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Neurological System

Febrile Convulsions

A generalized tonic-clonic seizure occurring in association with fever (>38°C) due to an extracranial illness, typically in children aged 3 months to 6 years. It is a diagnosis of exclusion, requiring ruling out CNS infection or other causes.

Also known as: Febrile Seizures, Fever Fits

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Referral and warning signs

When to refer

Refer to higher level care (HC4/Hospital) if: Seizure is prolonged (>15 minutes) or status epilepticus occurs. Seizure has focal features. Multiple seizures occur within 24 hours (Complex FS). Child is <12 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 (often admitted for assessment, investigation, and caregiver education/reassurance, especially if young).

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) - Simple Febrile Seizure
  • Rapid return to baseline neurological status after the seizure (post-ictal period usually short)
  • May recur during the same febrile illness
  • Complex Febrile Seizure features: Duration >15 minutes, focal features during seizure, or multiple seizures within 24 hours.

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, Influenza, Gastroenteritis) are common triggers
  • Bacterial infections (e.g., UTI, Otitis Media, Pneumonia) can trigger
  • Family history of febrile seizures
  • Certain vaccinations (small increased risk shortly after, e.g., MMR, DTaP)

Diagnosis

Clinical assessment

Diagnosis is based on typical history (age, fever, characteristic generalized seizure) AND careful exclusion of other potential causes, especially meningitis, encephalitis, cerebral malaria, epilepsy, metabolic disturbances (hypoglycemia), or head trauma.

Investigations

  • Temperature measurement
  • 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/unreliable in young infants).
  • Blood slide/RDT for malaria parasites (essential in endemic areas).
  • Random blood glucose (especially if prolonged seizure or altered consciousness).
  • Consider Lumbar Puncture (LP) and CSF examination IF: Signs suggestive of meningitis/CNS infection present, Child <12 months (signs may be subtle, lower threshold), Complex febrile seizure features, Incomplete recovery, Prior antibiotic use potentially masking meningitis. LP not routinely needed for simple febrile seizure in child >12-18 months with clear source of fever and normal exam post-seizure.
  • 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 (some sources use 6 months). 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, otitis media).

Pharmacological treatment

  • Antipyretic: Paracetamol 15 mg/kg orally or rectally every 6 hours as needed for fever. Ibuprofen can also be used.
  • 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 (see NEU001) if seizure >15-30 mins.
  • Prophylactic anticonvulsants (daily or intermittent during fever): Generally NOT recommended for simple febrile seizures due to side effects outweighing benefits.

Monitoring

Monitor temperature. Monitor for seizure recurrence. Assess neurological status after seizure for full recovery. Monitor vital signs. Assess response to treatment of underlying fever source.

Complications

  • Generally benign with excellent long-term prognosis for simple febrile seizures.
  • Recurrence is common (approx. 30-40% risk, higher if first seizure <1 year or family history).
  • Small increased risk of developing epilepsy later in life (absolute risk low, ~1-2% for simple FS, higher ~5-10% for complex FS or underlying risk factors).
  • Rarely, status epilepticus.
  • Parental anxiety.

Prevention

  • Primary prevention not generally possible.
  • Secondary prevention (preventing recurrence): Educate caregivers on prompt fever control measures (tepid sponging, antipyretics like paracetamol/ibuprofen) at the start of febrile illnesses. This may reduce risk slightly but doesn't eliminate it. Routine prophylactic AEDs not recommended.
  • 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, when to seek help).
  • Explain the signs that warrant immediate medical attention if another seizure occurs (prolonged, focal, breathing difficulty, signs of serious illness).
  • Discuss the risk of recurrence.

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/complex features. Consider LP if intracranial pathology cannot be clinically excluded, especially in children <12 months. Rectal diazepam should be available for prolonged seizures.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.1.5

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