Paediatrics - Febrile convulsions Assessment, treatment and education

Raftery, Sara, Febrile Convulsions: Assessment, Treatment and education, World of Irish Nursing 10 (3), March 2002 pp 27-28. Part 3, This month in part three of the Continuing Education module on Paediatrics, we tackle the issue of febrile convulsions. Previously in this module, part one dealt with assessment and intervention for gastroenteritis in children and part two dealt with juvenile arthritis.Subsequent articles will deal with a range of common paediatric illnesses and conditions including diagnosis and management of type 1 diabetes in children; the asthma emergency; treatment of UTIs; palliative care of the dying child; epilepsy in children; severe constipation in infants and young children; febrile convulsions; eating disorders; and the management of burns in children.Module co-ordinator: Moira Cassidy, RGN, staff writer with the World of Irish Nursing
By: Sara Raftery

Febrile convulsion, or febrile seizure, is broadly defined as a seizure accompanied by fever, without central nervous system infection, occurring in infants and children between six months and five years.1 It is important to note that this definition excludes fever which occurs in conjunction with neurological disease such as meningitis and encephalitis. There is some variation within the literature as to the exact range of normal temperature, with some studies suggesting it may be as wide as 35.6C 38.2C. 2 Febrile convulsions occur in 2%-5% of all children, making them the most common convulsive event in children less than five years old. They can be classified as simple or complex: simple a single generalised seizure which lasts less than 15 minutes complex a seizure lasting longer than 15-20 minutes with focal features.1 The complex febrile convulsion often recurs within a 24-hour period. Causes and risk factors It is not clear why some children experience febrile convulsions. Specific risk factors include: genetic propensity, particularly first-degree family history rapid elevations of temperature a temperature of less than 40C at the initial convulsion one or more previous occurrences;3 the risk of a second convulsion occurring is approximately 30%. Of the children who experience a second event 50% will have at least one additional recurrence. Children with simple febrile convulsions are slightly more at risk (approximately 1%) of developing epilepsy.1 Nursing management It is likely that children suffering a first febrile convulsion will present either to a paediatric A&E department or to their GP surgery.4 It is essential that the attending nurse be alert to the traumatic effect such an event will have on the childs parents.5 On presentation, initial nursing assessment and management is aimed at maintaining oxygenation and minimising the risk of complications. The nurse must remain with the child and family and ensure that oxygen, suction and resuscitation equipment are readily accessible. The child should be placed in a semi-prone position and protected from any additional injury. It is imperative that the nurse observe, assess and document the presenting characteristics of the febrile convulsion (see Table 1).

Table (1) Nursing Assessment during a febrile convulsion

Assess the childs colour Continuous assessment of vital signs including pulse oxymetry Accurate timing of the febrile convulsion Note for alterations in consciousness and document motor sensory and autonomic function 4 A soon as is appropriate record the childs temperature Assess family coping and offer brief explanations at this time If possible remove warm clothing
The medical treatment of febrile convulsion is much debated within the literature and local hospital protocols may differ.6 By the time the child presents to the A&E department it is likely that the febrile convulsion will have begun several minutes previously. Therefore anticonvulsant medication is often prescribed immediately. This tends to be administered either per rectum or intravenously. Following the administration of anticonvulsant drugs the nurse must continue to assess the child carefully and note for the cessation of the convulsion. Should it continue, medical reassessment and further administration of anticonvulsant medication is warranted. It is essential that the nurse offers ongoing advice, explanation and support for the family during the event, as many parents report fears that their child is going to die or to become brain damaged. 4,5 Antipyretic therapy As soon as is appropriate, antipyretic medication should be administered to reduce the childs temperature and thus the risk of subsequent febrile convulsions. Antipyretics are usually administered rectally, but if the child regains consciousness rapidly they may be taken orally. Both paracetamol and the non-steroidal antiinflammatory drugs have anti-pyretic actions.7 Warm clothes should also be removed and fluids should be introduced orally if tolerated, to prevent dehydration. Intravenous fluids may be warranted if the child is slow to recover from the febrile convulsion. Rapid cooling measures such as tepid sponging and fanning are no longer advocated in children.7 In order to determine and treat the underlying cause usually a bacterial or viral infection many children will be admitted to hospital following the initial febrile convulsion. There are no routine investigations indicated following such convulsions. Instead, investigations are conducted individually in order to ascertain each childs diagnosis. Ears, nose and throat should be carefully assessed and a chest x-ray may be ordered. It is likely that blood and urine samples will be obtained and a lumbar puncture may be indicated if meningitis is suspected. This period of hospitalisation also provides the nurse with a valuable opportunity to educate parents regarding detection of infection, temperature control, and measures to take should the child experience another febrile convulsion. Key responsibilities The key responsibilities of the nurse while the child is hospitalised involve: temperature monitoring pharmacological and non-pharmacological methods of temperature regulation maintaining child comfort ensuring adequate hydration assisting in the treatment of the underlying cause family education. Family education

It is essential that the nurse provides confident and honest information to parents following their childs convulsion. This information should be both written and verbal and must include the causes of febrile convulsion and the risk of subsequent events. It would be helpful for written information to be available in a number of languages in A&E departments. It is essential to stress the prognosis so that parents are fully aware that their child is likely to outgrow the risk of experiencing febrile convulsions. Parents should be informed that fever is a sign of infection. While it is useful to advise parents to purchase a thermometer, it is equally important that they learn to trust their own judgement. If fever is present, the child will feel hot, look flushed and may be listless or irritable. In addition, there may be signs of a specific associated infection such as: cough sore throat or ears pain passing urine. Parents should be advised to dress the child in light cotton clothing and to encourage frequent oral fluids. Antipyretics should be administered as soon as parents become aware of the increase in temperature. As stated, paracetamol tends to be the most commonly used drug and this is available in many forms. Parents may have personal preferences as to the route they choose to administer the antipyretic.

Information families will require prior to discharge Nature of febrile convulsions Causes of febrile convulsions Risk of recurrence Whether the child suffers pain or discomfort during the convulsion How to manage a high temperature in a child How to deal with another convulsion in the home Prognosis
Further Convulsions If the child has a further febrile convulsion parents should be advised to lie their child in semi-prone position. A prescription for rectal diazepam is often given to parents on discharge from hospital and the nurse is responsible for ensuring that they are confident and competent in its administration. An educational video is available and can be given to carers to view at home. Parents should be advised exactly when to administer anticonvulsant medication. They should also be asked to bring their child to a doctor following a convulsion in order to determine and address the underlying cause. Family Trauma Witnessing a febrile convulsion is a terrifying experience for a family. Studies have shown that parents imagine that their child is dying or in great pain. The nursing management of the child focuses upon the immediate care of the child in the A & E Department and temperature management. In addition, a significant emphasis by the nurse must placed on education of the family so that fever can be detected and treated, potentially preventing another febrile convulsion.

Sara Raftery is a nurse teacher in the Childrens Hospital, Temple Street, Dublin 1
References 1. American Academy of Pediatrics. Provisional Committee Quality Improvement, Subcommittee on Febrile

Seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996; 97 (5): 769-772. 2. Purssell E. The use of antipyretic medications in the prevention of febrile convulsions in children. J. Clinical Nursing 2000, 9: 473-480. 3. 4. 5. Boschert S. High Fever Raises Risk of Multiple Febrile Seizures. Paediatric News 1999; 33(2): 20. Rogers M, Febrile Convulsions. Paediatric Nursing 1995; 7 (5): 33-37. Miller R. The effect on parents of febrile convulsions. Paediatric Nursing 1996; 8 (9): 28-31.

6. Offringa M, Moyer VA. Evidence Based paediatrics: Evidence based Management of seizures associated with fever. BMJ 2001; 323 (7321): 1111-1114. 7. Casey G. Fever Management in Children. Nursing Standard 2000; 14 (40): 36-40.

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