Recognition and management of
febrile convulsions in children
Frances Alexandria Kavanagh, Paul Anthony Heaton, Anna Cannon
and Siba Prosad Paul
ABSTRACT
Febrile convulsions (FCs) are characterised by convulsions associated with fever
in children aged between 6 months and 6 years. FCs are relatively common and
affect 3–4% of children in western countries. This is the most common seizure
disorder seen in children. The cause of febrile illness in FC is usually benign and
most frequently due to acute viral infection. Convulsions secondary to an
intracranial infection (e.g. meningitis, encephalitis) or from acute electrolyte
imbalance should not be labelled as FCs. The diagnosis
is based mainly on clinical history, and further investigations are generally
unnecessary; management is largely symptomatic. Prolonged FC may need
anticonvulsant medication to stop the seizure. Referral to paediatric neurologists
may be considered in cases of complex or recurrent FC or in children where
there is a pre-existing neurological disorder. One third of children with a first FC
will develop a further FC during subsequent febrile illness; the likelihood
increases in presence of other risk factors. This article outlines the presentation,
management, investigations and prognosis for FC, and highlights how nurses in
different clinical settings can provide education, support and counselling to help
families return to normality after the event. An illustrative case study is also
included to highlight the challenges faced by health professionals while
managing children with this condition.
Key words: Febrile convulsions  ■ Fever phobia ■ Extracranial infections
■ Anticonvulsants ■ Viral infections
A
febrile convulsion (FC) has been defined as
convulsion associated with fever, caused by
infection or inflammation outside of the central
nervous system (CNS), in a young child who is
otherwise neurologically normal’ (National
Institute for Health and Care Excellence (NICE), 2013).
Meningitis and encephalitis may also cause convulsions and
fever, but these should not be labelled as FCs by convention
(NICE, 2013).
Frances Alexandria Kavanagh, Trainee Physician Associate,
Peninsula College of Medicine and Dentistry, Plymouth
Paul Anthony Heaton, Consultant Paediatrician, Yeovil
District Hospital
Anna Cannon, Matron in Paediatrics, Yeovil District Hospital
Siba Prosad Paul, Consultant Paediatrician, Torbay Hospital,
Torquay, siba@doctors.org.uk
Accepted for publication: October 2018
1156
FC is the most common reason for a child to present with
seizures to a health professional. In 2016–17, the UK saw
11 760 inpatient admission episodes related to FC
(Secondary Care Analysis, NHS Digital, personal
communication). These sudden unexpected convulsive
episodes in young children, or simply the fear of one, can
be distressing for both parents and health professionals; it
may lead to overzealous attempts to reduce the child’s
temperature and result in ‘fever phobia’ (Banks et al, 2013).
This article discusses the pathophysiology, presentation, and
management, and addresses the most common parental
questions regarding FC. An illustrative case study is also
included to highlight some of the challenges that health
professionals may encounter while managing a child with FC.
Epidemiology
Febrile convulsions are the most commonly encountered
childhood convulsions: they occur mostly between the ages
of 6 months and 6 years, with a peak incidence in children
aged 18 months (Paul and Eaton, 2013). About 6–15% occur
after 4 years of age, onset after the age of 5 years is unusual,
and the first FC should be diagnosed with caution in children
aged over 5 years (Paul and Chinthapalli, 2013). Some 9–35%
of first FCs are complex, in the sense that they are prolonged,
focal or recurrent (Waruiru and Appleton, 2004). Febrile status
epilepticus occurs in 5% of children who have FCs and is more
‘a
likely to be associated with focal features (Paul and Chinthapalli,
2013).
Although FCs are known to affect all ethnic groups the
incidence varies. The cumulative incidence of FC is estimated
to be between 2–5% in children from the USA and Western
Europe, between 6–9% in Japan and around 10% in children
of Indian ethnicity. The highest incidence is recorded at 14%
among children of the Chamorro population of Guam in the
Western Pacific (Waruiru and Appleton, 2004).
The cause of an FC is usually secondary to a febrile episode.
It is associated with either a viral or bacterial infection of extra-
cranial origin: the most common types are viral infections of
the upper respiratory tract and common childhood infections
due to herpes and other viruses; they also include bacterial
Ltd
upper and lower respiratory tract infections, and gastroenteritis
Healthcare
(Paul and Eaton, 2013). It is important that health professionals
remain aware of the high risk groups of children who are more
MA
likely to develop FC either from increased exposure or increased
© 2018
susceptibility to infections (Box 1).
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 CLINICAL

Box 1. Risk factors for febrile convulsions Table 1. How to differentiate between simple and complex febrile convulsions
■ Developmental delay Feature Simple febrile convulsions (FCs) Complex FCs

■ Discharge from a neonatal unit after 28 days Duration Short (less than 15 minutes) Longer (more than 15  minutes)

■ Day-care attendance Frequency Around 70% of all FCs Around 30% of all FCs

■ Family history of febrile convulsions Focal Generalised tonic-clonic seizures, Focal convulsion with or without
features no focal features secondary generalisation may be
■ Older siblings with infections observed
■ Iron and zinc deficiencies Recurrence No recurrence within 24 hours May present with recurrence of
Source: Graves et al, 2012 convulsive episodes during next
24 hours of the first one. Each
Pathophysiology episode may, however, be of short
duration i.e. 15 minutes or less
Fever is a normal physiological response to an infective or
inflammatory process. It has a beneficial role in fighting Postictal No postictal pathology or residual Todd’s paresis may be present (a
infections and provides a natural defence mechanism (Banks et gestures weakness period of paresis of affected limbs)
al, 2013).The exact cause of FC remains unknown; causation is Source: Paul et al, 2012
thought to be multifactorial and most likely due to a complex
interplay between environmental and genetic factors. In some Box 2. Red flags suggestive of central nervous system infection
children, high levels of cytokines are released during fever, ■ History of irritability, decreased feeding, or lethargy
which may temporarily cause abnormal electrical activity in
the brain, triggering an FC (Waruiru and Appleton, 2004; Paul ■ Complex febrile convulsions
and Chinthapalli, 2013). ■ Any physical signs of meningitis or encephalitis (neck stiffness, bulging fontanelle,
The precise mode of genetic inheritance is unknown, and photophobia, focal neurological signs)
polygenic inheritance is the most likely mechanism (Lux, ■ Drowsiness with limited response to social cues (lasting more than 1 hour)
2010). ‘FC susceptibility trait’ has been identified as an
autosomal-dominant pattern of inheritance in a small ■ Prolonged neurological deficit or postictal altered consciousness (more than 1 hour)
after the episode of convulsion stopped
number of families; associated receptors are also seen in
severe myoclonic epilepsy of infancy, which initially ■ Incomplete immunisation uptake in children
presents with prolonged fever and subsequent convulsions NB In young children (aged less than 12 months), classical signs of meningitis may
precipitated by fever (Mewasingh, 2014). be absent, and assessment by a senior paediatrician is necessary
Source: Najaf-Zadeh et al, 2013
Clinical presentation and types
FCs can manifest as tonic-clonic (tonic: muscles become tense Box 3. Differential diagnosis for febrile convulsions
and the body feels rigid; clonic: muscles contract and relax
rapidly causing convulsions), tonic or atonic convulsions (brief ■ Delirium or rigors
loss of muscle tone with the body becoming floppy) (Paul et al, ■ Kawasaki disease, vasculitis and other rheumatological conditions
2012). Fevers can occur at any time: before, during or
■ Central nervous system infections, e.g. meningitis, encephalitis
sometimes after the convulsion (Kool et al, 2013). FCs are
usually divided into simple and complex. Table 1 highlights ■ First presentation of epilepsy (Dravet syndrome, which often starts as febrile
how to differentiate between them. convulsion-like episodes)
The possibility of central nervous system (CNS) infection in ■ Reflex anoxic seizures
any febrile child with a convulsion should be considered, as it can
■ Breath-holding episodes
also be the only presentation of bacterial meningitis (Kneen and
Appleton, 2005). The incidence of bacterial meningitis has ■ Other infectious conditions
substantially reduced since the introduction of vaccines for Source: National Institute for Health and Care Excellence, 2013; Paul et al, 2013
Haemophilus influenzae type b, Neisseria meningitidis and
Streptococcus pneumoniae. A systematic review that included 14 Management
studies involving 4583 children concluded that there was a 0.2% Children should be promptly evaluated after an episode of FC. On
average risk of bacterial meningitis in those with an apparent first initial presentation, a child may need emergency stabilisation
simple FC and a 0.6% risk in children with complex FCs (Najaf- using the ABCDE (Airway, Breathing, Circulation, Disability,
Zadeh et al, 2013). Exposure) approach. Children with FCs are usually brought for
© 2018 MA Healthcare Ltd

Clinical judgement, a detailed history (including
immunisation history), an awareness of red flag features (Box
2) and a thorough clinical examination can all help exclude
serious causes (e.g. bacterial meningitis, encephalitis, etc.) It is
also important to consider other differential diagnoses (Box 3).
consultation after resolution of the convulsion and it is vital to
undertake a thorough assessment to identify the source of infection
(Hampers and Spina, 2011). Every child should be referred for
secondary care assessment following their first episode of FC to
exclude other possible differentials (Box 3) especially

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 Box 4. Seeking specialist opinion Table 3. Paediatric temperature variations with site of
■ First ever febrile convulsions (FCs) measurement

■ Complex FCs Measurement method Normal temperature range (°C)

■ Cause of fever remains unidentified or unexplained by the pathology elicited Rectal 36.6–38.0

■ Having a decreased consciousness level before the convulsion (recording the Ear 35.8–38.0
paediatric Glasgow Coma Scale or the AVPU (Alert, Voice, Pain, Unresponsive) score is Oral 35.5–37.5
suggested, as these are objective measurements)
Axillary 36.5–37.5
■ Focal neurological deficit identified on examination
Source: Canadian Paediatric Society, 2015
■ Abnormal behaviour or drowsiness after the convulsion, with a slow recovery (if
normal neurological or mental state not achieved within 1 hour) in infants aged less than 1 year (Lux, 2010). Box 4 highlights
■ Signs or symptoms of meningitis (irritability, photophobia, headache, neck stiffness) situations where specialist paediatric opinion should be sought.

■ Features of septicaemia and unwell child History

Source: Patel et al, 2015 A detailed history needs to be taken to establish whether it is
an episode of FC or the onset of epilepsy (NICE, 2018). It is
Box 5. Information to elicit from families of children presenting with febrile important to undertake another assessment once the child
convulsions
has stabilised; health professionals should explore a range of
■ Duration of febrile convulsions (FCs) issues with the parents as part of diagnosis (Box 5).
■ Prolonged postictal phases or presence of focal symptoms
Examination
■ Any rescue medications needed to terminate the episode (either by paramedics or A full head-to-toe physical examination (provided that the child is
the parents)
stable) should be undertaken by an experienced health
■ Family or previous personal history of FC professional, paying particular attention to physiological vital
signs and the child’s behaviour during the assessment. Table 2 and
■ Immunisation status of the child
Table 3 set out the ranges for normal physiological vital signs and
■ Recent foreign travel temperatures.The patient may be noted to be drowsy from
■ Recent systemic infections anticonvulsant medication administered by the emergency
responders. Any significant rashes (especially non-blanching
■ Recent antibiotic usage
petechial or purpuric rashes) that may be associated with invasive
■ Ongoing health conditions, especially neurological conditions such as cerebral palsy meningococcal disease should be noted and addressed (Barnetson
or unexplained neurodisability et al, 2016). It is essential to identify the presence of any red flag
■ Child’s food and fluid intake signs (Box 2).

Urine output and bowel opening, including diarrhoea

■
Investigations
■ Explore and consider parental concerns, e.g. ‘something is wrong’ Children presenting with a simple FC and with a clear source of
Source: Paul et al, 2012; Printz et al, 2016 infection identified may not need any investigations. However,
basic investigations (including blood glucose, full blood count,
Table 2. Normal vital parameters in children electrolytes, C-reactive protein, blood culture and urine dipstick
and culture) may be considered in children who are at the extremes
Age Weight (kg) Respiratory rate Heart rate (beats of age for developing the first episode of FC or where the source of
at rest (breaths per minute; infection has not been identified. Specialist investigations such as
Boys Girls EEG, CT/MRI scan of the brain should be reserved for episodes of
per minute; 5th–95th centile) complex FCs with focal features, where recurrence is frequent or in
5th–95th centile) children where epilepsy or an evolving neurodisability is suspected.
6 months 8 7
Lumbar puncture should be considered if meningitis is suspected
20–40 110–160
and undertaken when the child is clinically stable and has no signs
12 months 9.5 9
of raised intracranial pressure (Paul and Chinthapalli 2013; Printz
et al, 2016).
18 months 11 10 20–35 100–155

2 years 12 12 100–150 Treatment

Ltd

In most cases of FC the seizure will have terminated prior

Healthcare

3 years 14 14 90–140

4 years 16 16 20–30 80–135 to presentation at a healthcare facility. When the first FC has
5 years 18 18 occurred, observation for a few hours may be appropriate
MA

6 years 21 20 80–130 (not necessarily as an inpatient). The few children who are
© 2018

Source: Samuels and Wieteska, 2016 still convulsing at presentation will need stabilisation using the

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ABCDE approach and may need administration of appropriate
anticonvulsants such as benzodiazepines as per the advanced
paediatric life support (APLS) protocol (Samuels and Wieteska,
2016). Staff across all specialties will often experience an element
of panic when dealing with FCs in children, the consequence of
which can often be overaggressive and/or harmful management
with antipyretics or other measures to reduce fever. The use of
benzodiazepines is essential in stopping a prolonged seizure; a
common side effect of these medications is heavy sedation and
respiratory depression even when the correct doses are used.
Once the child is stabilised, appropriate management of
any specific pathology that has been identified is necessary
(e.g. fluids and antipyretics for gastroenteritis, antibiotics
for pneumonia, urinary tract infection or tonsillitis). If
further episodes of FC occur during the same inpatient stay,
these should be managed by appropriate anticonvulsant
medicines and other supportive care. The criteria for
considering admission are akin to that of any febrile child
or in whom a diagnosis of complex FC has been made.
A Korean simulation-based fever management module for
children with FC was found to be useful in educating nurses
about the condition; it involved 147 senior nursing students
being trained in the following debriefing categories: non-
technical skills, self-efficacy, critical thinking, and technical
skills (Kim et al, 2014). Such simulation-based training may
improve overall management of the condition.
Considering how common FCs are in clinical practice, nurses
working across different clinical environments have an important
role to play in identifying and managing affected children (Table
4). It is important to note that nurses who have prolonged contact
with families will often have more time to listen to parents about
their fears and expectations regarding treatment.They therefore
have a vital role in communicating parents’ feelings to medical
colleagues and advocating for the family if necessary.
Prognosis
Simple FCs usually have a good prognosis and children do not
experience any long-term complications. There is a one third
risk of having further FCs while in the vulnerable age range,
and the risk factors are listed in Box 6. Exact mortality from
FC remains difficult to measure accurately because it is rarely
a consequence. A large Danish epidemiological study
involving 1 675 643 children born between 1977 and 2004
found a slight increase in mortality in the 2 years following a
complex FC (adjusted mortality rate ratio 1.99 [95% CI 1.24-
3.21]), but no significant increase following a simple FC
(adjusted mortality rate ratio 1.09 [95% CI 0.72-1.64])
(Vestergaard et al, 2008). It is rare to die from an FC, although
there may be specific cases in which phenytoin can cause
arrhythmia—a well-known side effect—which is why this
medication is administered while the patient is on a cardiac
monitor. Accidental overdose with phenytoin has proved fatal
© 2018 MA Healthcare Ltd
in some cases in the UK (Evans 2012; Powell, 2017; Parveen,
2018).
Addressing parental concerns
An episode of FC may make parents extremely anxious and
they may want to discuss a number of issues with the health
CLINICAL
Table 4. The role of nurses in different settings
Specialist area Role
Health visitors ■■ Provide knowledge, address parental fears and dispel myths
about febrile convulsion (FC) (educating about the beneficial role
of fever in illness and rationale for using antipyretic agents)
■■ Provide education: written, oral and through support groups
■■ Safety net advice and inform about signs of deterioration and when
to seek further medical help (awareness of red flag signs)
■■ Record advice given in the child’s ‘red book’
■■ Consider the child’s home environment and location; whether
parents would be able to monitor the child closely overnight after
an episode of FC
Practice nurses ■■ Encourage uptake of immunisations
■■ Immediate stabilisation of a child having an episode of FC, or
appropriate referral to secondary care using the National Institute
for Health and Care Excellence traffic light system
■■ Identify
immigrant or children new to the area who may have had
a complex FC and have other ongoing medical needs
Emergency ■■ Depending on the scenario, immediate stablisation in a fitting
department child and/or record vital signs, such as temperature, heart rate,
nurses respiratory rate and capillary refill time
■■ Some nurses in advanced practitioner roles will be managing and
examining children, and may consider referral to paediatric services
Epilepsy ■■ Epilepsy nurses will provide support but would refer for EEG only
specialist if epilepsy is suspected
nurses
■■ Home visits and teaching how to use rescue anticonvulsant
medications
■■ Willget involved in only a few cases: complex consultations, a
suspicion of epilepsy or recurrence of seizures
Paediatric ■■ Acute management of pathologies causing the febrile episode
nurses
■■ Suggestion for, and administration of, antibiotics, if appropriate
■■ Head-to-toe assessment of child and regular monitoring while an
inpatient on the ward
■■ Educate parents and carers about what to do if the child has a
further FC: ensure the child is in a safe place, and place in the
recovery position. Call the emergency services and do not insert
anything in the child’s mouth. Loosen tight clothing around the neck
■■ Reassure parents of the benign nature of FCs and that they are
not epilepsy
Source: Gupta, 2011; Paul et al, 2012; Banks et al, 2013; National Institute for Health and Care
Excellence, 2017; 2018
Box 6. Risk factors for recurrent febrile convulsions
■ Onset of first febrile convulsion (FC) at the age of less than 18 months
■ Lower body temperature (less than 38°C) at onset of seizure
■ Shorter duration of fever (less than 1 h) before onset of seizure
■ A strong family history of FCs
■ History of other co-existing neurological condition
Source: Waruiru and Appleton, 2004; Jones and Jacobsen, 2007
 British Journal of Nursing, 2018, Vol 27, No 20
Box 7. Case study
A 16-month-old previously fit and healthy boy, who was reported to be fully immunised,
presented with a 4-minute history of generalised tonic-clonic seizure involving all four
limbs. He was found to be slightly hot at the time of the episode and was unresponsive
for a further 8 minutes when the seizures stopped on their own. He was slightly coryzal
and had had a cough for the preceding 2 days.
Assessment by the emergency nurse practitioner (ENP) revealed a quiet child who was
playing with his mother’s phone and who was responding appropriately to parents. His
vital observations were: temperature 39.3°C, pulse rate 164/min, respiratory rate
34/min, capillary refill time <2 seconds (central), saturations 98% in air and bedside
blood glucose measurement 5.6 mmol/l. He was alert on the AVPU (Alert, Voice, Pain,
Unresponsive) scale and had a paediatric Glasgow Coma Scale score of 15/15.
Tonsillitis with pus points was identified as the source of infection. Simple febrile
convulsions (FCs) secondary to tonsillitis were diagnosed and a plan made to discharge
him after 6 hours of observation in the short-stay paediatric unit.
The parents had migrated to the UK 3 years previously from Eastern Europe and had an older
daughter, aged 7 years. She had had a similar episode at the age of 2 years and had had
blood investigations, an EEG and a CT scan of the brain. Her diagnosis had been a simple
FC, and the family were given a dose of diazepam to be administered rectally if a future
episode occurred. However, she did not have further episodes. The parents expressed the
desire for a similar management strategy for their son.
Before he was transferred to the paediatric unit, the ENP took time to listen to his
parents about their fears around FC and their expectations regarding treatment. She
communicated their expectations to the paediatric consultant, who reiterated the
nurse’s reassurances, suggesting a throat swab and starting on oral penicillin, with
overnight admission to support the distressed parents and monitor the child. The family
were provided with an explanation about simple FC, reassured that their son was
generally well but had tonsillitis, and it was explained to them why the child would not
benefit from further investigations such as EEG, CT scan or blood tests.
The boy remained well overnight with no further seizures. At discharge the next day,
the parents were given a leaflet about FC by the paediatric nurse and told what to do if
the child were to have another FC, and management of fever in the future. The
paediatric nurse in the unit explained the need to complete the 10-day course of oral
antibiotics and to return for assessment if needed (for example, if the FC recurred
again, the child became more unwell or newer symptoms developed). The epilepsy
nurse specialist followed up the child’s the progress via telephone consultations over
the next year and then discharged the child to the GP.
professionals. The most common scenarios that cause anxiety
for parents are discussed below, and appropriate explanation
and reassurance need to be provided. Some concerns may be
related directly to fever phobia, parents’ previous experiences
or they may have read/heard something in the press/media.
They may have concerns about their child potentially suffering
brain damage or have different expectations if they have had
experience of a different healthcare system. The case study
(Box 7) highlights some of these challenges and shows how
nurses can help families during periods of anxiety and distress.
It is crucial to acknowledge that for parents an episode of FC,
particularly if it is the first, can be extremely distressing and/or
frightening, and they may need to be reassured that their child will
not die from the condition (Martinos et al, 2012). Advice should be
given regarding the condition being relatively common and that
occurrence diminishes with age and resolves by 6 years of age.
Information leaflets will aid recall and given the 1 in 3 risk of
recurrence, home care information is important and is a NICE
(2013) recommendation (Box 8).
Risk of recurrence
Parents should be informed that there is a 1 in 3 risk of
recurrence, as shown by several cohort studies, and 75% of
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recurrences occur within 1 year of the first convulsion (Waruiru
and Appleton, 2004; Lux, 2010). Risk factors for recurrence are
listed in Box 6, and children with all these risk factors have up
to an 80% chance of having further episodes, whereas those
with none of the risk factors have only a 4% chance of having
further FCs (Jones and Jacobsen, 2007; Paul et al, 2012).
Although most parents are usually advised of the one third risk
of recurrence, children considered to be at higher risk may need
special consideration, and adequate planning for future clinical
care should be made at discharge.
Risk of developmental delay
Parents should be reassured that children without underlying
developmental problems do not have lasting neurologic effects from
FCs (Lux, 2010). A population-based study in the UK involving 381
children with FCs reported that those with FCs perform as well as their
peers academically, intellectually, and behaviourally when assessed at
10 years of age (Verity et al, 1998).
Recurrent FCs have been shown to have an increased risk
of delayed language development and recognition memory
impairment, suggesting that the latter may be a consequence
of prolonged FCs (Martinos et al, 2012).Appropriate
developmental care support should be put in place in
selective cases where there may be concerns.
Parental request for neuroimaging
Children who have recurrent FCs, prolonged postictal
neurological deficits, and those with developmental
impairment or signs of a neurocutaneous syndrome should
be considered for neuroimaging. EEG may also be
considered in children with a focal FC, as this may be the
first indication of an evolving epilepsy disorder.
On establishing FC as the diagnosis, repeat investigation
is not warranted for further episodes, unless new clinical
findings are elicited (Paul and Chinthapalli, 2013). In cases
where parents may be worried about a brain tumour or brain
damage, and have an unrealistic expectation of their child
having a CT scan after an episode of a simple FC, the
situation should be dealt with empathetically by providing
explanation and reassurance.
Long-term risk of developing epilepsy
Concern that the underlying problem could be epilepsy is not
uncommon among parents (Lux 2010; Paul and Chinthapalli,
2013), so it should be emphasised that FCs are not epileptic
convulsions.The risks for developing epilepsy are distinct from
those linked to recurrence of FCs.
A family history of epilepsy, complex FCs and neuro
developmental impairment (e.g. cerebral palsy) are the three
main factors that increase a child’s risk of developing epilepsy.
In the absence of risk factors the probability of developing
epilepsy is 0.5% (the same as the background population risk);
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one risk factor raises this to 2.5%, and two to three risk factors
Healthcare
take it to 5–10% (Paul et al, 2012). The diagnosis of epilepsy in
children and young people should be established by a specialist
MA
paediatrician with training and expertise in childhood epilepsy
© 2018
(NICE, 2018).
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Rationale for using prophylactic antipyretics
‘Fever phobia’ is often demonstrated by parents, and even by
health professionals. Since the term was first coined in the 1980s,
studies have provided further evidence that fever in children is not
in itself dangerous and may have a beneficial role as a near-
universal and ancient response to infection in all warm-blooded
animals (Purssell and Collin, 2016). A recent Portuguese study
that explored parents’ and health professionals’ knowledge of
fever reported that the approach to paediatric fever differed
significantly even among health professionals (Martins and
Abecasis, 2016). Febrile seizures were the most feared effect of
untreated fever among 74% of parents and 92% of nurses,
however for 97% paediatricians it was irritability/discomfort.
Box 9 highlights some potentially harmful practices that
it is important for health professionals and parents to avoid
(NICE, 2017).This must be explained to the parents, and it
is important to emphasise that paracetamol/ibuprofen do not
prevent FC and should be used judiciously.
Interventions for FCs such as antipyretics and antiepileptic
drugs were subject to a Cochrane review in 2017 that analysed
40 articles involving 4265 participants (Offringa et al, 2017).
Systematic reviews have demonstrated no advantage of using
intermittent phenytoin, paracetamol or ibuprofen (and others,
such as phenobarbitone, sodium valproate, pyridoxine, zinc
sulfate, diclofenac, etc.) versus placebo in preventing further
FCs. Parents who may blame themselves for not administering
antipyretics before their child has a recurrence of another FC
may find this evidence useful. The only rationale behind the
administration of antipyretics is to make the child more
comfortable and possibly help them drink better to prevent
dehydration (Lux, 2010; Paul et al, 2012).
Prophylactic anticonvulsants
Studies show that after a specialist consultation most
parents prefer not to start regular anticonvulsant treatment.
Most children do not need or benefit from prophylactic
anticonvulsants and this treatment is not recommended in
UK practice. The Cochrane review highlighted that neither
continuous nor intermittent treatment with
antiepileptic/antipyretic drugs can be recommended for
children with febrile seizures (Offringa et al, 2017).
If epilepsy is suspected and the use of anti-epileptic
drugs is considered, the child should be referred to a
paediatric neurologist for further investigations.
Immunisations and FC
Immunisation is rarely followed by an episode of FC. Children
who have had an FC following immunisation are no more
likely to have a subsequent convulsion than those who have
had an FC associated with another cause for fever (Barlow et
© 2018 MA Healthcare Ltd
al, 2001). A Cochrane review of 53 000 children receiving the
MMR vaccine showed that the small risk of FCs increased
only in the first 2 weeks after vaccination (an additional 1-2
FCs per 1000 vaccinations) and was most likely related to
fever from the vaccine (Demicheli et al, 2012). This risk is
much lower with the DTaP/IPV/Hib vaccine (Sun et al, 2012).
It may be advisable to withhold the next administration
British Journal of Nursing, 2018, Vol 27, No 20
CLINICAL
Box 8. Initial management of febrile convulsions at home for parents
■ Parents of children at high risk of recurrence of febrile convulsion (FC) must be
provided with appropriate resuscitation training
■ If the convulsion lasts less the 5 min, seek medical advice once it has stopped; if it last
any longer, an ambulance should be called
■ Recurrent FCs where the tonic-clonic component lasts longer than 5 min should receive
rescue treatment with anticonvulsant medication
■ First-line treatment is buccal midazolam, or rectal diazepam, if preferred or when
midazolam is not available
■ Do not restrain the child or put anything in their mouth, but do protect the child from
injury, loosen tight clothes around the neck
■ When the convulsion stops, check the airway and place the child in the recovery
position
■ The child may be sleepy for up to 1 h following a convulsion and need to be monitored
Source: National Institute for Health and Care Excellence, 2013; 2018
Box 9. Interventions that should be avoided
■ Forehead chemical thermometers are unreliable and should not be used
■ Antipyretic agents do not prevent febrile convulsions and should not be used
specifically for the purpose
■ Tepid sponging is not recommended for the treatment of fever
■ Children with fever should not be undressed or overwrapped
■ Do not use antipyretic agents with the sole aim of reducing body temperature in
children with fever
■ When using paracetamol or ibuprofen in children with fever, do not give both agents
simultaneously
Source: National Institute for Health and Care Excellence, 2017
of immunisation for 48 hours following an FC. If the
parents are very anxious, referral to paediatric services to
arrange the next immunisation in a hospital environment in
a planned, controlled manner could help reassure them.
Conclusion
FCs are common in paediatric practice and there is usually an
excellent prognosis. It has been demonstrated throughout the
literature that there is a limited role for antipyretic therapy as it
does not prevent FCs, but they do have the advantage of
making the child more comfortable. Furthermore, the use of
prophylactic anti-epileptic drugs is not recommended in
routine clinical practice in the UK. BJN
Declaration of interest: none
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 LEARNING OUTCOMES
■■ Identify red flag features and instigate urgent referral/management for
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CPD reflective questions
■ Why is it important to identify children with febrile convulsions (FC) early and to be able to differentiate these from
seizures due to other conditions, e.g. evolving epilepsy, intracranial infections, electrolyte disturbances?
■ From your previous experience, think about a few challenges you may have faced while managing children with FCs and
the differences in parental expectations you encountered in those cases
■ Reflecting on the case study in this article, list a few scenarios where you have identified that nurses (or health visitors)
working in different clinical settings have made a difference either by recognising children with FC early or because they picked up deterioration in
clinical status, and therefore escalated concerns to a senior health professional
■ Discussion, providing appropriate information, explanation and reassurance, are vital for the successful management of
FC. How would you facilitate this with parents?
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© 2018 MA Healthcare Ltd
British Journal of Nursing, 2018, Vol 27, No 20
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