Febrile Convulsions : Remote triage

Febrile convulsions (FC) are the most common seizure disorder in children, affecting those aged 6 months to 5 years. These seizures occur in response to fever, often due to viral infections, and are generally benign without long-term neurological consequences. With an incidence of 2-5% in the pediatric population, effective triage of febrile convulsions is essential in emergency and primary care settings. Understanding the classification of FC—simple or complex—helps guide appropriate management and referral decisions.

Current guidelines prioritize reassurance, safety, and symptom control over aggressive treatment for febrile seizures. Routine use of antiepileptic medication is not recommended for simple febrile seizures due to their benign nature. If a seizure lasts beyond five minutes, benzodiazepines are the first-line treatment. While antipyretics are commonly used, evidence does not support their role in preventing recurrent febrile seizures.

Febrile Seizure Assessment

1. Determining if the Seizure Meets Febrile Convulsion Criteria

Did the seizure occur in association with a fever? (Parental report of fever is accepted.)

When did the fever start in relation to the seizure? (Before, during, or after?)

What was the peak temperature recorded, and how long did the fever last?

Did the child have any symptoms of illness before the fever started (e.g., runny nose, cough, vomiting, rash)?

Has the child ever had a fever-related seizure before?

Febrile Seizure Assessment - Question 2

2. Differentiating Between Simple and Complex Febrile Convulsions

How long did the seizure last? (Simple: <15 minutes; Complex: >15 minutes)

Was the seizure generalized (affecting the whole body) or focal (affecting one limb or side)?

Did the seizure occur more than once within 24 hours?

How long did the child remain drowsy or confused after the seizure? (Prolonged postictal drowsiness suggests complexity.)

Seizure Questionnaire

Febrile Seizure Assessment - Question 3

3. Red Flag Evaluation – Assessing for Serious or Life-Threatening Conditions

Was the seizure prolonged (lasting >5 minutes)?

Is the child still excessively drowsy, confused, or difficult to wake?

Is there any neck stiffness, irritability, photophobia, or a bulging fontanelle? (Suggests meningitis/encephalitis.)

Is there a petechial or purpuric rash? (A red flag for meningococcal disease.)

Did the child exhibit focal neurological deficits lasting more than 1 hour?

Are there signs of severe infection (e.g., persistent vomiting, rapid breathing, poor feeding, high-pitched cry, lethargy)?

Has the child had any recent antibiotic use? (May mask signs of bacterial meningitis.)

Febrile Seizure Assessment - Question 4

4. Evaluating the Underlying Cause of Fever

Has the child recently had symptoms such as runny nose, cough, or ear pain? (Suggests respiratory infection.)

Has the child recently had vomiting, diarrhea, or signs of dehydration? (Suggests gastrointestinal infection.)

Has the child developed a rash or skin lesions? (May indicate viral exanthem or bacterial infection.)

Has the child had recent exposure to illness (e.g., daycare, sick contacts)?

Has the child recently received antibiotics? (Could mask signs of infection.)

Has the child received any recent vaccinations that could be associated with post-vaccination fever? (e.g., MMR, DTaP)

Febrile Seizure Assessment - Question 5

5. Determining the Need for Immediate Medical Attention

Did the seizure last longer than 5 minutes? (Prolonged seizures require urgent care.)

Is the child struggling to breathe or showing signs of respiratory distress?

Is the child still unresponsive or excessively drowsy after the seizure?

Is there a stiff neck, persistent vomiting, or signs of meningitis?

Are there any signs of serious bacterial infection (e.g., petechial rash, sepsis signs)?

Febrile Seizure Assessment - Question 6

6. Assessing Risk Factors for Recurrence of Febrile Convulsions

Has the child had previous febrile convulsions?

Is there a family history of febrile seizures or epilepsy?

What was the child’s age at the time of the first febrile seizure? (Younger onset may indicate higher recurrence risk.)

Did the seizure occur at a lower temperature or during a rapid fever spike? (Rapid temperature rise can trigger febrile seizures.)

Febrile Seizure Assessment - Question 7

7. Evaluating Parents' Ability to Manage Febrile Convulsions at Home

Do the parents know how to place the child in the recovery position during a seizure?

Do they understand when to seek emergency care?

Do they have fever-reducing medications (e.g., acetaminophen, ibuprofen) available? (Antipyretics do not prevent febrile seizures but can improve comfort.)

Are they aware of seizure first aid and how to prevent injury during a seizure?

Febrile Seizure Assessment - Question 8

8. Assessing the Child’s Vaccination Status and Recent Immunizations

Is the child up to date with routine vaccinations?

Has the child recently received vaccines that can cause post-vaccination fever? (e.g., MMR, DTaP)

Are there any missed immunizations or unknown vaccine history? (Check for risk factors related to preventable infections.)

Febrile Seizure Assessment - Question 9

9. Determining Pre-Existing Medical Conditions Affecting Seizure Management

Does the child have any known neurological conditions or developmental delays?

Has there been any concern about the child’s neurodevelopmental progress? (Delays may suggest underlying pathology.)

Is the child taking any medications that could lower the seizure threshold?

Has the child ever been diagnosed with epilepsy or other seizure disorders?

Febrile Seizure Assessment - Question 10

10. Evaluating the Need for Further Investigations or Specialist Referral

Did the seizure have complex features? (e.g., prolonged, focal, recurrent within 24 hours)

Has the child had multiple febrile seizures with varying presentations?

Are there concerns about underlying metabolic, neurological, or infectious causes?

Has the child shown any developmental regression or unusual behavior patterns?

Are there any features suggesting an underlying neurological disorder, such as cerebral palsy or neurocutaneous syndromes?

Febrile Seizure Assessment - Question 11

11. Conditions That May Present Similarly to a Febrile Seizure

Could this be meningitis/encephalitis? (Check for irritability, neck stiffness, bulging fontanelle, prolonged postictal period, photophobia, petechial rash.)

Could this be febrile myoclonus? (Myoclonic jerks of the upper limbs during fever, lasting minutes to hours.)

Could this be rigors or delirium? (Acute confusion, shivering with fever, involuntary muscle tremors.)

Could this be syncope? (Sudden loss of consciousness, rapid recovery.)

Could this be breath-holding spells or reflex anoxic seizures? (Triggered by fright, pain, or emotional distress.)

Could this be due to head trauma? (Recent injury, possible concussion.)

Could this be hypoglycemia or metabolic disorders? (Check for developmental delay, faltering growth, hepatosplenomegaly.)

Could this be drug use or withdrawal? (Unexplained seizure in older children.)

Could this be epilepsy? (No fever, complex seizure, or neurodevelopmental concerns.)

Could this be an epilepsy syndrome?

Dravet syndrome: Fever-triggered seizures progressing to myoclonic/focal seizures, developmental delay.

Genetic epilepsy with febrile seizures plus (GEFS+): Febrile seizures continuing beyond 5 years, with afebrile seizures later.

Febrile Seizure Assessment - Question 12

12. Genetic and Neurological Conditions Associated with Seizures

Dravet Syndrome – Severe myoclonic epilepsy of infancy, with prolonged fever-triggered seizures progressing to myoclonic and focal seizures. Developmental delay follows.

Genetic Epilepsy with Febrile Seizures Plus (GEFS+) – Autosomal dominant disorder where febrile seizures persist beyond 5 years, and afebrile seizures may occur.

Sturge-Weber Syndrome – Neurocutaneous disorder with a unilateral port-wine stain in the trigeminal distribution, associated with leptomeningeal angiomatosis, seizures, and glaucoma.

Tuberous Sclerosis – Genetic disorder causing benign tumors in multiple organs; facial angiofibromas, hypopigmented macules ("ash-leaf spots"), shagreen patches, and periungual fibromas may suggest diagnosis.

Neurofibromatosis Type 1 (NF1) – Multiple café-au-lait spots, axillary freckling, Lisch nodules (iris hamartomas), and neurofibromas are characteristic.

Benzodiazepine Rescue Medication

Medication	Age Group	Recommended Dose	Administration	Repeat Dose
Buccal Midazolam	6–11 months	2.5 mg	Oromucosal solution	Once after 10 min (medical advice)
Buccal Midazolam	1–4 years	5 mg	Oromucosal solution	Once after 10 min (medical advice)
Buccal Midazolam	5–9 years	7.5 mg	Oromucosal solution	Once after 10 min (medical advice)
Rectal Diazepam	6 months – 1 year	5 mg	Rectal solution (⚠ Most products unlicensed <1 year)	Once after 10 min (if needed)
Rectal Diazepam	2–11 years	5–10 mg	Rectal solution	Once after 10 min (if needed)

Benzodiazepine rescue medication should only be started based on specialist advice, considering the child's febrile illness frequency, seizure type, parent/carer preferences, and an individualized risk-benefit assessment.

For febrile status epilepticus (FSE), rapid benzodiazepine administration and emergency follow-up care are crucial. Lumbar puncture is only recommended when CNS infection is suspected, as the risk of bacterial meningitis in first-time simple febrile seizures is low.

For febrile status epilepticus (FSE), rapid intervention with benzodiazepines and emergency follow-up care are essential. Lumbar puncture is only recommended in cases where central nervous system infection is suspected, as the risk of bacterial meningitis in first-time simple febrile seizures is low.

Aspect	Summary (Guideline Consensus)
Definition	A febrile seizure is a convulsion occurring in a child typically between ~6 months and 5 years of age, associated with fever ≥38 °C ↑ (100.4 °F) and no evidence of intracranial infection or other acute cause. By definition, the child has no prior afebrile seizures or pre-existing epilepsy.
Types	Febrile seizures are divided into simple vs complex: • Simple febrile seizure: Generalized, lasts <15 minutes ↓, and occurs once within 24 hours. • Complex febrile seizure: May have focal features, last ≥15 minutes ↑, or recur within 24 hours.
Risk Factors	Key predisposing factors include a family history of febrile seizures, viral infections causing fever, and (rarely) fever following immunizations (e.g., post–MMR). The highest incidence is around 18 months of age. Risk of recurrence is increased if the first seizure was at a younger age, if the fever was relatively low when the seizure occurred, or if there is a strong familial tendency.
Management	Initial care: Ensure airway, breathing, and circulation. If seizure lasts >5 minutes, use a benzodiazepine (e.g., rectal diazepam or buccal midazolam). Identify the cause of fever: Rule out serious infections such as meningitis; perform lumbar puncture if indicated. Routine investigations (e.g., EEG, neuroimaging) are not required for a single simple febrile seizure in a well child. Supportive care: Use antipyretics for comfort (although they do not prevent seizures). Provide reassurance to caregivers about the typically benign nature of febrile seizures.
When to Refer	Red flags: Signs of central nervous system infection (e.g., neck stiffness, bulging fontanelle, sepsis signs) or seizures presenting outside the usual 6 months–5 years range require urgent evaluation. Complex features: Focal onset, duration ≥15 minutes ↑, or multiple seizures in 24 hours often warrant specialist assessment (neuroimaging, EEG, pediatric neurology consult). If a child does not return to baseline quickly (continued drowsiness >1 hour post-seizure) or has focal neurologic deficits, urgent referral is essential.
Prognosis	Generally excellent. Simple febrile seizures are benign with minimal risk of death or lasting neurologic injury. About one-third of children experience a recurrent febrile seizure. The chance of developing epilepsy after a simple febrile seizure is only ~2%, rising slightly in cases of complex febrile seizures (5–8%). Intellectual development and behavior typically remain normal.

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