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 athology or metabolic derangement that could be the cause of the fit. Febrile fits, febrile convulsions and febrile convulsions are synonymous terms. Children with revious afebrile fits are e!cluded from this definition. "agnitude of #roblem $here is no com rehensive local e idemiological data. %tudies in &estern 'uro e (uote a figure of 3)* + of children < , years e! eriencing febrile fits with higher figures of u to -+ in .a an. $his ma/es febrile fits the single most common roblem in aediatric neurology. $y es of Febrile Fits Febrile fits are classified as either sim le or com le!. %im le febrile fits are short, < 0, minutes, generalised fits that do not occur more than once in a febrile e isode. Febrile fits that are either rolonged ( > 0, mins ) unilateral or recur within a single febrile e isode are classified as com le!. (1elson 2'llenberg,034-) 5ssues in management of Febrile Fits. $he ma6or issues are:) a) b) c) d) e) f) g) h) 7is/ of recurrent febrile fits. 7is/ of subse(uent afebrile, un rovo/ed fits or e ile sy. #rognosis for neurological, motor, intellectual and behavioural outcomes. 1eed for admission. 5nvestigations for the individual child. 1eed for electroence halogram (''8). 1eed for ro hylactic treatment. $y e of ro hylactic treatment to be used.

A)Risk of Recurrent Febrile Fits 7ecurrence of febrile fits is the largest ris/ for children with this condition. $he ris/ factors for such recurrence are: 'arly age of onset (< 0, months) ' ile sy in a first degree relative Febrile fits in a first degree relative 9ow degree of fever ( < *:C) during first febrile fit. ;rief duration between onset of fever and initial fit < first com le! febrile fit has not been consistently associated with an increased ris/ of recurrence. Children in nursery care are also at higher ris/ ( ;erg et al 0334, =nudsen 0336 )

$he overall ris/ of recurrence is 3:)*:+ and half of these go on to get a second recurrence ( <icardi ). >owever there is a range of ris/. $hose with ? or 0 ris/ factor have a low ris/ of < 0: +, whereas those with all ris/ factors have an almost 0::+ ris/. $he single most im ortant ris/ factors is age at onset with children < 0 year having a ,: + ris/ of recurrence com ared to @-+ for those above 0 year. ?nly 3)04+ of cases have 3 or more recurrences. >alf of all recurrences occur within 6 months and 3 (uarters have occurred by 0 year of the first febrile fit. "ost long lasting fits are the first e isode (<icardi ). ?nly 0.* + of children with an initial brief F.C. develo ed a rolonged recurrence lasting 3: minutes or more, and none of these had had an afebrile fit at 4 years of age (1elson 2 'llenberg 034-). >owever children with rior abnormal neurological develo ment may have a much higher ris/ of a rolonged recurrence (;erg 0334) 5n summary recurrent febrile fits are common es ecially among those with an early onset. "ost of these are brief and the number of recurrences has no bearing on long term neurological, motor, intellectual or behavioural outcomes (=nudsen 0336). B.Risk of Subsequent Afebrile Un ro!oked Fits or " ile s# 1on febrile fit follow F.C. in @ to 4 + of cases, a rate that is ,)0: times higher than the o ulation incidence of :.* ) :.- +. Conversely 0:)0,+ of atients with e ile sy have a com ared to a o ulation incidence for F.C. of 3)* +. ositive history for febrile fits

$he current feeling is that these children have inherited a lower threshold for fits that is manifested as F.C. during the age of susce tibility for this condition. 5nitial concerns arising from neurosurgical series about the relationshi between "esial $em oral %clerosis ("$%) and a receding history of rolonged febrile fits have been challenged by the findings of more recent cohort studies of adolescents with e ile sy, with or without a rior history of febrile fits ( ;erg 0333, Camfield 033* ). < recent study has also shown "75 evidence of "$% in relations of atients with intractable artial fits secondary to this condition even through some of them have never e! erienced a fit, febrile or otherwise. ( FernandeA 033- ). $his and other re orts of "75 evidence of "$% in children shortly after a febrile fit suggest that some individuals may have develo mental hi ocam al abnormalities that redis ose to F.C. and later e ile sy. 5n an individual child with febrile fits, features that redict a high ris/ of later non febrile fits are:) 0) <bnormal neurological develo ment before first febrile fit. @) Family history of idio athic e ile sy 3) Com le! febrile fits

*) 7ecurrent (B 3 ) sim le febrile fits <ll of the above suggest that the children concerned have inherited a tendency to e ile sy and ossibly also to develo "esial $em oral %clerosis. C. Prognosis for neurological$ motor$ intellectual and be%a!iour outcomes. $wo large cohort studies have shown that children who are develo mentally normal at the time of their first febrile fit continue to develo normally at follow)u (1elson 2 'llenberg, Cerity et al). $here was no difference between those who had sim le or com le! febrile fit in this res ect. Children with F.C. actually had better reading s/ills is one study (Cerity). <nother study showed that those who had e! erienced com le! febrile fit actually did better academically than those with sim le febrile fits, but the difference was not significant (=nudsen). &. 'eed for admission. 1ot all children with febrile fits need to be admitted. $he main reasons for admission are:) 0) $o e!clude intracranial athology es ecially infection @) Fear of recurrent fits 3) $o investigate and treat the cause of fever besides meningitis or ence halitis. *) $o allay arental an!iety, es ecially if they are staying far from the hos ital. 5f child can be observed for 6)- 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 unli/ely to have meningitis. Se!enteen ercent of meningitis resent (it% a febrile fit . >ence 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 re(uiring out atient care. 5deally the atient should be e!amined by a ediatric medical officer before the decision is made not to admit himDher. 5f a decision is made to send the child home the arents should be given clear instructions what to do in case the fit recurs or the fever ersists. 'eed for furt%er in!estigations $he need for blood counts, lumbar uncture, urinalysis, chest !)ray, blood culture etc., will de end on clinical assessment of the individual case. Measurement of serum calcium and electrol#tes are rarel# necessar# in c%ildren (it% febrile fits.

F) 'eed for "lectroence %alogram )""G) <lthough many ''8 changes have been re orted in children with febrile fits, both in recordings shortly after the fits and in interictal records, these findings do not hel in the management of the individual child and have no consistent rognostic value. >ence an ''8 is not indicated in children with febrile fits. *%is also a lies for t%ose (it% multi le recurrences and features of com le+ febrile fits.

G) 'eed for ro %#lactic treatment in F.C. and $he ma6or concern in febrile fits is rolonged fits leading to status e ile ticus that might ossibly result in neurological se(uelae. Febrile fits are a frightening e! erience for caregivers and some of them may see/ ro hylactic treatment to revent a recurrence. F.*# e of ro %#la+is $here are 3 o tions a) Continuous daily anticonvulsant thera y. #henobarbitone and sodium val orate have been used successfully to revent recurrences. >owever both these drugs have considerable side effects, namely behavioural, sedative and ossibly cognitive for henobarbitone and a distinct ris/ of he atoto!ity with sodium val orate. $hese ris/s are not in /ee ing with the benign nature of febrile fits. >ence it is now universally agreed to abandon the ractice of rescribing daily anticonvulsants for children with F.C. b) #ro hyla!is during febrile e isodes. $here are two a roaches, to administer anti yretics with onset of fever and to give rectal diaAe am su ositories with onset of fever. 8iving anti yretics is indicated by virtue of atient comfort, but has not been shown to reduce the recurrence rate of F.C. 8iving rectal diaAe an su ositories has been shown to be effective if fever is detected early and there is good com liance with the - hourly administration of this re aration. $he last @ limitations have been shown in large studies to render this a roach ineffective. ?ften caregivers are not aware of fever until the child has fitted. c) 7ectal DiaAe am solution to limit the duration of a febrile fit. 5n this a roach, caregivers are advised how to osition and care for a fitting child, and to administer rectal diaAe am solution at :., mgD/g if the fit lasts more than , minutes. *%ere are , commerciall# a!ailable strengt%s of rectal dia-e am$ namel# .mg and /0mg. C%ildren older t%an . #ears s%ould recei!e /0 mg. $he side effects of diaAe am in this situation are drowsiness, lethargy and ata!ia. 7es iratory de ression has not been documented with this dose of diaAe am in this situation. >owever as diaAe am may conceal signs of meningoence halitis the child should be e!amined by medical ersonnel and observed for a few hours if there is any doubt of an intracranial infection. 5f the arents do not have diaAe am at home this can be administered at the family doctors clinic or at a hos ital casualty. 5ntramuscular diaAe am is not useful as effective blood levels are only reached after almost an hour and the levels tend to be erratic. >owever if the rectal re aration of diaAe am is not available the intravenous re aration can be administered rectally at the same dose. $his is to avoid doctors wasting time trying to get intravenous access in a chubby fitting child. 7ectally administered diaAe am has an onset of action of 0)3 minutes and the effects last for about 0: minutes. 5f the fits recur after 0: minutes the diaAe am can be re eated rectally or intravenously. 5f the fits ersist or recur after that, then the child should be treated as a case of status e ile ticus.

"idaAolam however can be given intramuscularly in doses of :.3):.,mgD/g and has been shown to achieve thera eutic levels in 3 minutes.

Current Recommendation )See also A

endi+ /)

;ased on the above discussion, the following a roached is recommended: a) #arents of children with febrile fits should be counselled on the benign nature of this condition. b) $hey should be taught effective measures of tem erature control such as te id s onging with ta water and anti yretic administration. #aracetamol is still the safest anti yretic and can be given at a dose of 0, mgD/g 6 hourly. <lternately 1%<5Ds can also be used. $he mechanism of action of te id s onging namely heat loss from the body surface should be e! lained to the arents. c) $he arents should also be advised on first aid measures during a fit, if this was to recur namely: i i) Do not anic, remains calm. 1ote time of onset of fit. ii) 9oosen the childEs clothing es ecially around the nec/ ii iii) #lace the child in the left lateral osition with the head lower than the body. iii iv) &i e any vomitus or secretion from the mouth iv v) Do not insert any ob6ect into the mouth even if the teeth are clenched v vi) Do not give any fluids or drugs orally vi vii) %tay near the child until the fit is over and comfort the child as heDshe is recovering. vii viii)$he caregiver of c%ildren (it% a %ig% risk of recurrence$ ie more t%an 1 risk factors, should be su lied with a re aration of diaAe am rectal solution at :., mgD/g of the childs weight. $hey should be advised on how to administer this in case the fit last more than , minutes. i!) Rectal &ia-e am solution is a list C item in t%e Ministr# of 2ealt%3s drug list and hence should be available in all government health facilities. viii i!) 5n the event that the fit is not aborted by rectal diaAe an they should see/ urgent medical hel to sto the fit before status e ile tics develo s. i! !) 5f the fit is aborted, they should also see/ medical advise to determine the cause of the fever. $hese recommendations a ly both to children who have had a sim le or a com le! febrile fit.

References 0. <icardi : ' ile sy in children, @nd 'dition 5nternational 7eview of Child 1eurology series 033* #ages @,3)@4, @. <merican <cademy of #aediatrics #ractice #arameter : 9ong $erm $reatment of the child with sim le Febrile Fits, #aediatrics Col.0:3 1o.6 0333 age 03:4)03:3 3. ;erg <$, %hinnar %, Darefc/y <% et al : #redictors of 7ecurrent Febrile Fit <rch. #ediatric, <doles. "ed. 0334, 0,0:340)34*. ;erg <.$., %hinnar %, 9evy %7, $esta F. ". Childhood onset e ile sy with and without receding febrile fits 1eurology 0333F ,3 : 04*@)04*,. Camfield #, Camfield C, 8orden =, Dooley . &hat ty es of e ile sy are receded by febrile fitsG < o ulation based study of Children Dev. "ed. Child 1eurol 033*F 36: --4)-3@ 6. FernandeA 8, 'ffenberger ?, CiraA ;, etal >i ocam al "alformation as a cause of familial febrile fit and subse(uent

hi ocam al sclerosis 1eurology 033- F ,::3:3)304 4. Fu/uyama H., %e/i $., ?htsa/a C., "iara >, >ara " #ractical 8uidelines for #hysicians in the "anagement of febrile fits ;rain 2 Develo ment 0336F 0-: *43)*-* -. =nudsen F.I., Febrile Fits ) treatment and outcome ;rain 2 Develo ment 0336, 0-: *3-)**3. 3. 1elson =.;. 'llenberg .> #redictors of e ile sy in children who have e! erienced febrile fits 1 'ngl . "ed 0346, @3,:0:@3)0:33 0:. 1elson =.;. , 'llenberg ..>. #rognosis in children with febrile fits #ediatrics 034-, 60:4@:)4@4 00. "acdonald ;=, .ohnson <C, %ander .&<% %haron %D Febrile fits in @@: children ) neurological se(ualae at 0@ years follow)u 'ur 1eurol 0333F *0: 043)0-6 0@. Cerity C", 8reenwood 7, Dolding . 9ong term intellectual and behavioural outcomes of children with febrile fits 1. 'ngl. .. "ed 033-F 33-: 04@3)-

Members of Panel Dr >ussain 5mam >6 "uhammad 5smail (Chair erson) #rof "otilal #rof ?ng 9ai Choo Dr %ofiah <li Dr "alinee $hambyayah #rof Jabidi <Ahar >ussein Dr =oh Chong $uan Dr =hoo $ec/ ;eng

endi+ /. Flo( C%art For C%ildren 4it% Febrile Fits

Fit (it% Fe!er
'ote time of onset 5eft lateral osition 5oosen clot%ing

Fit sto s in less t%an . minutes Comfort c%ild Seek medical ad!ice on cause of fe!er

Fit lasts for more t%an . minutes

Rectal dia-e am a!ailable at %ome Administer rectal dia-e am

'o rectal dia-e am at %ome

Fit sto s Comfort c%ild Seek medical ad!ice on cause of fe!er

Fit does not sto

Famil# doctor or nearest medical facilit# Administer rectal dia-e am or 6ntra!enous dia-e am or 6ntramuscular mida-olam Fit does not sto Status e ile ticus rotocol Admit for furt%er care

Fit sto s 7bser!e c%ild Fit does not recur &etermine cause of fe!er Minor illness Fit recurs

Sus icion of serious illness or intracranial infection

&isc%arge after out atient *reatment. Admit for furt%er care