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Art & science |
| The
acute
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ofcare
young
people

JOSEPHINE G PATERSON

MANAGEMENT OF FEBRILE
CONVULSION IN CHILDREN
Siba Prosad Paul and colleagues discuss the aetiology, clinical
presentation, diagnosis and management of the most common
type of seizure in children, and set out best practice for their care
Correspondence
siba_prosad@yahoo.co.uk
Siba Prosad Paul is a specialty
trainee year 8 in paediatrics
at Bristol Royal Hospital for
Children, part of University
Hospitals Bristol NHS
Foundation Trust
Eleanor Rogers is fourth-year
medical student at the
University of Bristol
Rachel Wilkinson is an advanced
paediatric nurse practitioner at
St Richards Hospital, Chichester,
part of Western Sussex Hospitals
NHS Foundation Trust
Biswajit Paul is a consultant
resident neurologist at Gauhati
Medical College and Hospital,
Guwahati, India
Date of submission
March 1 2015
Date of acceptance
April 14 2015
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
journals.rcni.com/r/
en-author-guidelines

Abstract
The causes of febrile convulsions are usually benign.
Such convulsions are common in children and their
long-term consequences are rare. However, other
causes of seizures, such as intracranial infections,
must be excluded before diagnosis, especially in infants
and younger children. Diagnosis is based mainly on
history taking, and further investigations into the
condition are not generally needed in fully immunised
children presenting with simple febrile convulsions.
Treatment involves symptom control and treating the
cause of the fever. Nevertheless, febrile convulsions
in children can be distressing for parents, who should
ONE DEFINITION OF febrile convulsion is an event
associated with fever, but with no evidence of
intracranial infection or acute electrolyte imbalance,
that occurs in an infant or child aged between
six months and six years (Sadleir and Scheffer
2007). Such convulsions represent the most
common type of seizure in children and are one
of the most frequent presentations to emergency
departments (EDs). They are seen in between 3%
and 4% of white children, but are more common
in children of some other ethnic backgrounds:
between 6% and 9% of Japanese children,
for example, and between 5% and 10% of Indian
children (Mewasingh 2010).
Febrile convulsions are generally harmless to the
children concerned but can be extremely frightening
for their parents. It is therefore important that
parents anxiety is addressed sensitively to help
them to feel calmer and to enable ED teams to treat

18 May 2015 | Volume 23 | Number 2

be supported and kept informed by experienced

emergency department (ED) nurses. This article
discusses the aetiology, clinical presentation, diagnosis
and management of children with febrile convulsion,
and best practice for care in EDs. It also includes
a reflective case study to highlight the challenges faced
by healthcare professionals who manage children who
present with febrile convulsion.
Keywords
Children, paediatric, seizures, fever, high temperature,
febrile convulsions, epilepsy
children without repeated involvement of anxious
parents during resuscitation.

Aetiology and pathophysiology

The exact aetiology of febrile convulsion is
unknown, but it is considered to be the result
of a complex interplay between environmental
and genetic factors (Paul et al 2012, Chung 2014).
Fever in febrile convulsions is extra-cranial in
origin and the high temperature associated with
it is a normal physiological response to infection.
Mechanisms that could explain the process of
such convulsions include the release during fever
of cytokines, which cause temporary abnormal
electrical activity in the brain (Lux 2010a,
NHS Choices 2014).
In the UK, the most common infections
associated with febrile convulsion (Paul and Eaton
2013, NHS Choices 2014) are chickenpox, flu,
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Corbis

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Art & science | acute

care ofcare
young people
gastroenteritis, middle ear infections, respiratory
tract infections and tonsillitis.
The risk of febrile convulsion is increased
by positive family histories, with up to 40%
of children having such histories. Between 9% and
22% of children with siblings who have experienced
febrile convulsion experience it themselves, and the
likelihood that the other twin will experience febrile
convulsion is highest among monozygotic twins (Lux
2010a). Almost 50% of children in whom siblings
and one parent have experienced febrile convulsion
experience it too (Tejani 2015).
Pre-existing neurological conditions, such as
cerebral palsy, and iron and zinc deficiencies, are
also thought to increase the risk of febrile convulsion
(Paul et al 2012, Waqar Rabbani et al 2013).
Research demonstrates that the development
of febrile convulsion may be due mainly to
polygenetic inheritance (Paul and Chinthapalli
2013, Tejani 2015), although an autosomal
dominant pattern of inheritance known as a febrile
seizure susceptibility trait has been identified in
a few families (Tejani 2015). Although the exact
molecular mechanisms are yet to be understood
fully, underlying mutations in genes encoding
sodium channels and the gamma-aminobutyric acid
A receptor have been identified in children with
febrile convulsions (Tejani 2015).

Clinical presentation
The peak age of onset of febrile convulsion is
18 months, with up to 50% of children having first
episodes aged between 12 and 30 months. First
presentations of febrile convulsions in children
aged over three years are rare (Sadleir and Scheffer
2007, Chung 2014).
Children with febrile convulsion usually have
a temperature of more than 38C. Convulsions
can occur at any point during a febrile illness,
however, and children may not have a raised
temperature at the time of their seizures but may
subsequently develop one.
Signs and symptoms can include loss of
consciousness, global or focal twitching or jerking
of arms and legs, difficulty breathing, foaming at
the mouth, pallor or going blue, and eyes rolling
back in the head. After a seizure, children are often
drowsy and sometimes confused, and can take up to
30 minutes to wake properly (Department of Health
Australia 2010).
There are two types of febrile convulsion,
with 70% classified as simple and 30% as complex.
The characteristics of each are shown in Table 1.
Febrile status epilepticus, a severe form of complex
febrile convulsion lasting at least 30 minutes without
20 May 2015 | Volume 23 | Number 2

interim recovery, occurs in 5% of children with febrile

convulsion, and is more likely than other forms of
complex febrile convulsion to have focal features
(Sadleir and Scheffer 2007, Chung 2014, Tejani 2015).

Diagnosis
When children with febrile convulsion present
to EDs, healthcare professionals should take
detailed and accurate histories, and make physical
examinations, to rule out other diagnoses and to
identify the cause of fever. Differential diagnoses
of childhood seizures (Sadleir and Scheffer 2007,
Paul et al 2012) include:
Rigors with no loss of consciousness.
Febrile delirium, an acute and transient confused
state associated with fever.
Febrile syncope.
Breath-holding attacks, in which children
transiently lose consciousness due to voluntarily
holding their breath.
Reflex anoxic seizures, in which painful events or
shock causes children suddenly to become limp.
Such children may have low-grade pyrexia.
Evolving epilepsy syndrome.
Central nervous system (CNS) infections, such as
meningitis and encephalitis.
Histories are likely to come from childrens parents
or guardians, and healthcare professionals should be
careful to gather information on (Chung 2014):
The nature of the convulsion, for example
whether it is generalised or focal, and
its duration.
The duration of the post-ictal phase.
Recent illnesses or fever.
Recent antibiotic use.
Other symptoms, such as breathing difficulties
and diarrhoea.
Immunisation status.
Histories of febrile convulsions or previously
diagnosed neurological conditions.
Family histories of febrile convulsions, epilepsy
or sudden death.
Use of antipyretics.
Use of rescue anticonvulsants, such as diazepam
and midazolam, to terminate seizure. This
question may be asked of paramedic staff
rather than parents or guardians.
Examinations should include full neurological
assessments and healthcare professionals
should look for signs of meningeal irritation,
such as neck stiffness (Chung 2014). It is
therefore vital that they can recognise the signs
and symptoms of CNS infections, which can be
subtle in infants and young children (Paul and
Chinthapalli 2013).
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Table 1 Characteristics of simple and complex febrile convulsions

Simple

Complex

Tonic-clonic activity is generalised and without the

features of a focal seizure.
Each convulsion lasts for less than ten minutes.
Convulsions resolve spontaneously.
There are no further convulsions within the next
24 hours.

Each convulsion lasts more than ten minutes.

A second convulsion may occur within 24 hours.
There is a focal seizure in which, for example,
convulsions occur on only one side of the body.
Full consciousness is not regained within one hour.
There are post-ictal neurological abnormalities.
There is a brief period of paralysis, known as
a Todds paresis, after the convulsion.
Febrile status epilepticus occurs.

(Adapted from Sadleir and Scheffer 2007, Mewasingh 2010, Paul and Eaton 2013, Chung 2014)

The seriousness of illness in children should

not be assessed solely on the height of their
temperatures, and healthcare professionals should
also record each childs respiratory rate, oxygen
saturation, central capillary refill time, heart rate,
blood pressure, blood glucose level and paediatric
early warning score (PEWS) (Royal College of
Nursing 2013).
Clinicians should remember that children
who present during or immediately after febrile
convulsions will have a high PEWS and should be
reviewed urgently by a medical professional or
advanced emergency nurse practitioner. A high PEWS
is likely to persist for a short period of time due to
pyrexia and associated tachycardia and tachypnoea,
and ED nurses should continue to monitor the child
concerned until his or her transfer because a further
increase in PEWS should trigger a reassessment of
the childs condition.
Investigations should also be carried out in
children who show signs and symptoms of serious
illness or intracranial infection, such as meningitis
or pneumonia. Investigations are rarely necessary
in children who are aged over one year, are fully
immunised, have a clear focus of infection and have
had simple febrile convulsions (Oluwabusi and Sood
2012). However, further investigations should usually
be carried out in children who are less than one
year old, who are presenting with complex febrile
convulsions for the first time or who may have
symptoms that suggest CNS infections (National
Institute for Health and Care Excellence (NICE) 2013a).
In such cases, healthcare professionals can
request full septic screens including:
Full blood count and tests of C-reactive
protein, calcium, glucose, magnesium, urea and
electrolytes, and, if bacterial sepsis is suspected,
blood culture.
Urine dipstick and culture tests.
Chest X-rays.
EMERGENCY NURSE

Stool culture tests.

Lumbar puncture. However, because raised
intracranial pressure is difficult to assess in
the post-ictal period, this test should not be
undertaken immediately after a febrile convulsion.
In children with complex or recurrent febrile
convulsion, or those with neurological
abnormalities, magnetic resonance imaging,
computed tomography, electroencephalography
(EEG) or a combination of these can be considered
to rule out underlying or evolving neurological
problems. EEG is usually undertaken at least
48 hours after the febrile convulsion to prevent
post-ictal electrical activities being misinterpreted
as abnormal seizure activities (Paul et al 2012,
Shah et al 2014).
In children who have had recurrent episodes
of febrile convulsion and with clearly identified
sources of infection, repeat investigations
are not required. However, it is important
that healthcare professionals determine the
source of childrens infections and ensure
that they are managed appropriately (Paul and
Chinthapalli 2013).
A case study involving a young child with febrile
convulsion is shown on page 22.

Management
The first healthcare professionals to see children
with febrile convulsion are often emergency
nurses, who therefore have an important role
to play in managing the childrens condition.
Most such children present to EDs after their
episodes of convulsion are over, but a small
number present while still convulsing and must be
stabilised following the ABCDE approach. This is
generally done in a resuscitation room (Paul and
Chinthapalli 2013).
Witnessing convulsing children is distressing
for their parents. Such children appear pale,
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Art & science | acute

care ofcare
young people
Casestudy
A paediatric medical team was crash bleeped
to attend resuscitation urgently after a three-year-old
boy was rushed with his parents by ambulance to the
emergency department (ED).
The boys parents said that, while at home about five
hours earlier, he had become febrile. His parents had
given him paracetamol, but he had suddenly become
floppy and unresponsive. Worried that their son
had sustained brain damage due to high fever or was
about to die, the parents had called for an ambulance.
On the way to the ED, the right side of the boys body
had begun to twitch and the twitching progressed to
a generalised tonic-clonic seizure.
On arriving at the ED, the parents were extremely
distressed and, while the team stabilised the
boy, made initial observations and administered
medications, his parents were supported by a senior
ED staff nurse.
The family is of an Indian ethnic background. History
taking from the parents revealed that there was no
family history of epilepsy, although the boys mother
reported that she had experienced recurrent febrile
convulsion early in her life and had been treated with
sodium valproate till her sixth birthday.
Initial observations showed that the boy had
a temperature of 39.3C, a pulse rate of 166 beats
per minute, respiratory rate of 36 breaths per minute,
oxygen saturations of 91% in air and a central
capillary refill time of two seconds. His bedside blood
glucose level was 9.3mmol/L.
The boy was administered high-flow oxygen through
a face mask. An intravenous (IV) cannula was
inserted and the boy was administered a dose of IV
lorazepam 0.1mg/kg.
After 12 minutes, the boys seizure terminated but he
remained unresponsive and with a low Glasgow Coma
Scale score, of 10/15. He remained unresponsive for
a further 90 minutes.
During this period, laboratory results showed he had
a C-reactive protein level of 27 mg/L and a white cell
count of 14.8x109/L, but no electrolyte abnormalities
were detected.
On waking, the boy was confused and distressed,
and struggled to recognise his parents for another
22 May 2015 | Volume 23 | Number 2

25 minutes. Clinical examination revealed he

had bilateral inflamed tympanic membranes and
right-sided inflamed enlarged tonsils.
The boy was given a provisional diagnosis of complex
febrile convulsion and was put under neurological
observation. The possibility that he had contracted
another serious infection, such as meningitis or
encephalitis, was considered and documented.
Because there had been a prolonged period of
unresponsiveness before and after his seizure, he was
administered IV ceftriaxone and acyclovir in case of
intracranial bacterial and herpes infections.
Over the next 36 hours, the boys fever settled and
he recovered completely. His detailed neurological
assessment produced normal results. The team
discussed with the boys parents whether he should
undergo lumbar puncture but, in light of the parents
reluctance and the fact that the likelihood that
he had contracted an intracranial infection was
considered minimal, it was decided not to carry out
the procedure.
At 72 hours after admission, the boys blood
culture was reported to be negative and
IV medicines were discontinued. He was put
on a ten-day course of oral co-amoxiclav and his
discharge home was arranged.
At his discharge, his parents were given an
information leaflet on febrile convulsion.
A childrens nurse explained to them that, in view
of the boys complex febrile convulsion and family
history, he was at a high risk of further febrile
convulsions and gave them advice about the use of
antipyretics at home.
Two weeks later, the boy and his parents returned for
an electroencephalogram, which was subsequently
reported to be normal. After consulting a neurologist
while on holiday, his parents also organised
a magnetic resonance imaging scan of his brain,
which was also reported as normal.
The boy was discharged from the follow-up paediatric
clinic a year later, when the parents decided to move
the family to India. A summary of the boys medical
condition, including the investigations performed
and plan of management, was given to them. The boy
was reported to be developing normally and doing
well at school.
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cannot communicate, and can be frothing from

the mouth and actively fitting. Parents often
think their children are going to die because they
can appear lifeless during episodes. Baumer et al
(1981) interviewed 36 parents who had witnessed
their childrens first febrile convulsions and
reported that most thought that their children
were dying or were likely to die. It is therefore
vital that parents are adequately reassured and
that their concerns are addressed. It should be
acknowledged and explained that the experience
can be frightening, but they should be reassured
that their children will live.
If parents want to witness the resuscitation of
their children, appropriately trained healthcare
professionals should support them (Perry 2009).
The benefits of allowing parents to be present
(Maxton 2008, Keller 2011) include:
Giving them a sense of continual involvement in
their childrens care.
Giving children a sense of reassurance and safety
when they start to wake up and can see their
parents are present.
Helping parents to understand that their
children have received the best possible
care, and satisfying them that the healthcare
professionals have done everything they can to
make their children better.
Improving relationships between families and
healthcare professionals.
Healthcare professionals should also give parents
verbal and written advice about caring for their
children after febrile convulsions. This advice should
be based on (NICE 2013b):
Safe use of antipyretics.
Maintaining hydration, and identifying signs and
symptoms of dehydration.
Identifying non-blanching rash.
Checking children at night.
Seeking further help if children have further
seizures, if fevers last for more than five days or
if the childrens conditions deteriorate.
Resuscitation is also stressful for the staff supporting
the parents, especially if there is uncertainty about
when convulsing children will respond to medication.
Some children who have been given intravenous
(IV) lorazepam respond immediately, for example,
while others also need IV phenytoin or rapid sequence
induction by an anaesthetist before responding.
There is a risk in such cases that the information
staff provide to patients will distress them further
and staff need to judge what information to share on
a case-by-case basis.
Febrile convulsions are usually self-limiting but,
when they have lasted for more than five minutes,
EMERGENCY NURSE

anticonvulsant medication, such as per rectal

diazepam or buccal midazolam, may be needed
to stop them (Chung 2014). A list of medicines
commonly used in children presenting with febrile
convulsion is shown in Table 2, page 24.
Children with simple febrile convulsions, a clear
focus of infection and who appear well do not
require admission and can be discharged after
a period of observation in the ED or a short-stay
ward, preferably six hours after the episode
(Shah et al 2014). However, admission for observation
is recommended (NICE 2013b) if:
The child is under 18 months of age.
The child is ill.
There has been a prolonged or complex
febrile convulsion.
There is a risk of recurrence.
Meningitis or encephalitis is suspected.
There is no clear source of infection.
The child shows developmental delay or
neurological abnormalities.
The parents cannot cope or clinicians
think the parents cannot provide regular
monitoring immediately after the childs
febrile convulsion, or there are other
child-safeguarding concerns.
Treatment should be directed at treating the
source of infection and management of symptoms.
If bacterial infection is suspected, antibiotics may be
considered. Children should also be encouraged to
drink fluids to keep hydrated.
Parents and healthcare professionals often
assume that a raised temperature means an
increased risk of febrile convulsion, which often
leads to overuse of antipyretics (Banks et al
2013). However, research suggests that, although
antipyretics reduce body temperature, they do
not reduce febrile convulsion recurrence rates
(Strengell et al 2009, Lux 2010b, Banks et al 2013,
Chung 2014). Antipyretics should be administered
only to reduce discomfort, therefore, and to increase
the likelihood of drinking and thereby maintain
hydration (Banks et al 2013, Wragg et al 2014).
Paracetamol and ibuprofen can be administered,
unless they are contraindicated, although NICE
(2013b) recommends using only one because the
clinical benefit of using them together is small
and there is no evidence that the combination is
more effective than a single antipyretic agent in
reducing distress. Administering combinations of
antipyretics is common practice in hospitals but
provides no added benefit, increases the risk of
drug administration errors and overdoses, and gives
an incorrect message to parents (Banks et al 2013,
NICE 2013b, Wragg et al 2014).
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Art & science | acute

care ofcare
young people
Children with fever should not be under- or
overdressed, and infants heads should be left
uncovered (NICE 2013b). The temperature of the room
can be reduced, but it is not advisable to blow air
from a fan directly towards children or to give them a
sponge bath as these techniques can lead to peripheral
vasoconstriction, and raise body temperature even
further through shivering (NICE 2013b).
Long-term anticonvulsant medication is not
usually prescribed as prophylaxis for febrile
convulsions because trials have shown they do
not reduce the chance of developing epilepsy
and their potential side effects outweigh their
potential benefits (Strengell et al 2009, Lux 2010a,
Paul and Chinthapalli 2013, Shah et al 2014).
In specific circumstances, however, the benefits
can outweigh the risks and children are prescribed
benzodiazepines, such as rectal diazepam or buccal
midazolam, for use at home as a rescue therapy
to stop a seizure (Chung 2014). Benzodiazepines
to be administered by parents at home can be
prescribed for children who have frequent febrile
convulsions in short periods or convulsions that last
more than 15 minutes, as long as anticonvulsants
have been required previously to stop seizures, or the
children and their families live in geographically
isolated areas where they cannot receive immediate
medical assistance (Sadleir and Scheffer 2007,
Lux 2010a, Paul and Chinthapalli 2013).

Prognosis
Healthcare professionals and parents are usually
most concerned about the risk of seizure
recurrence of febrile convulsions and the risk
of epilepsy. For most children, however, febrile
convulsions have no long-term consequences,
and do not affect behaviour, learning or intelligence
(Chung 2014). It is important to emphasise that
febrile convulsions are not epileptic in origin and
children who have simple febrile convulsions are at
no greater risk of developing epilepsy than other
children (Mewasingh 2010).
One third of children who have one febrile
convulsion will have a second during a later
febrile illness. Healthcare professionals should
be aware of the risk factors for recurrence,
therefore, because they may need to counsel
the childrens parents accordingly and some
children may need rescue anticonvulsants.
Risk factors for recurrence of febrile
convulsions (Waruiru and Appleton 2004,
Sadleir and Scheffer 2007, Mewasingh 2010,
Chung 2014) include:
A strong family history of febrile convulsion.
Onset of first episode before 18 months of age.
Less than one hour of fever before onset of first
febrile convulsion.
Body temperature of less than 38C at the onset
of febrile convulsion.

Table 2 Medicines commonly used for children with febrile convulsion who present to emergency departments
Name

Dosage

Administration route

Frequency

Maximum dosage

When used

Paracetamol

15mg/kg

Oral or rectal,
or intravenous (IV)
during resuscitation

Between four
and six hourly

Four within 24hours

For pyrexia in
children with febrile
convulsion (FC)

Ibuprofen

5mg/kg

Oral

Between six
and eight hourly

Three within 24hours

For pyrexia in children

with FC unless they
are dehydrated

Diazepam

0.25mg/kg

IV or intraosseous

0.5mg/kg

Rectal

Second dose
ten minutes
after the first

Lorazepam

0.1mg/kg

IV

For an actively
convulsing child whose
seizure have lasted
more than five minutes

Midazolam

0.15-0.2mg/kg

IV

Only two doses of

benzodiazepines are to
be used irrespective of
the agents and whether
they are administered
singly or in combination

0.5mg/kg

Buccal

20ml/kg

IV

During resuscitation

More than two doses are

rarely required

In children with shock,

for example during
febrile illness due
to gastroenteritis

0.9% sodium
chloride solution

(Adapted from Advanced Life Support Group 2011, British National Formulary for Children 2015)

24 May 2015 | Volume 23 | Number 2

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Febrile convulsion will recur in 4% of children

for whom no risk factor applies but in 75% of those
for whom all four apply (Waruiru and Appleton
2004, Sadleir and Scheffer 2007). It is important
that healthcare professionals provide a realistic
view of the chances of recurrence depending on the
relevance of these risk factors so that parents are
fully informed and can act appropriately.

Summary
Febrile convulsion is the most common type
of childhood seizure and most children with
the condition have good prognoses, with few
going on to develop long-term health problems.
The diagnosis is clinical and it is important to
exclude serious intracranial infections, especially
after a complex febrile convulsion. Management
involves symptom control and treating the
cause of the fever.
Healthcare professionals need to support
parents, who are likely to be distressed and
frightened after convulsions have occurred. It is
essential that they provide guidance on, and dispel
myths about, fever management.

Implications for practice

Healthcare professionals can:
Raise suspicion of any serious pathology such as
intracranial infection.
Provide urgent clinical care for convulsing children.
Provide care for children, including monitoring
their temperature and other parameters, and make
them as comfortable as possible.
Instigate investigations and ensure childrens airways
are safe if they are being moved to other parts of
a hospital, such as the radiology department for
computed tomography scans, when they may not
have regained consciousness fully.
Reassure parents and advise them verbally and in
information leaflets before discharge on, for example,
the use of single antipyretics, fluid management and
what to do if their children have further convulsions.
Identify children who have missed immunisations
and encourage parents to ensure they are immunised.
Address parental concerns if febrile convulsions
have occurred after vaccinations because they may
be reluctant to immunise their children again.

Online archive
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Conflict of interest
None declared

References
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Advanced Paediatric Life Support: The Practical
Approach. Fifth edition. BMJ Books, London.
Banks T, Wall M, Paul SP (2013) Managing fever
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Baumer JH, David TJ, Valentine SJ et al (1981)
Many parents think their child is dying when
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Medicine and Child Neurology. 23, 4, 462-464.
British National Formulary for Children (2015)
National Formulary for Children 20142015.
British Medical Association and the Royal
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Chung S (2014) Febrile seizures. Korean
Journal of Pediatrics. 57, 9, 384-395.
Department of Health Australia (2010)
Emergency Department Factsheets: Febrile
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(Last accessed: April 17 2015.)
Keller L (2011) The advantages of family
presence during cardiopulmonary resuscitation.
Carle Selected Papers. 54, 2, 17-21.

EMERGENCY NURSE

Lux A (2010a) Treatment of febrile seizures:

historical perspective, current opinions,
and potential future directions. Brain and
Development. 32, 1, 42-50.

National Institute for Health and Care

Excellence (2013b) Clinical Knowledge
Summaries: Febrile Seizures. tinyurl.com/
kryqy6t (Last accessed: April 17 2015.)

Lux A (2010b) Antipyretic drugs do not reduce

recurrences of febrile seizures in children
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