Febrile seizure

Source:
Clinical Knowledge Summaries
Publication date:
01 November 2018

Abstract

Febrile seizure Last revised in November 2018 Summary Back to topFebrile seizure: Summary A febrile seizure is generally accepted to be a seizure accompanied by fever (temperature more than 38°C by any method), without central nervous system infection, which occurs in infants and children aged 6 months to 6 years.Simple febrile seizures are isolated, generalized, tonic-clonic seizures lasting less than 15 minutes, that do not recur within 24 hours or within the same febrile illness, with complete recovery within 1 hour.Complex febrile seizures have one or more of the following features: a partial (focal) seizure (movement limited to one side of the body or one limb); duration of more than 15 minutes; recurrence within 24 hours or within the same febrile illness; or incomplete recovery within 1 hour.Febrile seizures are the commonest form of childhood seizure up to the age of 2 years.Following a first febrile seizure, about one-third of children will have recurrent seizures.If a diagnosis of febrile seizure is suspected, assessment should include:Identifying red flag symptoms and signs suggesting a serious or life-threatening cause such as meningitis/meningococcal disease or encephalitis, and managing this appropriately.Identifying the underlying cause of fever, where possible.Asking about fever onset, peak temperature, duration, and relationship to the seizure.Asking about the seizure and any post-ictal drowsiness.Asking about previous seizure episodes and any family history of febrile seizures or epilepsy.Assessing the child's temperature, consciousness level, any focal neurological deficit, fluid status, and signs of an alternative cause of seizure.Most children will present to a healthcare professional after the febrile seizure has resolved. If a child is suspected of having an acute febrile seizure, parents/carers should be advised to:Give immediate first aid.Call an emergency ambulance or give emergency benzodiazepine rescue medication, depending on specialist advice.Immediate hospital assessment by a paediatrician should be arranged:For a first febrile seizure (or if a child has not been previously assessed by a paediatrician).If the child is less than 18 months of age, there is diagnostic uncertainty about the cause of the seizure, or for recurrent complex febrile seizure.If there is any focal neurological deficit, recent antibiotic use, or there is parental/carer anxiety or difficulty coping.Urgent hospital assessment should be considered if:There is unexplained fever and no apparent focus of infection.Referral to a paediatrician or paediatric neurologist should be arranged if:The child has neurodevelopmental delay and/or signs of a neurocutaneous syndrome or metabolic disorder.Parents/carers of a child with a history of febrile seizure should be given advice on:Sources of information and support.The prompt recognition and management of any future febrile seizure.The management of any future febrile illness.The fact that prophylactic antipyretics or antiepileptic drugs are not routinely prescribed, unless on the advice of a specialist.Ensuring all childhood immunizations are completed. Have I got the right topic? Back to topHave I got the right topic? From age 6 months to 6 years.This CKS topic covers the management of a child who presents with, or after, a suspected febrile seizure.This CKS topic does not cover the management of a child who has epilepsy or any other seizure disorder.There are separate CKS topics on Epilepsy, Feverish children - management, and Feverish children - risk assessment.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes October to November 2018 — reviewed. A literature search was conducted in October 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring, and new nodes on Assessment and Differential diagnosis have been added. Recommendations in the Management section have been updated in line with current literature. Back to top Previous changes Previous changes October 2013 — revised. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor changes have been made to the National Institute for Health and Care Excellence's (NICE) 'traffic light' system, and the evidence-base has been updated to reflect this.July 2011 — minor update. More precise paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency (MHRA). Prescriptions have been updated to reflect this revised dosing. Issued in July 2011.March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.September 2008 — minor typographical corrections to the Search strategy section. Issued in September 2008.February to June 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The title of the topic has changed from Febrile convulsion to Febrile seizure to reflect current terminology. A section on managing a child who is still having a seizure has been added.October 2006 — minor update. Antipyretic prescriptions updated in line with new doses of ibuprofen for children recommend by the British National Formulary (BNF). Issued in October 2006.October 2005 — minor technical update. Issued in November 2005.January 2005 — reviewed. Validated in March 2005 and issued in April 2005.September 2004 — minor technical update. Issued in September 2004.July 2001 — reviewed. Validated in November 2001 and issued in April 2002.October 1998 — written. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesNo new evidence-based guidelines since 1 October 2018.HTAs (Health Technology Assessments)No new HTAs since 1 October 2018.Economic appraisalsNo new economic appraisals relevant to England since 1 October 2018.Systematic reviews and meta-analysesNo new systematic reviews or meta-analyses since 1 October 2018.Primary evidenceNo new randomized controlled trials published in the major journals since 1 October 2018. Back to top New policies New policies No new national policies or guidelines since 1 October 2018. Back to top New safety alerts New safety alerts No new safety alerts since 1 October 2018. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 October 2018. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Be aware of when to suspect a diagnosis of febrile seizure.Identify which children should be admitted to hospital for further assessment.Provide self-management advice and information to parents and carers.Advise parents and carers about the immediate management of possible future febrile seizures. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators No QOF indicators were found during the review of this topic. Back to top QIPP - Options for local implementation QIPP - Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE quality standards NICE quality standards No NICE quality standards were found during the review of this topic. Background information Back to topBackground information Back to top Definition What is it? The exact definition of febrile seizure varies in the literature, but is generally accepted to be:A seizure accompanied by fever (temperature higher than 38°C by any method), without central nervous system infection, which occurs in infants and children aged 6 months to 5 years [AAP, 2011].A seizure occurring in childhood after one month of age associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure, and not meeting criteria for other acute symptomatic seizures [ILAE, 1993].Febrile seizures may be classified as simple or complex depending on the seizure duration, clinical features, and recurrence pattern [Waruiru and Appleton, 2004; AAP, 2011; Graves et al, 2012; Patel, 2015; Leung, 2018]:Simple febrile seizures are isolated, generalized, tonic-clonic seizures lasting less than 15 minutes, that do not recur within 24 hours or within the same febrile illness, with complete recovery within 1 hour.Complex febrile seizures have one or more of the following features: a partial (focal) seizure (movement limited to one side of the body or one limb); duration of more than 15 minutes; recurrence within 24 hours or within the same febrile illness; or incomplete recovery within 1 hour.Febrile status epilepticus describes a subgroup of complex febrile seizure where a febrile seizure lasts for 30 minutes or longer, or there are a series of seizures without full recovery in between that last for 30 minutes or longer [Seinfeld, 2014; Patel, 2015]. Back to top Causes What causes it? The exact cause of febrile seizures is unknown, but is thought to be an age-dependent response of the immature brain to fever, in combination with underlying genetic and environmental factors [Cross, 2012; Patel, 2015; Leung, 2018].GeneticAbout one-third of children with febrile seizures have a positive family history [Veisani, 2013].The background prevalence risk of 1 in 30 rises to 1 in 5 if one sibling is affected, and 1 in 3 if both parents and a sibling have been affected [Patel, 2015].The concordance rate is about 35–69% and 14–20% in monozygotic and dizygotic twins, respectively [Leung, 2018].Environmental (any febrile illness may cause febrile seizures) [Armon et al, 2003; Baumer, 2004; Graves et al, 2012; Whelan, 2017].Viral infection — this is the cause of fever in 80% of cases [Leung, 2018], with human herpes virus 6 (HHV-6) which causes roseola infantum (sixth disease) and influenze being common triggers [Whelan, 2017].Other infections — viral upper respiratory infections, otitis media, lower respiratory tract infection, urinary tract infection, and gastroenteritis are also common causes [Waruiru and Appleton, 2004; Patel, 2015; Leung, 2018].Post-immunization (rare) — vaccination with diphtheria-tetanus-pertussis and measles-mumps-rubella, for example, may be associated with an increased risk of febrile seizure, however, this is not a contraindication to vaccination, and childhood vaccinations should be completed as normal [Leung, 2018]. See the CKS topic on Immunizations - childhood for more information. Back to top Risk factors What are the risk factors? About 50% of children who present with a febrile seizure have no identified risk factors [Waruiru and Appleton, 2004], but possible risk factors for a first febrile seizure include:Family history of febrile seizure in first-degree relatives [Waruiru and Appleton, 2004; Sadleir and Scheffer, 2007].24% of affected children will have a first-degree relative who has had a febrile seizure.Concordance rates of febrile seizures are higher in monozygotic than dizygotic twins [Siqueira, 2010; Leung, 2018].Familial clustering studies indicate a doubling of risk in children when both parents, compared with one parent, had febrile seizures in childhood [Waruiru and Appleton, 2004].The more relatives affected, the greater the risk [Waruiru and Appleton, 2004].The peak temperature (rather than the rapidity of the temperature rise) [Siqueira, 2010; Leung, 2018].Zinc and iron deficiency.A small prospective case-control study (n =38) found statistically significant lower serum zinc levels in children with febrile seizures compared with age-matched controls [Ganesh and Janakiraman, 2008].A retrospective case-control study (n = 361) found that children with febrile seizures were almost twice as likely to be iron deficient as age-matched controls [Hartfield et al, 2009]. Back to top Prevalence How common is it? The prevalence of febrile seizures varies in the literature depending on the definition used, the age of the child, the inclusion criteria, and geographic region studied [Cross, 2012; Patel, 2015].Febrile seizures are the commonest form of childhood seizure up to the age of 2 years [Wilmshurst, 2015].A UK national cohort study of 13,135 children followed up from birth to 5 years with a health questionnaire, found 2.3% had febrile convulsions, and 20% of these presented with a complex febrile seizure [Verity, 1985].Febrile seizures are most common between 6 months and 6 years of age [Leung, 2018]. Onset is rare after 6 years of age [Waruiru and Appleton, 2004].Peak incidence is between 12–18 months of age [Leung, 2018].The male to female ratio is 1.6 to 1 [Leung, 2018].Febrile status epilepticus occurs in about 5% of children who have febrile seizures [Sadleir and Scheffer, 2007; Hesdorffer, 2011]. Back to top Complications What are the complications? Febrile seizures are generally benign with a normal cognitive outcome [Cross, 2012; Wilmshurst, 2015]. Possible complications following febrile seizure include:Parental/carer anxietyThis may be related to concern over recurrent episodes, how to manage an acute seizure, or fears about subsequent complications [Siqueira, 2010; Leung, 2018].Febrile status epilepticusThis accounts for about 25% of all status epilepticus in children [Patel, 2015], and about 5% of all febrile seizures [Sadleir and Scheffer, 2007].It is a risk factor for further prolonged seizures [Patel, 2015].There is a theorized risk of associated hypoxia, brain injury, hippocampal abnormalities, and an increased risk of temporal lobe epilepsy, however, the evidence in the literature is conflicting [Patel, 2015; Leung, 2018].There is a possible small increased risk of death following febrile status epilepticus [Chungath and Shorvon, 2008], however, the evidence in the literature is conflicting and some experts have not confirmed this association [Waruiru and Appleton, 2004].EpilepsyThere is a small increased risk of epilepsy in children who have had a febrile seizure, which varies in the literature depending on the type of seizure and duration of follow-up in studies [Leung, 2018].A UK prospective cohort study followed children from the onset of febrile seizure (n = 220) for a median of 24 years, and found that 6.7% of children developed epilepsy [Neligan, 2012].A US prospective cohort study of children following a simple or complex febrile seizure (n = 687) found a five-fold increased risk of developing unprovoked seizures compared with children with no history of febrile seizures [Annegers, 1987].The risk after a simple febrile seizure was 2.4%.The risk after a complex febrile seizure depended on the number of complex features: with one complex feature, the risk was 6–8%; 17–22% with two complex features; and 49% with three complex features.An evidence-based guideline for post-seizure management cites [Baumer, 2004]:The risk after a simple febrile seizure is 1–2.4% (the same as the general population).The risk after a complex febrile seizure is 4.1–6%.Risk factors for the development of epilepsy include [Waruiru and Appleton, 2004; Sadleir and Scheffer, 2007; Graves et al, 2012; Patel, 2015; Leung, 2018]:Short duration of fever (less than 1 hour) before the seizure.Complex febrile seizures.Family history of epilepsy.Neurodevelopmental abnormality before the onset of febrile seizures, such as cerebral palsy or hydrocephalus.Cognitive impairmentMemory impairment — a small UK prospective study (n = 34) found an increased risk of recognition memory impairment in children with prolonged febrile seizures lasting more than 30 minutes [Martinos, 2012].Language development — a population-based cohort study of pre-school children (n = 3157) did not find an increased risk of behavioural problems or difficulties with executive functioning, however, children with recurrent febrile seizures were at significantly increased risk of delayed language and vocabulary development [Visser, 2012].A UK population-based study (n = 381) of children with simple and complex febrile seizures found no adverse intellectual or behavioural problems when assessed at 10 years of age, compared with a control group [Verity et al, 1998]. Back to top Prognosis What is the risk of recurrence? Febrile seizures are usually self-limiting, and the majority of children have normal growth and development [Cross, 2012; Leung, 2018].Following a first febrile seizure, a prospective cohort study (n = 428) found that 31.8% of children had recurrent seizures [Berg et al, 1997]:17.1% of children had one recurrence.8.9% had two recurrences.5.8% had three or more recurrences.If febrile seizures are recurrent [Leung, 2018]:About 75% of recurrences will occur within one year of the first febrile seizure.About 90% will occur within two years.Risk factors for recurrent febrile seizures include [Knudsen, 1996; Berg et al, 1997; Waruiru and Appleton, 2004; Graves et al, 2012; Patel, 2015; Wilmshurst, 2015; Leung, 2018]:Early onset under 18 months of age.50% of children aged less than 12 months, and 30% of children aged more than 12 months, have recurrent febrile seizures [Patel, 2015].Family history of febrile seizures or epilepsy in a first-degree relative.Low-grade fever associated with seizure onset (less than 39°C).Short duration of fever before the seizure (less than 1 hour).History of complex febrile seizure.Multiple seizures in 24 hours or during the same febrile episode.Prolonged febrile seizure (lasting more than 15 minutes).Attendance at a day care nursery — presumed increased viral exposure and frequent febrile illness.Note: the greater the number of risk factors, the higher the recurrence rate. Diagnosis Back to topDiagnosis of febrile seizure Back to top Diagnosis When should I suspect a febrile seizure? Suspect a diagnosis of febrile seizure if a child has a fever or febrile illness and a reported or witnessed seizure:Typical features of a simple febrile seizure include:The child is aged 6 months to 6 years.The seizure usually lasts 2–3 minutes, and rarely lasts more than 10 minutes.The seizure is a generalized tonic-clonic type (muscle stiffening followed by rhythmical jerking or shaking of the limbs, which may be asymmetrical); twitching of the face; rolling back of the eyes; staring and loss of consciousness.There may be foaming at the mouth, difficulty breathing, pallor, or cyanosis.A brief post-ictal period of drowsiness, irritability, or confusion, with complete recovery within 1 hour.The child may have had a previous febrile seizure.Typical features of a complex febrile seizure include one or more of:A partial onset or focal features (movement limited to one side of the body or one limb).The seizure lasts more than 15 minutes.There is seizure recurrence within 24 hours or within the same febrile illness.There is incomplete recovery within 1 hour, and there may be prolonged post-ictal drowsiness or transient hemiparesis (Todd's palsy). Back to top Basis for recommendation Basis for recommendation The recommendations on when to suspect a febrile seizure are based on expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Hesdorffer, 2011; Mastrangelo, 2014; Patel, 2015; Leung, 2018].The information on the usual duration of a simple febrile seizure is based on expert opinion in review articles [Mastrangelo, 2014; Patel, 2015] and an evaluation of a prospective cohort study (n = 158), which found the median duration of a first febrile seizure was 4 minutes [Hesdorffer, 2011].The information that tonic clonic and other seizure signs may be asymmetrical is based on expert opinion in a review article [Patel, 2015].The information on additional clinical features is based on expert opinion in a review article [Leung, 2018].The information on the typical features of a complex febrile seizure are based on expert opinion in review articles [Waruiru and Appleton, 2004; Leung, 2018]. Back to top Assessment How should I assess a child with a suspected febrile seizure? If a diagnosis of febrile seizure is suspected on the basis of clinical features, assess the child for the underlying cause of fever and to exclude an alternative condition.Assess for:Red flag symptoms and signs suggesting a serious or life-threatening cause such as meningitis/meningococcal disease or encephalitis, and manage appropriately. See the CKS topics on Feverish children - risk assessment and Meningitis - bacterial meningitis and meningococcal disease for more information.Other conditions that may mimic a febrile seizure, and manage appropriately.Ask about:If fever was associated with the seizure.Reported parental perception of fever should be accepted as a valid indicator of fever.Be aware that fever can occur any time during or after a seizure, and the majority of febrile seizures occur within 24 hours of fever onset.When the fever started, peak temperature and duration, and any associated symptoms to suggest an underlying cause of febrile illness.The relationship of the onset of fever to the seizure.The characteristics and duration of the seizure, to help classify whether it is simple or complex. The duration of any post-ictal drowsiness.Any previous seizure episodes.Any recent antibiotic use (may mask signs of central nervous system infection).Any recent immunizations, missed immunizations, or unknown immunization history. See the CKS topic on Immunizations - childhood for more information.Neurodevelopmental history and any concerns.Whether the child attends daycare such as nursery (source of potential exposure to infection).Any family history of febrile seizures or epilepsy.Examine the child:Assess the level of consciousness, and check for any focal neurological deficit such as weakness of the hand, arm, or leg.Check the temperature after the seizure has ended.A temperature of more than 38°C is generally considered significant.Assess fluid status and for signs of dehydration. See the CKS topic on Feverish children - risk assessment for more information.Assess for other signs to identify the underlying cause of febrile illness, and manage appropriately. See the CKS topics on Feverish children - risk assessment and Feverish children - management for more information.Assess for stigmata of a neurocutaneous or metabolic disorder suggesting an alternative cause for seizure.Be aware that investigations are not usually needed in primary care.Consider measuring blood glucose if a child cannot be roused or is having an acute seizure episode, if possible and appropriate.Consider urine dipstick analysis and urine microscopy and culture if there is no clear focus for infection and the underlying cause of fever is uncertain. See the CKS topic on Urinary tract infection - children for more information. Back to top Basis for recommendation Basis for recommendation The recommendations on assessing a child with a suspected febrile seizure are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Feverish illness in children: assessment and initial management in children younger than 5 years [NICE, 2017], the American Academy of Pediatrics (AAP) clinical practice guideline Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure [AAP, 2011], an emergency medicine guideline An evidence and consensus based guideline for the management of a child after a seizure [Armon et al, 2003], and expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Siqueira, 2010; Cross, 2012; Graves et al, 2012; Patel, 2015; Leung, 2018].Assessing the child's historyThe recommendation to exclude central nervous system infection and the information on possible red flags are based on the AAP clinical practice guideline [AAP, 2011], an emergency medicine guideline [Armon et al, 2003] and expert opinion in review articles [Waruiru and Appleton, 2004; Patel, 2015].The recommendation to exclude other conditions that may present similarly to febrile seizure is based on expert opinion in a review article [Waruiru and Appleton, 2004].The recommendation to accept parental reports of fever is based on the NICE clinical guideline [NICE, 2017] and the UK guideline report, which used a Delphi consensus development process to reach agreement that fever should be assumed to be present if the 'history and examination were indicative' [Armon et al, 2003].The information that febrile seizures may occur before the fever is apparent, and the majority of febrile seizures occur within 24 hours of the onset of fever, is based on expert opinion in review articles [Cross, 2012; Leung, 2018].The recommendations on assessing the nature of fever, seizure symptoms, associated symptoms, and post-ictal period are based on the AAP clinical practice guideline [AAP, 2011] and expert opinion in a review article [Leung, 2018].The recommendation to check the child's immunization history is based on the fact there may be an increased risk of central nervous system infection or other serious infection, such as pneumonia, especially if there is a history of incomplete immunizations against Haemophilus influenza type b and Streptococcus pneumoniae [Patel, 2015].Examining the childThe recommendations on performing a full examination of the child are based on an emergency medicine guideline [Armon et al, 2003] and expert opinion in a review article [Leung, 2018].Investigations not routinely recommendedThe recommendation that investigations are not usually needed in primary care is based on the AAP clinical practice guideline [AAP, 2011] and expert opinion in a review article [Graves et al, 2012].The recommendation to consider measuring blood glucose is based on expert opinion in a review article [Siqueira, 2010].The recommendation to consider urine dipstick analysis is based on an emergency medicine guideline [Armon et al, 2003] and expert opinion in a review article [Leung, 2018]. Back to top Differential diagnosis What else might it be? Other conditions that may present similarly to a febrile seizure include:With feverCentral nervous system infection, such as bacterial meningitis/meningococcal disease or encephalitis. See the CKS topic on Meningitis - bacterial meningitis and meningococcal disease for more information.A systematic review found the overall pooled prevalence of bacterial meningitis was 0.2% in children with a first simple febrile seizure, and 0.6% in children with a first complex febrile seizure.Red flags include irritability, neck stiffness, petechial rash, photophobia, bulging fontanelle, decreased level of consciousness, prolonged post-ictal period, and focal neurological deficit (lasting more than one hour).Be aware that signs of meningeal irritation may be subtle or absent in children less than 12–24 months of age.Rigors or delirium (acute confusional state). See the CKS topic on Delirium for more information.Shivering (may occur with or without fever) — a perception of cold and involuntary muscle tremors that persist for several minutes. There is no loss of consciousness or involvement of facial or respiratory muscles.Febrile myoclonus — a benign disorder causing myoclonic jerks usually involving the upper limbs during fever. They may last from 15 minutes to several hours.Without feverSyncope — a transient loss of consciousness due to insufficient cerebral blood flow, often caused by hypotension. It is characterized by a rapid onset, short duration, and spontaneous complete recovery. Breath-holding spells or reflex anoxic seizures — brief, involuntary cessation of breathing often triggered by sudden unexpected fright, fear, or pain. May present with pallor or cyanosis and low tone, with possible loss of consciousness and transient tonic clonic movements if the apnoea is prolonged.Head injury. See the CKS topic on Head injury for more information.Hypoglycaemia or other metabolic disorders, such as a mitochondrial cytopathy — metabolic disorders may present with developmental delay, faltering growth, hepatosplenomegaly, and micro or macrocephaly.Drug use or withdrawal. See the CKS topic on Poisoning or overdose for more information.Epilepsy — suspect if there is no compelling history of fever, the seizure was complex, there were post-ictal signs, or there is neurodevelopmental delay. See the CKS topic on Epilepsy for more information.Epilepsy syndromes, such as:Dravet syndrome (severe myoclonic epilepsy of infancy) — a neurodevelopmental disorder characterized by prolonged intractable seizures initially triggered by fever. Typically over time seizures change to become myoclonic and later focal, with developmental delay associated.Genetic epilepsy with febrile seizures plus (GEFS+) — an autosomal dominant disorder where seizures continue beyond 6 years of age, and afebrile seizures may also occur.Other neurological conditions such as cerebral palsy or neurocutaneous syndromes where seizures may form part of the condition:Sturge-Weber syndrome may be suggested by a unilateral port-wine stain over the trigeminal area.Tuberous sclerosis may be suggested by facial angiofibromas, shagreen or leather patches, periungual fibromas, and hypopigmented macules ('ash-leaf spots').Neurofibromatosis may be suggested by cafe au lait spots, intertriginous freckling, iris hamartomas, and subcutaneous nodules. Back to top Basis for recommendation Basis for recommendation The information on the differential diagnosis of febrile seizure is based on the American Academy of Pediatrics (AAP) clinical practice guideline Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure [AAP, 2011], the Task Force Report of the International League Against Epilepsy (ILAE) Commission of Pediatrics Summary of recommendations for the management of infantile seizures [Wilmshurst, 2015], a UK emergency medicine guideline An evidence and consensus based guideline for the management of a child after a seizure [Armon et al, 2003], a systematic review of the risk of bacterial meningitis in children with a first febrile seizure [Najaf-Zadeh, 2013], and expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Siqueira, 2010; Cross, 2012; Mastrangelo, 2014; Patel, 2015; Leung, 2018].The information on the pooled risk of bacterial meningitis presenting as first febrile seizure is based on a systematic review of 14 studies [Najaf-Zadeh, 2013].The information on red flags suggesting central nervous system infection are based on an emergency medicine guideline [Armon et al, 2003] and expert opinion in review articles [Waruiru and Appleton, 2004; Patel, 2015].The information that signs of meningeal irritation may be subtle or absent in children less than 12–24 months of age is based on expert opinion in review articles [Waruiru and Appleton, 2004; Leung, 2018], and is also extrapolated from an emergency medicine guideline [Armon et al, 2003].The information on possible features of febrile myoclonus are based on expert opinion in a review article [Leung, 2018].The information on possible features of a metabolic disorder are based on expert opinion in a review article [Waruiru and Appleton, 2004]. Management Back to topManagement Scenario: Acute management of febrile seizure: covers the acute management of a child who is currently having a suspected or known febrile seizure.Scenario: Management after a febrile seizure: covers the management and follow-up of a child who has had a febrile seizure. Back to top Scenario: Acute management of febrile seizure Scenario: Acute management of febrile seizure From age 6 months to 6 years. Back to top Acute management of febrile seizure How should I manage a child having a febrile seizure? Most children will present to a healthcare professional after the febrile seizure has resolved. Advise parents/carers that if a child is having a suspected acute febrile seizure:Give immediate first aid to the child.Monitor the duration of the seizure by noting the time it starts.Protect the child from injury during the seizure by:Cushioning their head with your hands or soft material.Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.Do not restrain the child or put anything in their mouth.Check the airway and place the child in the recovery position when the seizure has stopped.Observe the child until they have recovered.Examine for, and manage, any injuries.If tonic-clonic movements last for more than 5 minutes:Call an emergency ambulance, orGive emergency benzodiazepine rescue medication if this has been advised by a specialist for a child with recurrent febrile seizures.Options are buccal midazolam or rectal diazepam (both drugs may be repeated once after 10 minutes if the seizure has not stopped).Call an emergency ambulance if, 10 minutes after the first dose of rescue medication:The seizure has not stopped.The child has ongoing twitching (although the larger jerking movements may have stopped).Another seizure has begun before the child regains consciousness. Back to top Benzodiazepine rescue medication Benzodiazepine rescue medication Benzodiazepine rescue medication should only be initiated following specialist advice, depending on the child's frequency and pattern of febrile illnesses and type of febrile seizures, the parent/carer wishes, and an individualized risk benefit assessment.Buccal midazolam may be given as oromucosal solution (dose repeated once after 10 minutes if necessary). Recommended doses are:6–11 months of age: 2.5 mg.1–4 years of age: 5 mg.5–9 years of age: 7.5 mg.Rectal diazepam may be given as rectal solution if preferred, or if buccal midazolam is not available (dose repeated once after 10 minutes if necessary). Recommended doses are:6 months to 1 year of age: 5 mg.2–11 years of age: 5–10 mg.[Waruiru and Appleton, 2004; Mastrangelo, 2014; Patel, 2015; BNF for Children, 2017] Back to top Basis for recommendation Basis for recommendation The recommendations on acute management of febrile seizure are based on the Task Force Report of the International League Against Epilepsy (ILAE) Commission of Pediatrics Summary of recommendations for the management of infantile seizures [Wilmshurst, 2015], a US research article on the emergency management of febrile status epilepticus [Seinfeld, 2014], and expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Sadleir and Scheffer, 2007; Siqueira, 2010; Cross, 2012; Graves et al, 2012; Mastrangelo, 2014; Patel, 2015].The recommendation to monitor seizure duration is based on expert opinion in a review article [Siqueira, 2010], as this helps to identify when ambulance transfer or benzodiazepine rescue medication is needed.CKS notes that some experts recommend a threshold seizure duration of 10 minutes after which active intervention is needed [Waruiru and Appleton, 2004; Wilmshurst, 2015]. CKS recommends a threshold duration of 5 minutes, based on the fact that seizures lasting longer than this often do not stop spontaneously, with an increased risk of possible complications [Sadleir and Scheffer, 2007; Mastrangelo, 2014]. This approach is supported by the expert opinion of previous external reviewers of this CKS topic.The Task Force for the ILAE Commission of Pediatrics found low-quality evidence to support a recommendation that early seizure termination within 10 minutes for complex febrile seizures is associated with a better outcome, and active intervention is rarely needed for simple febrile seizures [Wilmshurst, 2015].The recommendations on first aid measures are pragmatic, based on what CKS considers to be good clinical practice. This approach is supported by the expert opinion of previous external reviewers of this CKS topic.The recommendations to use rescue medication with midazolam or diazepam following specialist advice is based on expert opinion in review articles [Waruiru and Appleton, 2004; Cross, 2012; Mastrangelo, 2014; Patel, 2015] and the British National Formulary [BNF for Children, 2017]. This approach is supported by the expert opinion of previous external reviewers of this CKS topic.The recommendation to arrange ambulance transfer if a seizure persists 10 minutes after the first dose of rescue medication (if used) is based on the fact that prolonged seizures such as febrile status epilepticus rarely stop spontaneously, may be resistant to usual drug treatment, and earlier onset of drug treatment results in shorter total seizure duration and a reduced risk of short- and long-term complications [Seinfeld, 2014]. Back to top Scenario: Management after a febrile seizure Scenario: Management after a febrile seizure From age 6 months to 6 years. Back to top Admission or referral When should I admit or refer a child following febrile seizure? Arrange emergency ambulance transfer to Accident and Emergency if:There is suspected meningitis/meningococcal disease, or encephalitis. See the CKS topic on Meningitis - bacterial meningitis and meningococcal disease for more information.There is another suspected serious or life-threatening cause of fever, such as pneumonia or sepsis. See the CKS topic on Feverish children - risk assessment for more information.Arrange immediate hospital assessment by a paediatrician if:It is the first presentation of febrile seizure (or a subsequent febrile seizure and the child has not had previous specialist assessment).The child is less than 18 months of age (clinical signs of central nervous system infection may be subtle or absent).There is diagnostic uncertainty about the cause of the seizure.There are any features of a recurrent complex febrile seizure.There is any focal neurological deficit.There was a decreased level of consciousness prior to the seizure.The child has recently taken antibiotics (may mask the signs of central nervous system infection).There is parental/carer anxiety and/or difficulty coping.Consider urgent hospital assessment for a period of observation if:The child has unexplained fever and no apparent focus of infection.Arrange referral to a paediatrician or paediatric neurologist for further assessment, the urgency depending on clinical judgement, if:The child has neurodevelopmental delay and/or signs of a neurocutaneous syndrome or metabolic disorder. Back to top Basis for recommendation Basis for recommendation The recommendations on who to refer following a febrile seizure are largely based on the American Academy of Pediatrics (AAP) clinical practice guideline Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure [AAP, 2011], the Task Force Report of the International League Against Epilepsy (ILAE) Commission of Pediatrics Summary of recommendations for the management of infantile seizures [Wilmshurst, 2015], a UK emergency medicine guideline An evidence and consensus based guideline for the management of a child after a seizure [Armon et al, 2003], and expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Graves et al, 2012; Mastrangelo, 2014; Patel, 2015; Whelan, 2017; Leung, 2018].Arranging immediate hospital assessmentThe recommendation to arrange admission if a child is less than 18 months of age is based on the fact that clinical signs of central nervous system infection may be subtle or absent in children less than 12–24 months of age [Armon et al, 2003; Waruiru and Appleton, 2004; Mastrangelo, 2014; Leung, 2018].The recommendation to arrange admission if there are features of a recurrent complex febrile seizure is based on the need to exclude an alternative condition or underlying cause, using specialist neuroimaging [Armon et al, 2003; Mastrangelo, 2014; Patel, 2015; Wilmshurst, 2015; Leung, 2018].The recommendation to arrange admission if there is any focal neurological deficit or decreased level of consciousness is based on expert opinion in review articles [Patel, 2015; Leung, 2018].The recommendation to arrange admission if the child has recently taken antibiotics is based on the AAP clinical practice guideline [AAP, 2011] and the emergency medicine guideline [Armon et al, 2003].The recommendation to arrange admission if there is parental/carer anxiety and/or difficulty coping is based on the emergency medicine guideline [Armon et al, 2003] and expert opinion in a review article [Mastrangelo, 2014].Arranging urgent hospital assessment for a period of observationThis recommendation is based on expert consensus of opinion in the emergency medicine guideline, which states that observation for a period of at least two hours, or hospital discharge with 'good community review' should be arranged for children with no focus of infection, following urine sampling [Armon et al, 2003].Arranging referral to a paediatrician or paediatric neurologistThe recommendation that children with suspected neurodevelopmental delay or signs of a neurocutaneous syndrome should be referred is based on expert opinion in review articles, as neuroimaging (CT or MRI head) may be needed [Waruiru and Appleton, 2004; Patel, 2015].In addition, an EEG may be considered in children who have prolonged or complex febrile seizures, recurrences not associated with fever, or associated neurodevelopmental delay, stigmata of a neurocutaneous syndrome, or neurological deficits [Waruiru and Appleton, 2004; Mastrangelo, 2014; Leung, 2018]. The AAP clinical practice guideline does not recommend neuroimaging for the routine evaluation of a child with a simple febrile seizure, and notes that EEG findings have not been shown to predict recurrence of febrile seizures or future epilepsy risk in children with simple febrile seizures [AAP, 2011].In some cases of recurrent complex febrile seizures, intermittent or continuous antiepileptic drug prophylaxis may be initiated by a specialist depending on an individualized risk-benefit assessment [Whelan, 2017]. Back to top Self-management and follow-up Self-management and follow-up If a child has a confirmed diagnosis of febrile seizure:Provide advice and education to parents/carers about the nature of febrile seizures:Febrile seizures are not the same as epilepsy, and the risk of a child developing subsequent epilepsy is low.Short-lasting seizures are not harmful to the child.About 1 in 3 children will have another febrile seizure.The risk of febrile seizure reduces with age as the brain matures, and they are rare beyond 6 years of age.Provide advice on sources of information and support, such as:The patient information leaflet Febrile seizure (Febrile convulsion) available on the www.patient.info website.The NHS Choices leaflet Febrile seizures.Provide written advice on the prompt recognition and management of any future febrile seizure.Advise on immediate first aid measures and when to ring an ambulance.Advise on when and how to use benzodiazepine rescue medication at home, if this has been advised following specialist assessment.See the sections on Acute management of febrile seizure and Benzodiazepine rescue medication for more information.Provide written advice on the management of any future febrile illness.Advise that the intermittent use of antipyretics such as paracetamol and/or ibuprofen at the onset of fever is not recommended, as this does not reduce or prevent febrile seizure recurrence.Advise on the use of paracetamol and/or ibuprofen to reduce fever if the child is uncomfortable or distressed, and on measures to prevent dehydration. See the CKS topic on Feverish children - management for more information.Advise on when to seek immediate medical help if a serious or life-threatening cause of fever is suspected. See the CKS topic on Feverish children - risk assessment for more information.Do not routinely prescribe prophylactic antipyretics or antiepileptic drugs following a febrile seizure, unless on the advice of a specialist following hospital admission or referral.Advise that routine prophylactic drugs do not reduce or prevent febrile seizure recurrence.Advise parents/carers to ensure the child completes all childhood immunizations, even if the febrile seizure followed an immunization.Advise that the use of prophylactic antipyretics such as paracetamol and/or ibuprofen prior to any childhood vaccination is not recommended.Arrange appropriate follow-up in primary care, depending on clinical judgement. Back to top Basis for recommendation Basis for recommendation The recommendations on self-management and follow-up are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Feverish illness in children: assessment and initial management in children younger than 5 years [NICE, 2017], a Task Force Report of the International League Against Epilepsy (ILAE) Commission of Pediatrics Summary of recommendations for the management of infantile seizures [Wilmshurst, 2015], a UK emergency medicine guideline An evidence and consensus based guideline for the management of a child after a seizure [Armon et al, 2003], a Cochrane systematic review Prophylactic drug management for febrile seizures in children [Offringa, 2017], and expert opinion in review articles on febrile seizure [Waruiru and Appleton, 2004; Sadleir and Scheffer, 2007; Siqueira, 2010; Graves et al, 2012; Mastrangelo, 2014; Patel, 2015; Whelan, 2017; Leung, 2018].Providing advice and education to parents/carersThe information that the risk of developing subsequent epilepsy is low is based on expert opinion in a review article [Leung, 2018].The information that short-lived febrile seizures are not harmful and have no significant complications is based on expert opinion in a review article [Sadleir and Scheffer, 2007].The information on the recurrence risk of febrile seizure is based on expert opinion in a review article [Leung, 2018].Providing advice on the recognition and management of future febrile seizuresThe recommendations on first aid measures are pragmatic based on what CKS considers to be good clinical practice. This approach is supported by the expert opinion of previous external reviewers of this CKS topic.The recommendations to use rescue medication (buccal midazolam or rectal diazepam) following specialist advice is based on expert opinion in review articles [Waruiru and Appleton, 2004; Mastrangelo, 2014] and the British National Formulary [BNF for Children, 2017]. It may be used for children with recurrent prolonged febrile seizures or those at high risk of recurrent seizures [Patel, 2015]. This approach is supported by the expert opinion of previous external reviewers of this CKS topic.Expert opinion in a review article notes that recurrent brief febrile seizures do not normally need rescue medication, as there is no increased risk of brain injury [Patel, 2015]. Acute intervention at the time of febrile seizure does not alter the risk of developing epilepsy [Armon et al, 2003; Wilmshurst, 2015].Providing advice on the management of future febrile illnessThe recommendation that the intermittent use of antipyretic agents at the onset of fever does not alter the recurrence rate of febrile seizure is based on a Cochrane systematic review [Offringa, 2017], the ILAE Task Force Report [Wilmshurst, 2015] and expert opinion in review articles [Siqueira, 2010; Graves et al, 2012; Leung, 2018].The Cochrane systematic review found no evidence for the intermittent use of ibuprofen, diclofenac, or paracetamol compared with placebo in preventing recurrent febrile seizures.The recommendations on the appropriate use of antipyretic medication in children are based on the NICE clinical guideline on feverish illness in children [NICE, 2017].Prophylactic antipyretic and antiepileptic drugs not routinely recommendedA Cochrane systematic review of 30 randomized trials (n = 4256) studied the continuous or intermittent use of prophylactic antipyretic, antiepileptic, or other drugs compared with each other, placebo, or no treatment [Offringa, 2017].It found no significant benefit for the use of intermittent phenobarbitone, phenytoin, valproate, pyridoxine, or zinc versus placebo or no treatment. In addition, it found no evidence for the intermittent use of ibuprofen, diclofenac, or paracetamol compared with placebo in preventing recurrent febrile seizures.It found some evidence for seizure reduction with the use of prophylactic intermittent diazepam and continuous phenobarbitone, however, there was a high prevalence of adverse effects with the use of these drugs (in up to 30% of children) which outweighed their benefits, and the majority of studies were subject to methodological limitations. It concluded that prophylactic antiepileptic and antipyretic drugs are not routinely recommended for children with febrile seizures.This approach is supported by the ILAE Task Force Report [Wilmshurst, 2015] and expert opinion in review articles which found no good-quality evidence that the regular use of prophylactic antiepileptic drugs reduces the risk of recurrent febrile seizures or the risk of developing subsequent epilepsy [Waruiru and Appleton, 2004; Graves et al, 2012; Patel, 2015; Leung, 2018].Expert opinion in a review article notes that intermittent use of diazepam is similarly not recommended at the onset of fever, due to the risk of adverse effects, and the fact that recurrent febrile seizures may occur before recognition of fever [Graves et al, 2012].Expert opinion in another review article notes that in some cases of recurrent complex febrile seizures such as those with prolonged or frequent episodes, intermittent or continuous antiepileptic drug prophylaxis may be initiated by a specialist depending on an individualized risk-benefit assessment, to prevent or manage future seizures [Whelan, 2017].Advice on completing all childhood immunizationsThe recommendation to ensure that all childhood vaccinations are up-to-date is based on expert opinion in review articles [Siqueira, 2010; Leung, 2018]. In addition, a US cohort study (n = 679,942 children) found that children who had a febrile seizure following immunization were no more likely to have a subsequent seizure than children who had a febrile seizure associated with another cause for fever [Barlow et al, 2001].The recommendation not to use prophylactic antipyretics prior to vaccination is based on expert opinion in a review article [Leung, 2018].Arranging follow-up in primary careThe recommendation to arrange follow-up in primary care is pragmatic based on what CKS considers to be good clinical practice. This approach is supported by the expert opinion of previous external reviewers of this CKS topic. Supporting evidence Back to topSupporting evidence This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) clinical guideline Feverish illness in children: assessment and initial management in children younger than 5 years [NICE, 2017], a Task Force Report of the International League Against Epilepsy (ILAE) Commission of Pediatrics Summary of recommendations for the management of infantile seizures [Wilmshurst, 2015], the American Academy of Pediatrics (AAP) clinical practice guideline Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure [AAP, 2011], a UK emergency medicine guideline An evidence and consensus based guideline for the management of a child after a seizure [Armon et al, 2003], a Cochrane systematic review Prophylactic drug management for febrile seizures in children [Offringa, 2017], and expert opinion in review articles. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections. How this topic was developed Back to topHow this topic was developed This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website. Back to top Search strategy Search strategy Scope of searchA literature search was conducted for guidelines and systematic reviews on primary care management of febrile seizure.Search datesJuly 2013 - October 2018Key search termsThe terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 11th October 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases.S3 S1 OR S2S2 AB ( (febrile or fever* or pyrexia*) N2 (seizure* or convulsion* or fit or fits) ) OR TI ( (febrile or fever* or pyrexia*) N2 (seizure* or convulsion* or fit or fits) ) S1 (MH "Seizures, Febrile") Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences American Academy of Pediatrics (2011) Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 127(2), 389-394. [Abstract] Annegers, J.F., Hauser, W.A. and Shirts, S.B. et al (1987) Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med 316(9), 493-498. [Abstract] Armon,K., Stephenson,T., Hemingway,P., et al. (2003) An evidence and consensus based guideline for the management of a child after a seizure. 20(1), 13-20. [Abstract] Barlow,W.E., Davis,R.L., Glasser,J.W., et al. (2001) The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. 345(9), 656-661. [Abstract] Baumer, J.H. (2004) Evidence based guideline for post-seizure management in children presenting acutely to secondary care. Arch Dis Child 89(3), 278-280. [Abstract] Baysun,S., Aydin,O.F., Atmaca,E. and Yavuz,G.Y.K. (2005) A comparison of buccal midazolam and rectal diazepam for the acute treatment of seizures. Clinical Pediatrics. 44(9), 771-776. [Abstract] Berg,A.T., Shinnar,S., Darefsky,A.S., et al. (1997) Predictors of recurrent febrile seizures. A prospective cohort study. Archives of Pediatrics & Adolescent Medicine. 151(4), 371-378. [Abstract] Bhattacharyya,M., Kalra,V. and Gulati,S. (2006) Intranasal midazolam vs rectal diazepam in acute childhood seizures. Pediatric Neurology. 34(5), 355-359. [Abstract] BNF for Children (2017) British National Formulary for Children 2016-2017. British Medical Association and the Royal Pharmaceutical Society of Great Britain.. Chungath,M. and Shorvon,S. (2008) The mortality and morbidity of febrile seizures. Nature Clinical Practice Neurology. 4(11), 610-621. [Abstract] Cross, J.H. (2012) Fever and fever-related epilepsies. Epilepsia 53(S4), 3-8. [Abstract] Ganesh,R. and Janakiraman,L. (2008) Serum zinc levels in children with simple febrile seizure. Clinical Pediatrics. 47(2), 164-166. [Abstract] Graves,R.C., Oehler,K. and Tingle,L.E. (2012) Febrile seizures: risks, evaluation, and prognosis. American Family Physician. 85(2), 149-153. [Abstract] Hartfield,D.S., Tan,J., Yager,J.Y., et al. (2009) The association between iron deficiency and febrile seizures in childhood. Clinical Pediatrics. 48(4), 420-426. [Abstract] Hesdorffer, D.C., Benn, E.K.T. and Bagiella, E. et al (2011) Distribution of febrile seizure duration and associations with development. Ann Neurol 70(1), 93-100. [Abstract] International League Against Epilepsy (1993) Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia 34(4), 592-596. [Abstract] Knudsen,F.U. (1996) Febrile seizures - treatment and outcome. 18(6), 438-449. [Abstract] Koren,G. (2000) Intranasal midazolam for febrile seizures. A step forward in treating a common and distressing conditions. British Medical Journal. 321(7253), 64-65. Lahat,E., Goldman,M., Barr,J., et al. (2000) Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. British Medical Journal. 321(7253), 83-86. [Abstract] Leung, A.K.C., Hon, K.L. and Leung, T.N.H. (2018) Febrile seizures: an overview. Drugs in Context 7, 1-12. [Abstract] Martinos, M.M., Yoong, M. and Patil, S. et al (2012) Recognition memory is impaired in children after prolonged febrile seizures. Brain 135(10), 3153-3164. [Abstract] Mastrangelo, M., Midulla, F. and Moretti, C. (2014) Actual insights into the clinical management of febrile seizures. Eur J Pediatr 173(8), 977-982. [Abstract] McIntyre,J., Robertson,S., Norris,E., et al. (2005) Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet. 336(9481), 205-210. [Abstract] Mewasingh,L.D. (2010) Febrile seizures. Clinical Evidence. BMJ Publishing Group Ltd.. www.clinicalevidence.com [Free Full-text] Najaf-Zadeh, A., Dubos, F. and Hue, V. et al (2013) Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis. PLoS One 8(1), 1-8. [Free Full-text] National Collaborating Centre for Women's and Children's Health (2013) Feverish illness in children: assessment and initial management in children younger than 5 years (full NICE guideline). Clinical guidance 160. National Centre for Health and Care Excellence.. www.nice.org.uk [Free Full-text] Neligan, A., Bell, G.S. and Johnson, A.L. et al (2012) Long-term risk of developing epilepsy after febrile seizures: a prospective cohort study. Neurology 78(15), 1166-1170. [Abstract] NICE (2017) Feverish illness in children: assessment and initial management in children younger than 5 years. National Institute for Health and Care Excellence. www.nice.org.uk/ [Free Full-text] Offringa,M. and Newton,R. (2012) Prophylactic drug management for febrile seizures in children (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] Offringa, M., Newton, R. and Cozijnsen, M.A. et al (2017) (Cochrane Review). John Wiley & Sons, Ltd.. www.cochranelibrary.com/ [Free Full-text] Patel, N., Ram, D. and Swiderska, N. et al (2015) Febrile seizures. British Medical Journal 351, 1-7. [Abstract] Rosenbloom,E., Finkelstein,Y., Adams-Webber,T. and Kozer,E. (2013) Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis. European Journal of Paediatric Neurology. 17(6), 585-588. [Abstract] Sadleir,L.G. and Scheffer,I.E. (2007) Febrile seizures. British Medical Journal. 334(7588), 307-311. Seinfeld, S., Shinnar, S., Sun, S. and et al (2014) Emergency management of febrile status epilepticus: results of the FEBSTAT study. Epilepsia 55(3), 388-395. [Abstract] Siqueira,L.F. (2010) Febrile seizures: update on diagnosis and management. Revista Da Associacao Medica Brasileira. 56(4), 489-492. [Abstract] Strengell,T., Uhari,M., Tarkka,R., et al. (2009) Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Archives of Pediatrics & Adolescent Medicine. 163(9), 799-804. [Abstract] van Stuijvenberg,M., Derksen-Lubsen,G., Steyerberg,E.W., et al. (1998) Randomized, controlled trial of ibuprofen sysrup administered during febrile illnesses to prevent febrile seizure recurrences. Pediatrics. 102(5), E51. [Abstract] Veisani, Y., Delpisheh, A. and Sayehmiri, K. (2013) Familial history and recurrence of febrile seizures: a systematic review and meta-analysis. Iran J Pediatr 23(4), 389-395. Verity,C.M., Greenwood,R. and Golding,J. (1998) Long-term intellectual and behavioral outcomes of children with febrile convulsions. 338(24), 1723-1728. [Abstract] Verity, C.M., Butler, N.R. and Golding, J. (1985) Febrile convulsions in a national cohort followed up from birth. Prevalence and recurrence in the first five years of life. British Medical Journal 290(6478), 1307-1310. [Abstract] Visser, A.M., Jaddoe, V.W. and Ghassabian, A. et al (2012) Febrile seizures and behavioural and cognitive outcomes in preschool children: the Generation R study. Dev Med Child Neurol 54(11), 1006-1011. [Abstract] Waruiru,C. and Appleton,R. (2004) Febrile seizures: an update. Archives of Disease in Childhood. 89(8), 751-756. [Abstract] Whelan, H., Harmelink, M. and Chou, E. et al (2017) Complex febrile seizures - a systematic review. Disease-a-month 63(1), 5-23. [Abstract] Wilmshurst, J.M., Gaillard, W.D. and Vinayan, K.P. et al (2015) Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia 56(8), 1185-1197. [Abstract]