GUIDELINE FOR THE MANAGEMENT OF

Transcription

1 GUIDELINE FOR THE MANAGEMENT OF Reference: Febrile Convulsions Version No: 1 Applicable to All children admitted with Febrile Convulsion to the Children s Hospital for Wales Classification of document: Area for Circulation: Author: Group Consulted: Ratified by: Guideline Children s Hospital for Wales Dr A Semmens, Associate Specialist, Coral Rees, Anita Tyler, Paediatric Nurse Practitioners Practitioners within the Children s Hospital for Wales Current literature Child Health Guideline Meeting January 2012 Date Published: May 2012 Version Number Date of Review Reviewer Name Completed Action Approved By Date Approved New Review Date Disclaimer These have been ratified at the Child Health Guideline Meeting, however clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of theindividual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

2 Febrile convulsions are convulsions brought on by fever in infants and small children. They are common and occur in approximately 3% of healthy children, ages 6 months to 6 years. They are usually associated with a simple viral infection but other underlying causes of fever must be considered, including illnesses which should be covered by antibiotics and antivirals such as meningitis, UTI and encephalitis. Febrile convulsions are benign, with minimal morbidity & essentially no mortality. The onset of the convulsion may be sudden, with little evidence of preceding illness. The convulsion may be terrifying for the parents to observe they frequently believe their child is dying & may attempt resuscitation measures. They can be classified as simple febrile convulsions or complex febrile convulsions. Simple febrile convulsions (70%) Duration less than minutes (In practice, most are much shorter: under 2 minutes.) Generalised: i.e without focal features Do not recur within 24 hours, or within the same febrile illness Complex / atypical febrile convulsions (30%) Prolonged (last more than 20 minutes) Focal features Recur within 24 hours or within the same febrile illness A febrile convulsion can be termed complex because of points 1,2 or 3 listed above. Febrile convulsions lasting more than 30 minutes constitute febrile status, a medical emergency. Management The mainstay of the management is to treat the convulsion itself (many will have terminated by the time you see them in a hospital setting), identify the illness that caused the convulsion & treat the illness accordingly. Termination of the convulsion is described in the convulsions guideline. After the convulsion Identify the focus of the cause of the fever & treat accordingly. In children 6-12 months with no clear focus, a full septic work up including LP should be considered. Febrile convulsions are rare in children under 6 months. A febrile child <6 months with a convulsion and no clear focus of infection should have a full septic screen including LP. Decisions not to do this should be discussed with a consultant and clearly documented in the notes. If the child has been on oral antiobiotics and are clinically unwell, an LP may be required to ensure meningitis is not being masked discuss with a senior doctor. LP is contra-indicated in the presence of focal signs, raised intra cranial pressure & clotting abnormalities. If the cause of the febrile convulsion is found, if it is simple in nature & the parents are happy, they may be discharged, once back to normal. (Febrile convulsion parent information leaflets should be provided)

3 FEBRILE CONVULSIONS Simple febrile convulsion Complex febrile convulsion TREATMENT AND MANAGEMENT Terminate convulsion as per APLS guideline Determine cause of fever - treat accordingly Focus identified investigations not necessarily indicated Focus not identified as per febrile child guideline Reconsider diagnosis if previous afebrile convulsions, progressive neurological condition, signs of CNS infection or <6 months old DISCHARGE When return to normal neurological status Focus identified and treated accordingly Parent education verbal and written information given Fever control Clothing should be minimal: nappy alone or lighter outer layer depending on ambient temperature. Oral fluids should be encouraged. Tepid sponging / baths & fans are not recommended. Treatment of a fever with regular paracetamol or ibuprofen does not prevent a febrile convulsion. They may be used for pain & discomfort associated with the fever, or due the underlying illness such as otitis media. Parents should understand the reasons for its use and should be discouraged from using it solely to reduce the child s fever. Ibuprofen can be associated with renal damage. Long term issues Children prone to febrile seizures are not considered to have epilepsy, as epilepsy is characterized by recurrent seizures that are not triggered by a fever. The overall recurrence risk for further febrile convulsions is 30-40%. The main predictors of risk are; Earlier age of onset - first febrile seizure before 1 yr of age : risk 50% - first febrile seizure after age 3 yrs: risk 20% Other associated risk factors are family history of febrile seizure, lower fever at time of seizure and if the seizure occurs soon after the fever begins.

4 The risk of future afebrile convulsions (epilepsy) is increased by; - Family history of epilepsy - Neurodevelopmental problem - Complex / atypical febrile convulsions No risk factors: risk of subsequent epilepsy approx 1% (similar to population risk) 1 risk factor: 2% More than 1 risk factor: 10% Children who have prolonged, recurrent convulsions (rare), may benefit, after discussion with a consultant, from having a buccal midazolam kit at home. The parents can then administer this if the convulsion has not spontaneously terminated within 5 minutes, whilst ringing for an ambulance. General paediatric follow up may be indicated in some circumstances. If there is a strong family history of febrile convulsions and epilepsy, please send a copy of the discharge summary to: either Dr Frances Gibbon or Dr Johann Te Water Naude (Consultant Paediatric Neurologists) for their discussion for possible referral to the Welsh Epilepsy Research Network References BMJ Publishing Group Limited 2009: Febrile Convulsions Patient Leaflets National Institute of Neurological Disorders and Stroke: Febrile Seizures Fact Sheet Clinical Practice guidelines: Febrile Convulsions. Royal Children s Hospital Melbourne British Paediatric Neurology Association, Paediatric Epilepsy Training Additional Documents: Parent Information on Febrile Convulsions Follows on page 5 to 6. Designed to be printed back to back and folded to A5 leaflet

5 What is a febrile convulsion? A febrile convulsion is a fit or seizure caused by a fever. They are caused by a sudden change in your child s body temperature. A high temperature is a sign of infection somewhere in the body. Are febrile convulsions common? 1 in 30 children will have a febrile convulsion at one time or another. This usually happens between the ages of 6 months and 6 years. 2 out of 3 children will not have another convulsion Will a febrile convulsion cause long term problems for my child? Febrile convulsions are not harmful for your child. They do not cause brain damage. They are, however, very upsetting for parents to witness. Will my child go on to develop epilepsy following a febrile convulsion? This is unlikely, however, a very small number of children who have febrile convulsions go on to have epilepsy. Will my child have febrile seizures with every illness which causes a fever? What should I do if my child has a further febrile convulsion? There is nothing you can do to stop the convulsion. The most important things to do are: remain calm don t panic place your child on a soft surface, lying on their side or back do not restrain your child do not put anything in the child s mouth, including fingers if your child is sick (vomits), clear it away from their mouth try to watch exactly what is happening so you can describe it later time how long the convulsion lasts do not put a child who is having a febrile convulsion in the bath Call an ambulance if: The convulsion lasts for more than 5 minutes Your child does not wake up when the convulsion stops You are concerned. If the convulsion stops in less than 5 minutes: See your GP as soon as possible so that they can examine your child and decide where the infection is. About one third of children will have a febrile seizure again during a subsequent infection. Recurrence is more likely if: the first febrile seizure happened when your child was younger than 18 months old you have a family history of febrile seizures

6 If I give my child paracetamol or ibuprofen, will this stop them from having a further convulsion? Treatment of a fever with paracetamol or ibuprofen does not prevent a febrile convulsion. What should I do if my child has another temperature? A fever or temperature is the body s natural response to infection. However, if your child is in discomfort or pain, paracetamol can be given. Clothing should be minimal a nappy alone is fine or a light outer layer depending on room temperature. Regular fluids should be given to your child to prevent dehydration. DO NOT use tepid sponging, baths or fans to try and lower the temperature Regular use of ibuprofen in febrile children is not recommended. If any ibuprofen is given, you must make sure your child has a good fluid intake. Febrile Convulsions in Children Parent Information Leaflet Will my child need to be admitted to hospital? If the cause of the febrile convulsion is found and the child has had a simple febrile convulsion they will not need to be admitted. If the source of the infection is not easily identified, further investigations may need to be done to identify what has caused the febrile convulsion and the child will be admitted for observation and treatment if necessary.