs are: neck stiffness; petechial rash, photophobia; Kernig's sign; Brudzinski's
sign; bulging fontanelle; reduced level of consciousness.

Call 999/112/911 ambulance/senior help if: the seizure lasts >10 minutes after giving the first dose of
anticonvulsant medication (this includes ongoing twitching even if large jerking movements have
stopped, OR a further seizure before the child recovers consciousness); OR serious illness is
suspected.

Classification [3, 4]
Simple febrile seizures
These are generalised, tonic-clonic seizures lasting less than 15 minutes, which do not recur within 24 hours or
within the same febrile illness.

Complex febrile seizures

These have one or more of the following: [5]

Focal features at onset or during the seizure.

Duration of more than 15 minutes.
Recurrence within the same febrile illness.

Febrile status epilepticus

This is a febrile seizure lasting for longer than 30 minutes.
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NB: other types of seizure related to acute illness in children are: [1]

Febrile myoclonic seizures. [6]

Afebrile convulsions in young children with mild gastroenteritis - clusters of seizures with/without fever
over several days, in the setting of gastroenteritis. The prognosis is good.

Epidemiology [3]
Between 2% and 5% of European children have a febrile convulsion. [7]
By definition, febrile convulsions occur between 6 month and 5 years of age. There are uncommon
atypical occurrences outside this age range (particularly between 3 and 6 months old and between 5
and 6 years old) which nonetheless otherwise fit the definition of a febrile convulsion.
Most are the simple febrile seizure type. Complex febrile seizures occur in about 20% and febrile
status epilepticus in about 5%.
Susceptibility to febrile convulsions follows a multifactorial polygenic mode of inheritance with a
maternal preponderance in transmission. There is a 27% risk in a child with an affected mother and
6% with an affected father. [8]
Iron-deficiency anaemia has been suggested as being associated with febrile convulsions. However,
studies have shown both increased and decreased risk of febrile convulsions in children with iron-
deficiency anaemia compared to non-anaemic controls. [9, 10]

Aetiology [1]
The mechanisms are unknown. It is uncertain whether the degree of fever or the rate of rise of temperature is a
trigger in febrile seizures.

Genetic factors are involved: there is a family history of febrile seizures in 24%. Inheritance patterns are probably
polygenic, although in a few families a particular gene or autosomal dominant inheritance has been identified.

Causes of fever in children with febrile seizures

The vast majority are:

Viral infections
Otitis media
Tonsillitis

Other causes of fever with seizure are:

Gastroenteritis
Post-immunisation

Serious illnesses which need excluding are:

Meningitis and septicaemia.
Urinary tract infection (UTI).
Lower respiratory tract infection.
Cerebral malaria (if history is suggestive of it).

Assessment [3]
History
Including:

Eyewitness account of the seizure: conscious level prior to seizure, duration, focal or generalised,
time taken to recover and state of the child afterwards.
Symptoms of meningitis or septicaemia, such as: rapid onset of illness, abnormal behaviour or cry,
stiffness or floppiness, vomiting, (and meningism in older children). Early symptoms are: leg pains,
cold hands and feet, pallor or mottled skin. [11]
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Establish whether it was a febrile seizure. This may be difficult to decide if the seizure occurs early in
the illness. Parental perceptions of fever are valid.
Past/family history of febrile seizure or epilepsy.

Examination

Vital signs, conscious level, rash (blanching or non-blanching), fontanelle, meningism.

Look for focus of infection.

NB:

For babies and young children, clinical examination (more than history) is important in detecting
serious illness. The vital signs are informative (temperature, pulse rate, respiratory rate and effort,
capillary perfusion and oxygen saturation - compare with the normal range for the child's age). [12]
The National Institute for Health and Care Excellence (NICE) traffic light system can help assess the
likelihood of serious illness in a child with fever. [13]

When to refer urgently [3]

First febrile seizure.
Serious illness not excluded.
Previous history of febrile seizure with:
Child <18 months of age (meningitis is harder to detect in this age group).
Diagnostic uncertainty about the cause of the present seizure.
A complex seizure (as defined above - these are more likely to recur or be due to
intracranial infection compared with simple seizures).
Antibiotics taken currently/recently (in case these mask signs of meningitis).
Early review by a doctor is not possible.
Home circumstances are unsuitable.

Also, consider referral if no focus of infection is found (for a period of observation and to investigate for
UTI).

Paediatric assessment [2]

Admit and treat as meningitis if there are any alarming features:
Drowsy before seizure OR Glasgow Coma Scale (GCS) <15 at one hour after seizure.
Neck stiffness.
Petechial (non-blanching) rash.
Bulging fontanelle.

Admit and review (review within two hours by paediatric registrar, to consider lumbar puncture (LP)), if:
Under the age of 18 months.
Complex seizure.
The child has had antibiotics.
No focus of infection is found: consider admission.

Other children may go home if the child is well, the parents agree, they are able to manage the child at
home and they can promptly access medical care. (See 'Advice for parents', below).

Initial investigations [1, 2]

Initial investigations are according to the febrile illness rather than the seizure itself. These may include:

Blood tests: FBC, erythrocyte sedimentation rate (ESR), glucose, U&E, coagulation, culture.
Urine microscopy/culture if: age <18 months, complex seizure or no focus of infection found.
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LP should be considered for:
A child <12 months - LP advised unless a paediatric registrar decides against LP and will
review within two hours.
A child 12-18 months - has a low threshold for LP.
Any 'serious features' (see details relating to hospital assessment above).

Contra-indications to LP

Reduced consciousness (GCS <13 or falling consciousness level).

Septicaemic shock (poor perfusion, tachycardia, low blood pressure).
Likely invasive meningococcal disease (rapid onset of illness, haemorrhagic rash).
Signs of raised intracranial pressure (coma, abnormal posture or pupils, high blood pressure, low
pulse, papilloedema).
Focal neurology.
Bleeding tendency - known or clinically suspected.

Differential diagnosis [3]

Rigors.
Syncope.
Breath-holding spells.
Reflex anoxic seizures - a precipitant (eg, a minor bump) causes vagally mediated cardiac asystole
lasting many seconds - the child may be pale, floppy, and lose consciousness, followed by tonic and
clonic movements.
Apnoea.
Postictal fever (unlikely unless the seizure lasted >10 minutes; usually they would have a temperature
>38C).
Other cause of seizures - eg, epilepsy, head injury, encephalitis, hypoglycaemia, hypocalcaemia,
poisoning, other metabolic disorders, neurological disorders.
Afebrile seizures with gastroenteritis. [1]

Further management [3]

Children may be managed at home if:

The child looks well.

Parents understand how to treat febrile illness and further seizures, have prompt access to medical
care and are happy with this plan (see 'Advice for parents', below).
Arrange review; the timing depends on the clinical condition - early review is advisable if the cause of
fever is unclear.

Remember:

Review the child and address questions a parent may have.

Consider outpatient referral if:
An alternative cause for seizures is suspected - eg, epilepsy or a neurodevelopmental
condition.
Parental request or concerns.

Advice for parents [3]

Explanation is important, as seizures can be very frightening for parents. The following points should be covered
and a leaflet provided:

What febrile seizures are.

How to treat fever at home - remove excess clothing, give fluids, give antipyretics if the child is
uncomfortable. Tepid sponging or excessive cooling are not recommended. Check for a non-blanching
rash, check for dehydration and stay with the child at night.
First aid if the child has a fit - position; do not put anything in their mouth.
When to call 999/112/911 ambulance - a seizure lasting more than five minutes.
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When and how to seek urgent medical advice - any seizure, serious symptoms such as non-
blanching rash, lack of normal alertness, dehydration, the child getting worse, the parent worried and
fever for more than five days.

Prognosis [1, 14]

Generally the prognosis is very good:

By definition, febrile seizures do not recur beyond the age of 5 years approximately.
There is no evidence for an increased risk of death, even for children with status epilepticus. [3]
Intellect is not affected.
Febrile seizures recur in about 30%.
Risk factors for recurrence are: family history of febrile seizures, onset aged <18 months, lower
temperature or shorter duration of fever at onset.
Risk of epilepsy: 2-7% of children with febrile seizures will go on to develop epilepsy with afebrile
seizures, the risk being higher with complicated febrile convulsions. [8]

Prevention [3]
Immunisations do not appear to increase the risk of recurrent febrile seizures.
There is no evidence that antipyretics reduce the number of febrile seizures. [13]
A Cochrane review found no clinically important benefits for children with febrile seizures treated with
intermittent oral diazepam, phenytoin, phenobarbital, intermittent rectal diazepam, valproate,
pyridoxine, intermittent phenobarbital, intermittent ibuprofen or for diclofenac. [15]

Further reading & references

1. Sadleir LG, Scheffer IE; Febrile seizures. BMJ. 2007 Feb 10;334(7588):307-11.
2. Armon K, Stephenson T, MacFaul R et al.; An evidence and consensus based guideline for the management of a child
after a seizure. Emerg Med J 2003; 20:13-20
3. Febrile seizure; NICE CKS, October 2013 (UK access only)
4. Chung S; Febrile seizures. Korean J Pediatr. 2014 Sep;57(9):384-95. doi: 10.3345/kjp.2014.57.9.384. Epub 2014 Sep 30.
5. Patel AD, Vidaurre J; Complex febrile seizures: a practical guide to evaluation and treatment. J Child Neurol. 2013
Jun;28(6):762-7. doi: 10.1177/0883073813483569. Epub 2013 Apr 10.
6. Dooley JM, Hayden JD; Benign febrile myoclonus in childhood. Can J Neurol Sci. 2004 Nov;31(4):504-5.
7. Patterson JL, Carapetian SA, Hageman JR, et al; Febrile seizures. Pediatr Ann. 2013 Dec;42(12):249-54. doi:
10.3928/00904481-20131122-09.
8. Diagnosis and management of epilepsy in adults; Scottish Intercollegiate Guidelines Network - SIGN (2015)
9. Habibian N, Alipour A, Rezaianzadeh A; Association between Iron DeficiencyAnemia and Febrile Convulsion in 3- to 60-
Month-Old Children: ASystematic Review and Meta-Analysis. Iran J Med Sci. 2014 Nov;39(6):496-505.
10. Yousefichaijan P, Eghbali A, Rafeie M, et al; The relationship between iron deficiency anemia and simple febrile convulsion
in children. J Pediatr Neurosci. 2014 May;9(2):110-4. doi: 10.4103/1817-1745.139276.
11. Thompson MJ, Ninis N, Perera R, et al; Clinical recognition of meningococcal disease in children and adolescents.
Lancet. 2006 Feb 4;367(9508):397-403.
12. Davies F; Paediatric health: Recognising the sick child, Electronic Doctor
13. Feverish illness in children - Assessment and initial management in children younger than 5 years; NICE Guideline (May
2013)
14. Graves RC, Oehler K, Tingle LE; Febrile seizures: risks, evaluation, and prognosis. Am Fam Physician. 2012 Jan
15;85(2):149-53.
15. Offringa M, Newton R; Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev. 2012
Apr 18;4:CD003031. doi: 10.1002/14651858.CD003031.pub2.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Huw Thomas Dr Colin Tidy Dr Adrian Bonsall
Document ID: Last Checked: Next Review:
1149 (v27) 25/06/2015 23/06/2020
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