ttingham Children s Hospital ttingham University Hospitals Seizure with Fever Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Guideline for the management of seizure(s) presenting with fever Keshav Kallambella (Specialist Registrar) Colin Dunkley (Consultant Paediatrician) William Whitehouse (Consultant Paediatric Neurologist) Directorate & Speciality Directorate: Family Health Children Speciality: Neurosciences Date of submission September 2016 Date when guideline reviewed September 2019 Guideline Number 1993 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Children or young people presenting with seizure with fever to acute paediatric services Management of children or young people presenting with seizure with fever to acute paediatric services Key Words Paediatrics. Children. Seizure, convulsion fit, febrile fever Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? 1a meta analysis of randomised controlled trials 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process Put a cross (X) in the highest level of evidence. x CEWT (Children s Epilepsy Workstream in Trent) Staff at ttingham Children s Hospital via the Guidelines E-mail process. Staff at the ttingham Children s Hospital Target audience This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. www.cewt.org.uk Page 1 of 5 December 2016
ttingham Children s Hospital ttingham University Hospitals Document Control Document Amendment Record Version Issue Date Author V1 April 2011 Kiran Damera (Specialist Registrar), Colin Dunkley (Consultant Paediatrician) William Whitehouse (Consultant Paediatric Neurologist) V2 May 2016 Keshav Kallambella, Specialist Registrar Contributors: Kiran Damera, Colin Dunkley, Katherine Martin, William Whitehouse, Mal Ratnayaka, Rachael Wheway, Catie Picton, Ann Brown, Kirsten Johnson, Hani Faza General tes: This guideline has been developed through CEWT, a collaborative network of health professionals. It is designed to complement a range of guidelines and pathways available at www.cewt.org.uk and is aligned with national recommendations. This ttingham guideline is a local implementation of this regional guideline. Summary of changes for new version: Further detail regarding prognosis of further seizures and epilepsy. Further detail regarding indications for buccal midazolam and follow up Statement of Compliance with Child Health Guidelines SOP This guideline has followed Child Health Guideline SOP. It has been circulated to all Paediatric Senior staff and comments incorporated before uploading to the Trust Guideline site. Martin Hewitt Clinical Guideline Lead 16 th December 2016 www.cewt.org.uk Page 2 of 5 December 2016
ttingham Children s Hospital ttingham University Hospitals Definitions and background Fever : Recorded temperature >37.8 or perceived to have fever by parents/carers around time of seizure Febrile Seizures : (Sometimes termed Febrile Convulsion ) A convulsive seizure in infancy or childhood between 6 months and 5 years of age (peak age 18-22 months) associated with fever but without evidence of intracranial infection or defined cause of seizure. Population studies report a cumulative incidence of 2 5% 1. The seizure may occur before the fever becomes apparent, and well before the illness causing the fever is manifest. 2 Types of febrile seizures: Simple Febrile Seizures: A single generalised (no focal features) seizure lasting <10 min (2/3 of all febrile seizures) Complex Febrile Seizures: Multiple seizures in same illness or 10 min or focal features (either during the seizure of afterwards e.g. Todd s palsy). (1/3 of all febrile seizures) Acute symptomatic seizures with fever: Other conditions can cause seizure associated with fever. These include Intracranial infections (e.g. meningitis/encephalitis/brain abscess) Gastroenteritis or sepsis with electrolyte abnormalities or hypoglycaemia Epilepsy with fever-related seizures: Seizures can be precipitated by fever in children with a known epilepsy or first presentation of an epilepsy. Other situations mimicking febrile seizures or epileptic seizures: Fever with rigors Fever with delirium Fever with reflex syncope Fever with hypotonic-hyporesponsive episodes www.cewt.org.uk Page 3 of 5 December 2016
ttingham Children s Hospital ttingham University Hospitals Prognosis Risk factors predisposing to febrile seizures Previous febrile seizure Family history (first degree relative) Risk of future febrile seizures 3 Antipyretics can be used but there is no evidence that they reduce risk of febrile seizures. Antiepileptic drugs do not usually have any role in reducing the risk of future febrile seizures. Overall 30% will develop further febrile seizures. The risk can be individualised: Risk Factors: Early age of onset (<18months) Family history of febrile seizures Lower temperature (<40 C) (Complex features not a risk factor) Risk of epilepsy 4 Overall 3% of children with febrile seizures will go on to have some type of epilepsy (recurrent afebrile epileptic seizures) at some point. The risk can be individualised: Risk Factors: Abnormal neurology prior to first febrile seizure Family history of afebrile seizures Complex febrile seizure References 1. Febrile seizures: an update. C Waruiru, R Appleton Arch Dis Child 2004; 89:751-756 2. Cross JH, Fever and fever-related epilepsies. Epilepsia, 53(Suppl. 4):3 8, 2012 3. Berg et al 1997. Arch Pediatr Adolesc Med 151, 371-378 4. Nelson & Ellenberg 1978. Pediatrics 61, 720-7 5. CEWT Guideline Framework www.cewt.org.uk 6. The management of children and young people with an acute decrease in conscious level, RCPCH guideline, 2015 7. http://www.nice.org.uk/guidance/cg102 8. http://www.nice.org.uk/guidance/cg160 9. Complex Febrile Seizures: A Practical Guide to Evaluation and Treatment J Child Neurol June 2013 28: 762-767 10. Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child with a Simple Febrile Seizure. Pediatrics Vol. 127. 2 February 1, 2011 pp. 389-394 11. Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, Johnston P, Harper MB. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics. 2010 Jul; 126(1):62-9. www.cewt.org.uk Page 4 of 5 December 2016
Prolonged Convulsive Seizure Guideline 5 Reduced Conscious Level Guideline 6 Meningitis /Meningococcal Sepsis Guidelines Further Paediatric Assessment History and examination Paracetamol and/or Ibuprofen prn Identify source of fever, investigate & treat (see NICE feverish illness guidelines) Routine investigations are not indicated in all children with febrile seizures Consider LP if concerning features * (note contraindications) Senior review prior to discharge Once fit for discharge: Discuss risk of future seizures Consider home Buccal Midazolam if convulsive seizure >5 minutes, particularly if recurrent. Ensure prescribed with individualised care plan and parental training. Febrile seizure and fever advice and written information ttingham Children s Hospital ttingham University Hospitals Seizure(s) with Fever in Children Continuing convulsive seizure > 5 minutes? Decreased conscious level? Before seizure onset Or > 1 hour after seizure end Or longer than typical post-ictal period for child in question Meningism or Meningococcal shock? Any concerning feature?* First Febrile Seizure? OR clear focus of infection? OR Parental concern? Known or suspected epilepsy? Contraindications for Lumbar Puncture 6 Signs of raised intracranial pressure** even if GCS is 15 A GCS of less than or equal to 8 A deteriorating GCS Focal neurological signs GCS equal to or less than 12 after a seizure lasting more than 10 minutes Clinical evidence of circulatory shock or meningococcal disease A CT or MRI scan suggesting CSF pathway obstruction *Concerning Features: Any prolonged convulsion > 5 mins Complex febrile seizures o Multiple seizures in same illness o Focal features Infant < 18 months Prior treatment with antibiotics Drowsy before the seizure or > 1 hour post seizure More than 3 days illness GP contact in last 24 hrs Meningism (neck stiffness, photophobia, irritability) n-blanching rash (petechiae, purpura) **Signs of raised intracranial pressure o bulging fontanelle o pupillary dilation unilateral/bilateral) or loss/impairment of pupillary reaction to light o bradycardia (heart rate < 60/min) o hypertension (mean BP >95th centile for age) o abnormal breathing pattern or posture) Focal neurology Review epilepsy and management Inform epilepsy specialist nurse Review need for admission or earlier outpatient appointment The management of epilepsy is outside scope of this guideline 2 Follow up Most do not require follow up. Follow up probably needed for: Having recurrent febrile seizures Prescribed home Buccal Midazolam Children with seizure with fever < 6 months or > 5 years Needing follow up for other reasons e.g. neurodevelopment problems etc. Previous febrile seizures AND Focus of infection identified AND significant parental concern Lead Author Page 5 of 5 Issued: June 2010 Manage according to cause Consider discharge Discuss risk of future seizures Febrile seizure and fever management advice and written information www.cewt.org.uk