CLINICAL GUIDELINE FOR THE EVALUATION OF A CHILD PRESENTING WITH FEVER AND SEIZURE V3.0

CLINICAL GUIDELINE FOR THE EVALUATION OF A CHILD PRESENTING WITH FEVER AND SEIZURE V3.0 Clinical Guideline Template Page 1 of 18

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1. Aim/Purpose of this Guideline 1.1. This guideline applies to all medical and nursing staff caring for a child presenting with fever and seizure. The aim is to provide clear information to provide up to date best clinical practice. 2. The Guidance 2.1. A distinction must be made between a child with 'fever and seizure' and 'febrile seizure'. In the former the cause may be a Central Nervous System infection. CNS infection must be excluded before a diagnosis of febrile seizure can be made. In older children history and clinical examination will suggest CNS infection in nearly all cases. In the infant and toddler clinical diagnosis of CNS infection is not always obvious so a lower threshold for investigation and treatment is needed. Febrile seizures are common but benign; however they can be very frightening for families. Explanation and advice are an important part of the management of children with febrile seizures. The terms convulsion or fit may be used instead of seizure. The terms are interchangeable. 2.2 Febrile seizures Definition a seizure occurring in a child aged from six months to five years, precipitated by fever arising from infection outside the nervous system in a child who is otherwise neurologically normal. " 2.2. Generally seizures associated with fever, in a child who has previously had afebrile seizures, are not described as febrile. Seizures during fever in those who have central nervous system abnormalities are not usually considered to be simple febrile seizures. 2.3. Febrile seizures occur in 2-5 % of children. They are the commonest seizure type in infants and young children, with a peak at 18-24 months. A family history of febrile seizures will be found in 5.4%. 2.4. Most febrile seizures occur at the start of an illness, 50% occur at temperatures less than 40 C. 2.5. Classification 2.6. SIMPLE febrile seizure A primary generalised seizure lasting </= 15 minutes and not recurring within 24 hours. Seizures may be tonic and or clonic and are non-focal. 2.7. COMPLEX febrile seizure 88% of febrile seizures are simple. Page 2 of 13

Seizure is > 15 minutes in duration or fit is focal or re-occurs within 24 hours of first fit. 2.8. Treatment and evaluation 1. Treatment of seizure Treatment of seizure if prolonged is as per status epilepticus protocol. Check blood glucose. 2. Treatment of pyrexia Antipyretics e.g. paracetamol, ibuprofen. Clothing should be minimal. However, NICE guidance Fever in children younger than 5 years states anti pyretics do not prevent febrile convulsions. They should be used if the child appears distressed due to fever. 3. Treatment of cause of pyrexia Antibiotics if indicated. 2.9. Evaluation of child with first febrile seizure. 2.10. Most children will have a minor infection; however a seizure may be the first sign of CNS infection. If CNS infection is suspected treatment should be instituted following appropriate investigations. Re-evaluation of continued treatment should be made in the light of cultures or PCR results. 2.11. In 13-16% of children with meningitis, seizures are the presenting sign. Meningeal signs and symptoms may be absent in 30-35%, most of whom are under 18 months. A number of studies have looked at the incidence of meningitis in children presenting with fever plus seizure, cases of meningitis are uncommon, 0-4%. 2.12. Which children presenting with fever and seizure should have a lumbar puncture? Any child presenting with symptoms or signs suggesting meningitis. If there are signs of raised intracranial pressure or reduced level of consciousness, lumbar puncture should be deferred and the child should be evaluated by a middle grade or consultant. Cranial imaging may benecessary. Serious consideration should be given to performing a lumbar puncture in those aged 18 months and under, unless there are concerns about raised intracranial pressure or reduced level of consciousness, or other contraindications to lumbar puncture. In cases where CSF examination has not been done, the rational for this should be written in patients notes The child should regularly be re-assessed and need for lumbar puncture reviewed. If unsure this should be discussed with a more senior doctor. Page 3 of 13

o Note- Otitis media may coexist with meningitis. o Note- CNS infection is more likely if the febrile seizure was complex. 2.13. Document discussion and verbal consent for lumbar puncture with parents and patient. 2.14. Collect CSF for mc&s, protein and glucose and take sample for PCR. Note each request for a specific PCR will require a minimum of 1/2 a ml (universal container) 2.15. Serum may also be taken for PCR. (EDTA 2ml) 2.16. Other Investigations. Most children will have a viral aetiology for their fever, most present with respiratory tract symptoms and signs. Many children will have recovered from their seizure by the time they are seen. Where the child appears well and alert no investigations may be required. For such children re-evaluation is essential to exclude evolving serious bacterial infection. The risk of serious bacterial infection in first time febrile seizure is low, 12% in one series. Investigations performed in the acute illness should be guided by clinical assessment. Occult bacteraemia is more common in infants. o Urine for m,c&s should be sent if there is no obvious focus of infection 2.17. EEG and Cranial Imaging. EEG and cranial imaging are not indicated following a simple febrile seizure (unless other concerns indicate a need for imaging). 2.18. Further management following the diagnosis of a simple febrile seizure. Unless there is clinical doubt about the child's developmental or neurological state, the parents should be told that the prognosis is very good. It is important to reassure and explain the nature of febrile seizures to the parents. In addition a patient leaflet( Your Child has had a febrile seizure RCHT048) should be given to parents. 2.19. Recurrence risk There is a risk of further simple febrile seizures in one third of children. 15% have more than 1 recurrence, 9% more than 3 febrile seizures. 70% of recurrences are within 1 year, 90% within 2 years. o The risk of a recurrence is 50% if child was under 1 year when had first episode, risk if first episode in child > 3yrs is 20%. o Risk of recurrence is greater if there is neurological impairment or FH of febrile or afebrile seizures. Page 4 of 13

o The risk of recurrence increases to 52%, if there is a positive family history in a first degree relative. o If first febrile seizure was prolonged it is likely any further ones will also be prolonged. 2.20. Risk of subsequent epilepsy The risk of subsequent epilepsy is 2-4%, slightly increased compared to the incidence of epilepsy in the paediatric population. The risk is increased if there is a positive family history of afebrile seizures. In children whose neurologic or developmental status was suspect or abnormal prior to seizure and if seizure was complex the risk of developing epilepsy is 18 times higher than children without febrile seizures. There are epilepsy syndromes where fits occur with fever, several kindreds have been described. 2.21. Prevention of further febrile seizures. Daily phenobarbitone or sodium valproate has been shown to reduce recurrent febrile seizures but the potential side effects outweigh this benefit. No medications have been shown to reduce the future onset of afebrile seizures. (evidence I+) Consideration may be given to the use of diazepam or midazolam at the start of a seizure - in children with recurrent febrile seizures, which have previously been prolonged. Antipyretics do not prevent additional febrile seizures. 2.22. Immunisations There is no contra indication; however there is a risk of febrile seizure in any child after immunisation so parents should be advised about this. 2.23. Information and Reassurance for parents Information given to parents should include: An explanation of the nature of febrile seizures, including information about the prevalence and prognosis. Instructions about the management of fever, the management of a seizure, and the use of rectal diazepam/midazolam as appropriate. This advice should be given verbally (recorded in notes), and a supplemental leaflet given (RCHT048). 2.24. Follow Up Most children do not require outpatient follow up. For those where there is diagnostic uncertainty about the nature of the seizures (febrile or non-febrile) or if there has been repeated febrile seizures discuss with consultant regarding outpatient follow up. 2.25. Evidenced based medicine. There are several consensus statements on the management of febrile seizures from the RCPCH and American Academy of Paediatrics. Evidence for the incidence of meningitis in children with fever and seizure comes from several large studies. The indications for lumbar puncture in children with no meningeal signs is based on studies showing low incidence of meningitis and consensus statements which Page 5 of 13

recognise the possible absence of meningeal signs in those under 19 months. The only area where there is grade 1+ evidence is with regard to prophylactic treatment to prevent further febrile seizures. Thus the use of no prophylactic treatment is grade A. Page 6 of 13

3. Monitoring compliance and effectiveness Element to be All elements from suggested audit tool in Appendix 4. monitored Lead Audit Lead Tool For suggested audit tool, see Appendix 4. Frequency Annually or per case for review purposes. Reporting Audit Lead. Child health audit and guidelines meeting. arrangements Acting on Audit Lead. To be reported to Child Health Audit and Guidelines recommendations meeting. Recommendations and learning will be passed to relevant and Lead(s) medical and nursing management and staff. Change in practice and lessons to be shared Required changes to practice will be identified and actioned within three months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 13

Appendix 1. Governance Information Document Title Date Issued/Approved: 9 th Nov 2017 Clinical guideline for the evaluation of a child presenting with fever and seizure V3.0 Date Valid From: 9 th Nov 2017 Date Valid To: 9 th Nov 2020 Directorate / Department responsible (author/owner): Dr. S.Harris, Paediatric Consultant. Contact details: 01872 253041 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Guideline for medical and nursing staff providing clear evidence based best practice for evaluation of a child presenting with fever and seizure. Includes, parental information, suggested audit checklist and flow chart. Paediatric, Child Health, Fever, Seizure RCHT PCH CFT KCCG Medical Director Date revised: 9 th Nov 2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Clinical guideline for the evaluation of a child presenting with fever and seizure V2.0 Child health Audit and guidelines. Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): David Smith Not Required {Original Copy Signed} Name: Caroline Amukusana {Original Copy Signed} Internet & Intranet Intranet Only Page 8 of 13

Document Library Folder/Sub Folder Clinical / Paediatrics Links to key external standards None 1. Joint Working Group of the Research Unit of the Royal College of Physicians and the British Paediatric Association. Guidelines forthe management of convulsions with fever. BMJ. 1991;303:634-6. 2. Poth RA, Belfer RA. Febrile seizures: a clinical review. Compr Ther, 1998; 24(2):57-63.3.Offinga M et al. Prevalence of febrile seizures in Dutch schoolchildren. Paediatr Perinat Epideiol, 1991;5(2):181-84. Baumann Robert J. Technical Report: Treatment of the Child With Simple Febrile Seizures. Pediatrics, 1999; 103(6): p. e86. 5. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. American Academy of Paediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Paediatrics. 1996 May;97(5):769-72; discussion 773-5 6. Offringa M et al. Seizures and fever: can we rule out meningitis on clinical grounds alone? Clin Pediatr, 1992;31(9):514-22. Related Documents: 7. Rutter N Smales OR. Role of routine investigation in children presenting with their first febrile convulsion. Arch Dis Child,1977;52(3): 188. 8. De La Torre Espi M et al. Short term evolution of febrile syndromes accompanied by seizures. Rev Esp Pediatr, 1997;53(315):205-209 9. Hampers LC et al. Setting based practice variation in the management of simple febrile seizure. Acad Emerg Med, 2000;7(1):21-27. 10. Offringa M. Febrile seizures. Evidenced based paediatrics and child health. BMJ publishing group, London. Edited Moyer VA et al. 2000. 189-196. 11. Joffe A McCormick M DeAngelis C.Which children with febrile seizures need lumbar puncture? A decision analysis approach Am J Dis Child, 1983; 137(12):1153-6. 12. Stokes MJ et al. Viruses and febrile convulsions. Arch Dis Child, 1977; 52: 129-133. 13. Abuekteish F et al. Demographic characteristics and risk factors in first febrile Page 9 of 13

Training Need Identified? seizures. Tropical Doctor, 2000;30(1):25-27. 14. Trainer JL et al. Children with first time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med, 2001; 8(8):781-7. 15. FU Knudsen, A Paerregaard, R Andersen and J Andresen Long term outcome of prophylaxis for febrile convulsions. Arch Dis Child. 1996; 74(1):13-8. 16. A van Esch et al. Family history and recurrence of febrile seizures. Arch Dis Child. 1977;52: 129-133. 17. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics,1978;61:720-727. 18. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976;295(19):1029-33. 19. Lerche H et al. Generalised epilepsy with febrile seizures plus: Further heterogeneity in a large family. Neurology, 2001;57(7):1191-1198. 20. Rantala H et al. A meta-analytic review of the preventive treatment of recurrences of febrile seizures. DARE. J Pediatrics 1997;131(6):922-925. 21. Barlow WE et al. The risk of seizures after receipt of whole cell Petussis or MMR vaccine. N Engl J Med, 2001;345(9):656-61. 22.NICE clinical guideline 160. Feverish illness in children.may 2013 No Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) Oct 10 V1.0 Initial Issue Dr. Sian Harris. Paediatric Consultant June 2013 V2.0 Reformat and update Dr. Sian Harris. Paediatric Consultant Tabitha Fergus Deputy ward Nov 2017 V3.0 No changes Sian Harris, Paediatric Consultant Page 10 of 13

All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 11 of 13

Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed Clinical guideline for the evaluation of a child presenting with fever and seizure V3.0 Directorate and service area: Child Health. Name of individual completing assessment: Tabitha Fergus Is this a new or existing Policy? Existing Telephone: 01872 252800 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Guideline for medical and nursing staff providing clear evidence based best practice for evaluation of a child presenting with fever and seizure. Includes, parental information, suggested audit checklist and flow chart. 2. Policy Objectives* Clear evidence based best practice for evaluation of a child presenting with fever and seizure. 3. Policy intended Evidenced based, standardised practice. Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? Audit Children and families presenting with fever and seizure. Workforce Patients Local groups x Please record specific names of groups Clinical Guideline Group Paediatric Directorate Guideline agreed External organisations Other Page 12 of 13

7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age X X Child health guideline Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity X X X X X X Sexual X Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No X 9. If you are not recommending a Full Impact assessment please explain why. No areas indicated Page 13 of 13

Signature of policy developer / lead manager / director Chris Warren Date of completion and submission 09/11/2017 Names and signatures of members carrying out the Screening Assessment 1. Chris Warren 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Chris Warren Date 09/11/17 Page 14 of 13

Appendix 3. Checklist and Recommended Audit Tool. A useful checklist to aid evaluation of a child presenting with fever and seizure. This list is also recommended for audit. Do the case notes contain? An accurate description of the seizure, including its duration? Information about the nature of the episode? (What was child doing/where did it occur/recent meals/recent activity). A record about the family history with regard to febrile and non-febrile seizures? The age at first seizure? The temperature on admission? Whether signs of meningitis were present or absent? When they were first noted? An assessment of the cause of the fever? The child's neurodevelopmental state when recovered (estimated as far as practical)? A neurodevelopmental history should form part of the initial clerking. The blood glucose concentration, if the child was seen during a seizure? Was the following information recorded as being given to parents? An estimate of the likely prognosis, what to do if further seizures occur, and advice about future immunisation? Parent advice leaflet RCHT-048? Discharge summary - Does the discharge summary sent to the general practitioner contain information on the abovepoints? Page 15 of 13

Appendix 4. Flow Chart. HAS THE CHILD BEEN FITTING FOR LONGER THAN 5 MINUTES NO HISTORY AND EXAMINATION Is CNS infection suspected? YES YES TREAT STATUS EPILEPTICUS CHECK blood sugar IS THERE EVIDENCE OF RAISED INTRACRANIAL PRESSURE YES OR YES IS THERE REDUCED LEVEL OF CONSCIOUSNESS? YES DISCUSS WITH SENIOR DOCTOR CONSIDER NEUROIMAGING TREAT SUSPECTED INFECTION NO NO IS CHILD <18MONTHS LOW THESHOLD WITH FEVER AND NO YES FOR LP DISCUSS LUMBAR PUNCTURE OBVIOUS FOCUS? WITH MIDDLE CSF for mc&s, GRADE DR. biochemistry and PCR NO DID CHILD HAVE ANTIBIOTICS PRIOR TO PRESENTATION? YES EVALUATE FOR OTHER SOURCE OF INFECTION CONSIDER Blood cultures, PCR, swabs, Urine culture, CXR, FBC, CRP, Viral titres. IN AN OTHERWISE WELL CHILD IT MAY BE THAT NO OTHER SPECIFIC INVESTIGATIONS ARE REQUIRED ARE THERE UNDERLYING NEUROLOGICAL OR DEVELOPMENTAL CONCERNS? NO CHILD NEUROLOGICALLY NORMAL WITH NO CNS INFECTION PRESENTING WITH FEVER AND SEIZURE Y ES CONSIDER INVESTIGATIONS FOR EPILEPSY or other CNS disorders.g. EEG, MRI, bloods. EXPLANATION TO CARERS ABOUT FEBRILE CONVULSIONS PLUS WRITTEN INFORMATION EVALUATE RISK OF FURTHER FEBRILE CONVULSIONS AND ADVICE PARENTS Page 16 of 13

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