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Referral and warning signs
When to refer
Refer to HC4/Hospital if: Seizure is prolonged (>15 minutes) or status epilepticus occurs. Seizure has focal features. Multiple seizures occur within the same illness. Child is <12-18 months (lower threshold for LP/admission). Signs suggestive of meningitis or encephalitis are present. Child does not return to baseline neurological status quickly after the seizure. First febrile seizure (for assessment and caregiver education/reassurance).
Red flags
- Seizure lasting > 15 minutes (Status Epilepticus)
- Focal seizure features (e.g., involving only one side of body)
- Signs of meningitis/encephalitis (neck stiffness, bulging fontanelle, persistent altered consciousness, petechial rash)
- Age < 6 months
- Incomplete recovery or persistent neurological deficit after seizure
- Multiple seizures in 24 hours (complex febrile seizure)
Signs and symptoms
- Fever (>38°C) preceding or accompanying the seizure
- Generalized tonic-clonic seizure (may be other types, but typically generalized)
- Seizure usually brief (typically <5 minutes, almost always <15 minutes)
- Rapid return to baseline neurological status after the seizure (post-ictal period usually short)
- May recur during the same febrile illness
Risk factors
- Age between 3 months and 6 years (peak 12-18 months)
- High fever (often rapid rise in temperature)
- Viral infections (e.g., URI, Roseola) are common triggers
- Family history of febrile seizures
- Certain vaccinations (small increased risk shortly after)
Diagnosis
Clinical assessment
Diagnosis is based on typical history (age, fever, characteristic seizure) AND careful exclusion of other potential causes, especially meningitis, encephalitis, cerebral malaria, epilepsy, metabolic disturbances (hypoglycaemia), or head trauma.
Investigations
- Temperature measurement
- Blood slide/RDT for malaria parasites (essential in endemic areas)
- Random blood glucose (especially if prolonged seizure or altered consciousness)
- Thorough clinical examination for source of fever (ears, throat, chest, urine) and signs of CNS infection (neck stiffness, bulging fontanelle, Kernig's/Brudzinski's signs - may be absent in young infants).
- Consider Lumbar Puncture (LP) and CSF examination if: signs of meningitis/CNS infection present, child <12-18 months (signs may be subtle), prolonged or focal seizure, incomplete recovery, or prior antibiotic use potentially masking meningitis.
- Consider Full Blood Count (FBC), Urinalysis, Chest X-ray based on clinical findings to identify source of fever.
Diagnostic criteria
Diagnosis of exclusion: 1. Convulsion associated with fever >38°C. 2. Child aged >3 months and <6 years. 3. No evidence of CNS infection or inflammation. 4. No acute systemic metabolic abnormality known to cause convulsions. 5. No history of previous afebrile seizures.
Management
Non-pharmacological management
- During seizure: Place child in recovery position (on side) to protect airway, loosen clothing, ensure safety (remove harmful objects), do not restrain, do not put anything in the mouth.
- After seizure: Tepid sponging to help lower temperature.
- Identify and treat the underlying cause of the fever (e.g., malaria, pneumonia, UTI).
Pharmacological treatment
- Antipyretic: Paracetamol 15 mg/kg orally or rectally every 6 hours as needed for fever.
- If actively convulsing (>5 minutes): Diazepam 0.5 mg/kg rectally (using suppositories or diluted parenteral solution via rectal tube). Maximum dose 10 mg. May repeat once after 10 minutes if seizure continues.
- If seizure persists despite rectal diazepam or IV access available: Lorazepam 0.1 mg/kg IV (max 4mg) or Diazepam 0.2-0.3 mg/kg IV slowly (max 10mg). Refer to status epilepticus management if seizure >15-30 mins.
- Follow specific Ugandan treatment algorithms/guidelines.
Monitoring
Monitor temperature. Monitor for seizure recurrence. Assess neurological status after seizure for full recovery. Monitor vital signs.
Complications
- Generally benign with excellent long-term prognosis.
- Recurrence is common (approx. 30% risk).
- Small increased risk of developing epilepsy later in life (slightly higher if complex features: focal, prolonged >15min, multiple in 24h, pre-existing neurodevelopmental issues, family history of epilepsy).
- Rarely, status epilepticus (prolonged seizure requiring more aggressive treatment).
- Parental anxiety.
Prevention
- Primary prevention not generally possible.
- Secondary prevention (preventing recurrence): Educate caregivers on prompt fever control measures (tepid sponging, antipyretics like paracetamol) at the start of febrile illnesses. Prophylactic anticonvulsants are generally NOT recommended due to side effects outweighing benefits.
- Educate caregivers on seizure first aid.
Patient education
- Reassure caregivers about the generally benign nature of simple febrile seizures and that they do not cause brain damage.
- Explain the difference between febrile seizures and epilepsy.
- Teach fever control measures (tepid sponging, paracetamol/ibuprofen).
- Teach basic seizure first aid (recovery position, safety).
- Explain the signs that warrant immediate medical attention if another seizure occurs (prolonged, focal, breathing difficulty, signs of serious illness).
Uganda-specific notes
Malaria is a very common cause of fever in Uganda; always test for malaria. Meningitis must be actively excluded, especially in young infants or if seizure has atypical features. Consider LP if intracranial pathology cannot be clinically excluded, especially in children <18 months. Rectal diazepam should be available for prolonged seizures.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.1.5
- Uganda Clinical Guidelines (UCG) 2023
Chapter 9, Section 9.1.1 (Status Epilepticus, if applicable)