Clinical Practice Guidelines Management of Febrile Fits

Definations:
Febrile fits (F.C.) are defined as fits occurring in association with fever in children between
3 months and 6 years of age, in whom there is no evidence of intracranial pathology or
metabolic derangement that could be the cause of the fit. Febrile fits, febrile convulsions
and febrile convulsions are synonymous terms. Children with previous afebrile fits are
excluded from this definition.

Magnitude of Problem
There is no comprehensive local epidemiological data. Studies in Western Europe quote a
figure of 3-4 % of children  5 years experiencing febrile fits with higher figures of up to
8% in Japan. This makes febrile fits the single most common problem in paediatric
neurology.

Types of Febrile Fits

Febrile fits are classified as either simple or complex. Simple febrile fits are short,  15
minutes, generalised fits that do not occur more than once in a febrile episode. Febrile fits
that are either prolonged (  15 mins ) unilateral or recur within a single febrile episode
are classified as complex. (Nelson &Ellenberg,1978)

Issues in management of Febrile Fits.

The major issues are:-

a) Risk of recurrent febrile fits.

b) Risk of subsequent afebrile, unprovoked fits or epilepsy.
c) Prognosis for neurological, motor, intellectual and behavioural outcomes.
d) Need for admission.
e) Investigations for the individual child.
f) Need for electroencephalogram (EEG).
g) Need for prophylactic treatment.
h) Type of prophylactic treatment to be used.

A)Risk of Recurrent Febrile Fits

Recurrence of febrile fits is the largest risk for children with this condition.
The risk factors for such recurrence are:
 Early age of onset ( 15 months)
 Epilepsy in a first degree relative
 Febrile fits in a first degree relative
 Low degree of fever (  40C) during first febrile fit.
 Brief duration between onset of fever and initial fit

A first complex febrile fit has not been consistently associated with an increased risk of
recurrence. Children in nursery care are also at higher risk ( Berg et al 1997, Knudsen
1996 )
The overall risk of recurrence is 30-40% and half of these go on to get a second
recurrence ( Aicardi ). However there is a range of risk. Those with O or 1 risk factor
have a low risk of  10 %, whereas those with all risk factors have an almost 100% risk.
The single most important risk factors is age at onset with children  1 year having a 50
% risk of recurrence compared to 28% for those above 1 year. Only 9-17% of cases have
3 or more recurrences.

Half of all recurrences occur within 6 months and 3 quarters have occurred by 1 year of
the first febrile fit.

Most long lasting fits are the first episode (Aicardi ). Only 1.4 % of children with an initial
brief F.C. developed a prolonged recurrence lasting 30 minutes or more, and none of these
had had an afebrile fit at 7 years of age (Nelson & Ellenberg 1978).
However children with prior abnormal neurological development may have a much higher
risk of a prolonged recurrence (Berg 1997)

In summary recurrent febrile fits are common especially among those with an early onset.
Most of these are brief and the number of recurrences has no bearing on long term
neurological, motor, intellectual or behavioural outcomes (Knudsen 1996).

B.Risk of Subsequent Afebrile Unprovoked Fits or Epilepsy

Non febrile fit follow F.C. in 2 to 7 % of cases, a rate that is 5-10 times higher than the
population incidence of 0.4 - 0.8 %.

Conversely 10-15% of patients with epilepsy have a positive history for febrile fits
compared to a population incidence for F.C. of 3-4 %.

The current feeling is that these children have inherited a lower threshold for fits that is
manifested as F.C. during the age of susceptibility for this condition.

Initial concerns arising from neurosurgical series about the relationship between Mesial
Temporal Sclerosis (MTS) and a preceding history of prolonged febrile fits have been
challenged by the findings of more recent cohort studies of adolescents with epilepsy, with
or without a prior history of febrile fits ( Berg 1999, Camfield 1994 ). A recent study has
also shown MRI evidence of MTS in relations of patients with intractable partial fits
secondary to this condition even through some of them have never experienced a fit,
febrile or otherwise. ( Fernandez 1998 ). This and other reports of MRI evidence of MTS
in children shortly after a febrile fit suggest that some individuals may have developmental
hippocampal abnormalities that predispose to F.C. and later epilepsy.

In an individual child with febrile fits, features that predict a high risk of later non febrile
fits are:-
1) Abnormal neurological development before first febrile fit.
2) Family history of idiopathic epilepsy
3) Complex febrile fits
4) Recurrent (> 3 ) simple febrile fits
All of the above suggest that the children concerned have inherited a tendency to epilepsy
and possibly also to develop Mesial Temporal Sclerosis.

C. Prognosis for neurological, motor, intellectual and behaviour outcomes.

Two large cohort studies have shown that children who are developmentally normal at the
time of their first febrile fit continue to develop normally at follow-up (Nelson &
Ellenberg, Verity et al). There was no difference between those who had simple or
complex febrile fit in this respect. Children with F.C. actually had better reading skills is
one study (Verity). Another study showed that those who had experienced complex
febrile fit actually did better academically than those with simple febrile fits, but the
difference was not significant (Knudsen).

D. Need for admission.

Not all children with febrile fits need to be admitted. The main reasons for admission are:-
1) To exclude intracranial pathology especially infection
2) Fear of recurrent fits
3) To investigate and treat the cause of fever besides meningitis or encephalitis.
4) To allay parental anxiety, especially if they are staying far from the hospital.

If child can be observed for 6-8 hour in a casualty ward, most of these concerns can be
addressed, a child that is running around normally a few hours after a fit with fever is
unlikely to have meningitis. Seventeen percent of meningitis present with a febrile fit .
Hence the child should only be discharged from the observation ward when the underlying
cause for the fever has been ascertained to be a minor illness only requiring outpatient
care. Ideally the patient should be examined by a pediatric medical officer before the
decision is made not to admit him/her.
If a decision is made to send the child home the parents should be given clear instructions
what to do in case the fit recurs or the fever persists.

Need for further investigations

The need for blood counts, lumbar puncture, urinalysis, chest x-ray, blood culture etc., will
depend on clinical assessment of the individual case. Measurement of serum calcium
and electrolytes are rarely necessary in children with febrile fits.

F) Need for Electroencephalogram (EEG)

Although many EEG changes have been reported in children with febrile fits, both in
recordings shortly after the fits and in interictal records, these findings do not help in the
management of the individual child and have no consistent prognostic value. Hence an
EEG is not indicated in children with febrile fits. This also applies for those with
multiple recurrences and features of complex febrile fits.

G) Need for prophylactic treatment in F.C. and

The major concern in febrile fits is prolonged fits leading to status epilepticus that might
possibly result in neurological sequelae.

Febrile fits are a frightening experience for caregivers and some of them may seek
prophylactic treatment to prevent a recurrence.

F.Type of prophylaxis

There are 3 options

a) Continuous daily anticonvulsant therapy. Phenobarbitone and sodium valporate have
been used successfully to prevent recurrences. However both these drugs have
considerable side effects, namely behavioural, sedative and possibly cognitive for
phenobarbitone and a distinct risk of hepatotoxity with sodium valporate. These risks
are not in keeping with the benign nature of febrile fits. Hence it is now universally
agreed to abandon the practice of prescribing daily anticonvulsants for children with
F.C.

b) Prophylaxis during febrile episodes.

There are two approaches, to administer antipyretics with onset of fever and to give
rectal diazepam suppositories with onset of fever.
Giving antipyretics is indicated by virtue of patient comfort, but has not been shown to
reduce the recurrence rate of F.C. Giving rectal diazepan suppositories has been
shown to be effective if fever is detected early and there is good compliance with the
8 hourly administration of this preparation. The last 2 limitations have been shown in
large studies to render this approach ineffective. Often caregivers are not aware of
fever until the child has fitted.

c) Rectal Diazepam solution to limit the duration of a febrile fit.

In this approach, caregivers are advised how to position and care for a fitting child,
and to administer rectal diazepam solution at 0.5 mg/kg if the fit lasts more than 5
minutes. There are 2 commercially available strengths of rectal diazepam, namely
5mg and 10mg. Children older than 5 years should receive 10 mg. The side effects
of diazepam in this situation are drowsiness, lethargy and ataxia. Respiratory
depression has not been documented with this dose of diazepam in this situation.
However as diazepam may conceal signs of meningoencephalitis the child should be
examined by medical personnel and observed for a few hours if there is any doubt of
an intracranial infection. If the parents do not have diazepam at home this can be
administered at the family doctors clinic or at a hospital casualty.
Intramuscular diazepam is not useful as effective blood levels are only reached after
almost an hour and the levels tend to be erratic. However if the rectal preparation of
diazepam is not available the intravenous preparation can be administered rectally at
the same dose. This is to avoid doctors wasting time trying to get intravenous access
in a chubby fitting child. Rectally administered diazepam has an onset of action of 1-3
minutes and the effects last for about 10 minutes. If the fits recur after 10 minutes the
diazepam can be repeated rectally or intravenously. If the fits persist or recur after
that, then the child should be treated as a case of status epilepticus.
 Midazolam however can be given intramuscularly in doses of 0.3-0.5mg/kg and has
been shown to achieve therapeutic levels in 3 minutes.

Current Recommendation (See also Appendix 1)

Based on the above discussion, the following approached is recommended:
a) Parents of children with febrile fits should be counselled on the benign nature of this
condition.
b) They should be taught effective measures of temperature control such as tepid
sponging with tap water and antipyretic administration. Paracetamol is still the safest
antipyretic and can be given at a dose of 15 mg/kg 6 hourly. Alternately NSAIDs can
also be used. The mechanism of action of tepid sponging namely heat loss from the
body surface should be explained to the parents.

c) The parents should also be advised on first aid measures during a fit, if this was to
recur namely:

i i) Do not panic, remains calm. Note time of onset of fit.

ii) Loosen the child’s clothing especially around the neck
ii iii) Place the child in the left lateral position with the head lower than the body.
iii iv) Wipe any vomitus or secretion from the mouth
iv v) Do not insert any object into the mouth even if the teeth are clenched
v vi) Do not give any fluids or drugs orally
vi vii) Stay near the child until the fit is over and comfort the child as he/she is
recovering.
vii viii)The caregiver of children with a high risk of recurrence, ie more than 3 risk
factors, should be supplied with a preparation of diazepam rectal solution at 0.5
mg/kg of the childs weight. They should be advised on how to administer this in case
the fit last more than 5 minutes.
ix) Rectal Diazepam solution is a list C item in the Ministry of Health’s drug list
and hence should be available in all government health facilities.
viii ix) In the event that the fit is not aborted by rectal diazepan they should seek urgent
medical help to stop the fit before status epileptics develops.
ix x) If the fit is aborted, they should also seek medical advise to determine the cause of
the fever.

These recommendations apply both to children who have had a simple or a complex febrile
fit.
References

1. Aicardi : Epilepsy in children, 2nd Edition International Review of Child Neurology

series 1994 Pages 253-275
2. American Academy of Paediatrics Practice Parameter : Long Term Treatment of the
child with simple Febrile Fits, Paediatrics Vol.103 No.6 1999 page 1307-1309
3. Berg AT, Shinnar S, Darefcky AS et al : Predictors of Recurrent Febrile Fit Arch.
Pediatric, Adoles. Med. 1997, 151:371-378
4. Berg A.T., Shinnar S, Levy SR, Testa F. M.
Childhood onset epilepsy with and without preceding febrile fits Neurology 1999; 53 :
1742-1748
5. Camfield P, Camfield C, Gorden K, Dooley J
What types of epilepsy are preceded by febrile fits? A population based study of
Children
Dev. Med. Child Neurol 1994; 36: 887-892
6. Fernandez G, Effenberger O, Viraz B, etal
Hippocampal Malformation as a cause of familial febrile fit and subsequent
 hippocampal sclerosis
Neurology 1998 ; 50:909-917
7. Fukuyama Y., Seki T., Ohtsaka C., Miara H, Hara M
Practical Guidelines for Physicians in the Management of febrile fits
Brain & Development 1996; 18: 479-484
8. Knudsen F.U., Febrile Fits - treatment and outcome
Brain & Development 1996, 18: 438-449.
9. Nelson K.B. Ellenberg JH
Predictors of epilepsy in children who have experienced febrile fits
N Engl J Med 1976, 295:1029-1033
10. Nelson K.B. , Ellenberg J.H.
Prognosis in children with febrile fits
Pediatrics 1978, 61:720-727
11. Macdonald BK, Johnson AC, Sander JWAS Sharon SD
Febrile fits in 220 children - neurological sequalae at 12 years follow-up
Eur Neurol 1999; 41: 179-186
12. Verity CM, Greenwood R, Dolding J
Long term intellectual and behavioural outcomes of children with febrile fits
N. Engl. J. Med 1998; 338: 1723-8

Members of Panel
Dr Hussain Imam Hj Muhammad Ismail (Chairperson)

Prof Motilal

Prof Ong Lai Choo

Dr Sofiah Ali

Dr Malinee Thambyayah

Prof Zabidi Azhar Hussein

Dr Koh Chong Tuan

Dr Khoo Teck Beng

Appendix 1. Flow Chart For Children With Febrile Fits

Fit with Fever

Note time of onset

Left lateral position
Loosen clothing

Fit stops in less than 5 minutes Fit lasts for more than 5 minutes

Comfort child
Seek medical advice on cause of fever

Rectal diazepam available at home No rectal diazepam at home

Administer rectal diazepam
Fit stops Fit does not stop Family doctor or nearest medical facility
Comfort child Administer rectal diazepam or
Seek medical advice Intravenous diazepam or
on cause of fever Intramuscular midazolam

Fit stops Fit does not stop

Observe child

Fit does not recur Fit recurs Status epilepticus protocol

Determine cause of fever Admit for further care

Minor illness Suspicion of serious illness

or intracranial infection

Discharge after outpatient

Treatment.

Admit for further care