Febrile Convulsion (Febrile Seizure) in Children

1. Clinical Overview

Summary

Febrile convulsions are seizures occurring in children aged 6 months to 5 years, associated with fever (temperature ≥38°C), in the absence of intracranial infection, metabolic disturbance, or history of afebrile seizures. [1,2] They represent the most common type of childhood seizure, affecting 2-5% of children in Western populations and up to 8-14% in Asian populations. [3,4]

The distinction between simple and complex febrile seizures is fundamental to clinical management and prognosis. Simple febrile seizures are generalised tonic-clonic seizures lasting less than 15 minutes, occurring once within a 24-hour period, with complete neurological recovery within 1 hour. [2] Complex febrile seizures are characterised by focal features, prolonged duration (≥15 minutes), or recurrence within 24 hours, and warrant more detailed investigation. [1,2]

Despite causing extreme parental anxiety, simple febrile convulsions are benign with excellent long-term neurodevelopmental outcomes. [5,6] The key clinical priorities are: (1) excluding serious underlying infection, particularly meningitis; (2) distinguishing simple from complex seizures; and (3) providing comprehensive parent education and reassurance. Importantly, antipyretic medications do NOT prevent recurrence—this is a critical teaching point repeatedly confirmed by high-quality evidence. [7,8]

Key Facts Card

Clinical Pearls

"The Fever Rise, Not the Height": Febrile seizures occur due to the rapid RATE of temperature rise, not the absolute temperature. A child can seize at 38.5°C if temperature rises quickly. This explains why seizures often occur early in a febrile illness, sometimes before parents recognise the fever. [3]

Antipyretics Don't Prevent Recurrence: Multiple high-quality RCTs and a Cochrane systematic review have definitively shown that regular antipyretics (paracetamol, ibuprofen) do NOT reduce the risk of further febrile convulsions. Treat fever for comfort, not prevention. [7,8]

Roseola (HHV-6) Alert: Human herpesvirus 6 (HHV-6, causing roseola/exanthem subitum) is the single strongest viral trigger for febrile seizures, responsible for up to 20% of first febrile seizures. [9,10] The classic pattern: high fever for 3 days, then rash appears as fever breaks—the seizure often occurs just before or as the rash appears.

The "Rule of 15": Simple = less than 15 minutes duration + single episode in 24 hours + generalised + age 6mo-5yr + full recovery in less than 1 hour. Any deviation = Complex FC requiring more detailed evaluation.

Why This Matters Clinically

Febrile convulsions cause extreme parental anxiety—many parents genuinely believe their child is dying during the episode. Effective reassurance and education are crucial and often inadequately delivered. While most febrile convulsions are benign, the key clinical challenge is excluding meningitis or other serious bacterial infection, particularly in young or unimmunised children. [1,2] Complex febrile seizures, especially prolonged febrile seizures (febrile status epilepticus), may be the presenting feature of Dravet syndrome (SCN1A mutation) and warrant specialist referral. [14]

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2. Epidemiology

Incidence & Prevalence

Febrile seizures are the most common seizure type in childhood, with significant geographic and ethnic variation in prevalence. [3,4]

Age Distribution:

• 6 months – 5 years (by definition)
• Peak incidence: 12-18 months
• 50% of first febrile seizures occur in the second year of life
• Rare before 6 months (raises concern for structural abnormality or meningitis)
• Rare after 5 years (consider other seizure types) [3]

Risk Factors for First Febrile Seizure

Non-Modifiable:

• Age 6 months – 5 years
• Family history of febrile convulsions in first-degree relative (10-20% have affected parent or sibling) [11]
• Family history of epilepsy
• Male sex (slight predominance, M:F = 1.3-1.6:1)
• Developmental delay (increases risk of complex FC)
• Genetic factors: SCN1A, GABRG2 mutations associated with more severe phenotypes [14,15]

Fever-Related:

• HHV-6 (roseola) infection—strongest viral trigger [9,10]
• Influenza A infection
• Recent vaccination (particularly MMR, DTP)—risk increase is small and transient [16]
• Otitis media, URTI, gastroenteritis (most common fever sources)

Risk Factors for Recurrence

The prospective Berg cohort study (n=428) identified four independent predictors of recurrence, which form the basis for counselling parents. [11]

Recurrence Risk by Number of Factors (Berg et al.): [11]

• 0 factors: ~12% recurrence
• 1 factor: ~25-30% recurrence
• 2 factors: ~50% recurrence
• 3-4 factors: > 70% recurrence

Risk Factors for Subsequent Epilepsy

The risk of developing epilepsy after febrile seizures is increased compared to the general population (general population risk ~0.5%). [12,13]

Risk factors for epilepsy after FC: [12,13]

• Complex febrile seizure (especially focal or prolonged)
• Family history of epilepsy
• Pre-existing neurodevelopmental abnormality
• Multiple recurrent febrile seizures
• Febrile status epilepticus

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3. Pathophysiology

Mechanism of Febrile Seizures

The pathophysiology of febrile seizures involves a complex interplay between the developing brain's vulnerability to temperature changes, genetic factors, and inflammatory responses. [17,18]

Step 1: Fever Onset and Cytokine Release

• Infection (usually viral) triggers innate immune response
• Release of pyrogenic cytokines: IL-1β, IL-6, TNF-α, prostaglandin E2
• Hypothalamic thermoregulatory set-point elevated
• Cytokines may have direct pro-convulsant effects on neurons [17]

Step 2: Immature Brain Susceptibility

• The developing brain (6 months – 5 years) has heightened susceptibility to seizures
• Enhanced neuronal excitability during this age window
• Immature inhibitory (GABAergic) circuits
• Temperature-sensitive ion channels (TRPV1, TRPM8) may alter neuronal excitability [18]
• Immature blood-brain barrier may allow greater cytokine penetration

Step 3: Temperature-Dependent Neuronal Hyperexcitability

• Rapid rise in temperature (rate of change) is key, not absolute temperature
• Fever increases neuronal metabolic demands
• Enhanced glutamatergic (excitatory) neurotransmission
• Reduced GABAergic (inhibitory) neurotransmission
• Respiratory alkalosis from tachypnoea may contribute [17]

Step 4: Seizure Generation

• Synchronised abnormal neuronal discharge
• Generalised tonic-clonic activity (simple FC)
• Focal onset suggests underlying structural/developmental abnormality or genetic epilepsy syndrome (complex FC)

Simple vs Complex Classification (ILAE/AAP)

The distinction between simple and complex febrile seizures is fundamental and guides investigation, management, and prognosis. [1,2]

Febrile Status Epilepticus:

• Febrile seizure lasting ≥30 minutes
• Medical emergency requiring aggressive treatment
• Occurs in ~5% of febrile seizure presentations
• Associated with increased risk of subsequent temporal lobe epilepsy
• May be the presenting feature of Dravet syndrome (SCN1A mutation) [14]

Genetic Considerations

Strong familial tendency exists (polygenic inheritance pattern). [14,15]

Clinical Pearl: Any child presenting with prolonged (> 15 min) or repeated febrile seizures in the first year of life should be considered for Dravet syndrome screening (SCN1A testing), particularly if there is incomplete recovery or developmental regression. [14]

Common Fever Sources

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4. Clinical Presentation

History

Seizure Description (obtain from witness):

• Duration of seizure (time onset to resolution)
• Semiology: generalised tonic-clonic vs focal features
• Eye position: rolling back (generalised) vs deviated to one side (focal)
• Limb movements: symmetric bilateral vs unilateral
• Colour change: cyanosis is common during tonic phase
• Post-ictal period: drowsiness, confusion, duration of recovery
• Any recurrence within 24 hours

Fever and Illness History:

• Duration of fever
• Maximum temperature recorded (if known)
• Symptoms of underlying infection (coryza, cough, ear pulling, vomiting, diarrhoea)
• Time from fever onset to seizure
• Any rash (timing relative to fever)
• Antibiotic use (may mask meningitis)

Past Medical History:

• Previous febrile seizures (number, frequency)
• Previous afebrile seizures
• Developmental milestones (delay increases risk of complex FC)
• Neurodevelopmental conditions
• Immunisation status (critical for LP decision)

Family History:

• Febrile seizures in first-degree relatives
• Epilepsy in family
• Dravet syndrome or other epilepsy syndromes

Symptoms

Typical Presentation:

• Child aged 12-18 months (peak age)
• Fever from viral illness (URTI, otitis media, roseola)
• Sudden onset of generalised tonic-clonic seizure
• Witnessed by terrified parent/caregiver
• Duration typically 1-5 minutes (feels much longer to parents)
• Post-ictal drowsiness lasting 30-60 minutes
• Full recovery to normal behaviour

Associated Symptoms (from underlying infection):

• Coryza, cough (URTI)
• Ear pain, irritability, ear pulling (otitis media)
• Rash appearing as fever breaks (roseola—classic pattern)
• Vomiting, diarrhoea (gastroenteritis)
• Increased work of breathing (LRTI)

Atypical Presentations Requiring Careful Evaluation:

• Focal seizure (jerking one limb, eye deviation to one side)
• Prolonged seizure > 15 minutes
• Multiple seizures within 24 hours
• Seizure at onset of fever (very short duration of fever before seizure)
• Seizure with low-grade fever (38-38.5°C)
• Incomplete neurological recovery > 1 hour post-seizure

Signs

During Seizure (if witnessed):

• Generalised tonic-clonic movements
  • "Tonic phase: stiffening, eyes rolled back, apnoea"
  • "Clonic phase: rhythmic bilateral limb jerking"
• Perioral cyanosis (common; due to breath-holding during tonic phase)
• Unresponsive to verbal and physical stimuli
• Possible urinary incontinence
• Possible frothing at mouth

Post-Ictal Examination:

• Drowsy but rousable
• May be irritable or clingy
• Normal tone returns (hypotonia may persist briefly)
• Full recovery expected within 1 hour (simple FC)
• Temperature elevated (confirm fever)

Signs of Underlying Infection (systematic examination essential):

• ENT: Red, bulging tympanic membrane (AOM); pharyngitis; rhinorrhoea
• Respiratory: Tachypnoea, increased work of breathing, focal chest signs
• Skin: Blanching viral exanthem vs non-blanching petechial/purpuric rash
• Abdomen: Tenderness (UTI, mesenteric adenitis)

Red Flags

[!CAUTION] Red Flags — Exclude serious bacterial infection/meningitis if:

• Age less than 6 months or > 5 years (outside typical FC age range)
• Bulging fontanelle (in infants less than 18 months)
• Neck stiffness (Kernig's/Brudzinski's positive)
• Non-blanching petechial or purpuric rash (meningococcal septicaemia)
• Prolonged post-ictal drowsiness (> 1 hour) or failure to return to baseline
• Focal seizure or focal neurological signs post-ictally
• Complex seizure features (prolonged, focal, recurrent)
• Incomplete or unknown immunisation status (Hib, pneumococcal)
• Pre-treatment with antibiotics (may mask meningitis)
• Paroxysmal irritability with high-pitched cry
• No clear source of fever identified

[!WARNING] Think Meningitis If: Any of the above red flags are present. Meningitis can present with seizure AND fever and may be clinically indistinguishable from benign febrile seizure. Have a LOW threshold for lumbar puncture in children less than 12 months, unimmunised children, or those with incomplete recovery.

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5. Clinical Examination

Structured Approach

Immediate Assessment (ABCDE if actively seizing or immediate post-ictal):

1. Airway: Patent? Positioning? Secretions?
2. Breathing: SpO₂, respiratory rate, effort
3. Circulation: Heart rate, capillary refill, colour
4. Disability: GCS/AVPU, pupils, glucose (POC)
5. Exposure: Temperature, rash (blanching vs non-blanching)

General Inspection:

• Level of consciousness (should improve rapidly)
• Hydration status (mucous membranes, skin turgor, tears)
• Colour (pallor, cyanosis, mottling)
• Rash (timing, distribution, blanching)
• Behaviour (interaction with parents, consolability)

Neurological Examination (Post-Ictal)

This is critical to distinguish simple from complex FC and exclude meningitis.

Meningeal Signs

Clinical Pearl: Classical meningeal signs are UNRELIABLE in children less than 18 months. In this age group, look for: bulging fontanelle, paroxysmal irritability, inconsolable crying, high-pitched cry, and "paradoxical irritability" (irritable when held, calmer when left alone).

Full Infection Screen Examination

Essential to identify fever source:

The Glass Test

For any child with fever AND rash:

• Press a clear glass firmly against the rash
• Blanching rash (disappears under pressure): Usually benign viral exanthem
• Non-blanching rash (persists under pressure): URGENT—assume meningococcal septicaemia until proven otherwise

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6. Investigations

Approach to Investigations

The AAP Clinical Practice Guidelines provide evidence-based recommendations for investigation. [1,2] The key principle is that investigations should be directed at identifying the source of fever and excluding serious bacterial infection, NOT at the seizure itself in simple FC.

First-Line Investigations (All Patients)

Laboratory Tests

Evidence: Routine blood tests are NOT required in simple febrile seizures in well-appearing children with clear fever source. [1,2]

Lumbar Puncture

Lumbar puncture recommendations have evolved significantly. The AAP 2011 guidelines provide evidence-based indications. [1]

Indications for LP:

LP NOT Routinely Required:

• Simple FC in well, fully immunised child > 12 months with clear fever source and complete recovery [1,2]

Contraindications to LP (perform CT first if present):

• Signs of raised ICP (papilloedema, focal neurology, GCS less than 9)
• Haemodynamic instability
• Coagulopathy
• Skin infection at LP site

Neuroimaging

AAP Recommendation: Neuroimaging should NOT be performed routinely in the evaluation of the child with a simple febrile seizure. [1]

EEG

Evidence: Multiple studies demonstrate that routine EEG after simple FC does not predict recurrence or epilepsy risk and is NOT recommended. [1,2]

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7. Management

Acute Seizure Management (Emergency Protocol)

If Actively Seizing on Arrival:

Benzodiazepine Doses:

APLS Seizure Algorithm Principles:

1. ABC takes priority over stopping seizure
2. Time the seizure accurately
3. First benzodiazepine at 5 minutes
4. Second benzodiazepine at 10 minutes
5. Escalate to IV lorazepam or phenytoin by 15-20 minutes
6. Consider phenobarbital or anaesthetic agents if refractory

Post-Ictal Management

Simple Febrile Convulsion Protocol:

1. Confirm diagnosis: Meets criteria for simple FC (age 6mo-5yr, generalised, less than 15min, single in 24h, full recovery)

2. Identify fever source: Comprehensive examination

   • ENT examination (otoscopy essential)
   • Respiratory examination
   • Urine dipstick/MC&S if no clear source

3. Treat fever for comfort:

   • Paracetamol 15 mg/kg (max 1g) OR
   • Ibuprofen 10 mg/kg (max 400mg)
   • NOT to prevent recurrence (ineffective per Cochrane review) [7,8]

4. Observation period: 1-4 hours post-seizure to ensure recovery

5. Parent education: Essential component (see below)

6. Safety netting: Clear written and verbal instructions

7. Discharge: If well, clear fever source, child recovered, parents educated

Complex Febrile Convulsion Protocol:

1. Lower threshold for investigations: Consider FBC, CRP, blood culture, urine MC&S

2. Consider LP: Especially if less than 12 months, unimmunised, pre-treated with antibiotics, incomplete recovery

3. Consider admission: For observation, investigation, parental anxiety

4. Outpatient follow-up: Paediatric neurology referral indicated

Antipyretic Evidence (Critical Teaching Point)

[!IMPORTANT] Cochrane Systematic Review 2017 [7]:

• Reviewed all RCTs of antipyretic prophylaxis for febrile seizure recurrence
• Pooled data from multiple trials
• Conclusion: There is NO evidence that antipyretic drugs reduce febrile seizure recurrence
• Antipyretics treat discomfort, NOT seizure risk
• This finding is Level 1a evidence

Why Antipyretics Don't Work:

• Febrile seizures occur with rapid temperature RISE
• By the time parents detect fever, the rapid rise has already occurred
• Antipyretics cannot prevent the initial spike
• Seizures often occur before parents are aware of fever

Anticonvulsant Prophylaxis

AAP Recommendation (2008): [2]

• Continuous anticonvulsant prophylaxis is NOT recommended for simple febrile seizures
• Intermittent prophylaxis (diazepam at fever onset) is NOT routinely recommended

Evidence Against Prophylaxis:

• Phenobarbital: Reduces recurrence but causes significant behavioural/cognitive side effects; risks outweigh benefits [2]
• Valproate: Effective but hepatotoxicity risk in young children; NOT recommended
• Intermittent diazepam: May reduce recurrence but side effects (sedation, ataxia) problematic; NOT routinely recommended
• Carbamazepine/Phenytoin: Ineffective

When Prophylaxis Might Be Considered:

• Recurrent prolonged febrile seizures (febrile status epilepticus)
• High parental anxiety despite education
• Very frequent recurrences
• Discuss with paediatric neurology

Parent Education (Critical Component)

This is arguably the most important intervention. Many parents leave ED without adequate education.

Key Messages to Deliver:

1. Reassurance:

   • "Febrile convulsions are common—2-5% of all children have one"
   • "Your child is NOT at risk of brain damage or death from a simple febrile convulsion"
   • "Most children grow out of these by age 5-6 years"

2. Recurrence Counselling:

   • "There is a 30% chance of another seizure with future fevers"
   • "This does NOT mean your child has epilepsy"
   • Explain risk factors (younger age, family history)

3. Antipyretic Counselling:

   • "Medicine like Calpol/Nurofen will make your child more comfortable but will NOT prevent seizures"
   • "Giving these medicines regularly will NOT reduce the risk of another fit"

4. What To Do If It Happens Again:

   • Stay calm
   • Note the time (important)
   • Place child on side (recovery position)
   • Do NOT put anything in their mouth
   • Do NOT restrain movements
   • Move dangerous objects away
   • Call ambulance (999) if seizure lasts > 5 minutes
   • Bring child to hospital after first seizure or if concerned

5. When to Seek Urgent Help:

   • Seizure lasting > 5 minutes
   • Child not waking within 1 hour
   • Rash that doesn't fade when pressed
   • Stiff neck or very unwell appearance
   • Another seizure within 24 hours

Provide Written Information: Leaflet with key points and emergency contact numbers.

Disposition

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8. Complications

Immediate (Minutes-Hours)

Early (Days)

Late (Months-Years)

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9. Prognosis & Outcomes

Natural History

• Febrile seizures occur ONLY within the 6 month – 5 year age window
• Children "grow out of" febrile convulsions as the brain matures
• 95% of children with simple FC have normal development
• Risk of febrile seizures decreases with each year of age > 18 months

Long-Term Outcomes

Evidence for Benign Prognosis (Large Cohort Studies)

National Collaborative Perinatal Project (USA): [5]

• n = 431 children with febrile seizures
• Followed to age 7 years
• No difference in IQ, academic achievement, or behaviour compared to controls
• Even children with recurrent or prolonged FC had normal outcomes

Danish National Registry Study: [6]

• Population-based cohort
• Long-term follow-up
• Confirmed benign prognosis for simple febrile seizures
• Academic and employment outcomes normal

Prognostic Factors

Good Prognosis (Majority):

• Simple febrile convulsion
• Age > 12 months at first episode
• No family history of epilepsy
• Normal neurodevelopment
• Normal post-ictal recovery

Increased Epilepsy Risk:

• Complex febrile convulsion (especially focal or prolonged)
• Family history of epilepsy
• Pre-existing developmental delay
• Multiple recurrent febrile seizures
• Febrile status epilepticus
• Abnormal neurology between seizures

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10. Special Considerations

Vaccination and Febrile Seizures

Post-vaccination febrile seizures have been studied extensively. [16]

Key Counselling Points:

• Post-vaccination FC does NOT increase epilepsy risk
• Benefits of vaccination far outweigh small transient seizure risk
• History of FC is NOT a contraindication to vaccination
• Consider paracetamol prophylaxis only for parental anxiety (does not prevent seizures)

Dravet Syndrome Considerations

Dravet syndrome (severe myoclonic epilepsy of infancy) often presents with prolonged febrile seizures. [14]

When to Suspect Dravet:

• Prolonged febrile seizures (> 15-30 minutes) in first year of life
• Hemi-clonic seizures (unilateral) with fever
• Seizures triggered by bathing or warm weather
• Developmental plateau or regression after age 1 year
• Seizures refractory to standard treatment
• Family history of GEFS+ or SCN1A mutations

Investigation:

• SCN1A gene testing (most cases de novo)
• EEG (may be normal initially)
• MRI (usually normal)

Implications:

• Avoid sodium channel blockers (carbamazepine, phenytoin, lamotrigine)—may worsen seizures
• Requires specialist paediatric neurology management
• Guarded prognosis for development

GEFS+ (Generalised Epilepsy with Febrile Seizures Plus)

GEFS+ is a familial epilepsy syndrome with variable phenotypes. [15]

Features:

• Febrile seizures persist beyond age 6 years
• Afebrile generalised seizures may develop
• Variable phenotypes within same family
• Associated genes: SCN1A, SCN1B, SCN2A, GABRG2

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11. Viva Questions & Model Answers

Question 1: "A 14-month-old is brought in after a witnessed generalised tonic-clonic seizure lasting 3 minutes. Temperature is 39.2°C. Walk me through your assessment."

Model Answer: "This presentation is consistent with a febrile seizure. My priorities are: first, confirming the child has fully recovered from the seizure; second, identifying the fever source; and third, excluding serious bacterial infection, particularly meningitis.

On assessment, I would confirm the child is now alert and interactive with normal neurological examination. I would perform a full examination to identify the fever source—checking ears, throat, chest, and considering urine if no source found.

Given the age of 14 months and assuming the child is fully immunised and has returned to baseline, this meets criteria for a simple febrile seizure: generalised, less than 15 minutes, single episode, age 6 months to 5 years.

Per AAP guidelines, in a well-appearing child over 12 months with a simple febrile seizure, clear fever source, and complete immunisations, routine investigations including lumbar puncture are not required.

Management would focus on treating the underlying infection, providing parent education about the benign nature of febrile seizures, and safety netting for when to return."

Question 2: "The parents ask if giving Calpol regularly will prevent future seizures. How do you respond?"

Model Answer: "This is a very common and important question. I would explain that multiple high-quality studies and a Cochrane systematic review have conclusively shown that regular antipyretic medication does NOT reduce the risk of further febrile seizures.

The reason is that febrile seizures occur because of the rapid rate of temperature rise, not the absolute temperature. By the time parents detect a fever and give medication, the rapid rise has already occurred—often the seizure happens before parents even realise the child has a fever.

I would emphasise that paracetamol and ibuprofen are still useful for making the child more comfortable when they have a fever, but they should not be given with the expectation of preventing seizures. This is important because it avoids both unnecessary medication use and false reassurance."

Question 3: "What factors would make you consider lumbar puncture in this child?"

Model Answer: "The AAP 2011 guidelines provide evidence-based recommendations for lumbar puncture in febrile seizures.

LP should be strongly considered if there are any clinical signs of meningitis: bulging fontanelle, neck stiffness, prolonged altered consciousness, petechial rash, or paroxysmal irritability.

LP is an option to consider in several situations: if the child is between 6-12 months of age, which is a lower threshold because signs of meningitis are subtle in infants; if the child has incomplete Hib or pneumococcal immunisations or unknown immunisation status; or if the child has been pre-treated with antibiotics which may mask meningitis.

Importantly, LP is NOT routinely required in a well-appearing, fully immunised child over 12 months with a simple febrile seizure, clear fever source, and complete recovery."

Question 4: "What is the risk of epilepsy following febrile seizures?"

Model Answer: "The risk of developing epilepsy after febrile seizures is slightly increased compared to the general population but remains low overall.

For simple febrile seizures, the risk is approximately 1-2%, compared to 0.5% in the general population—so roughly 2-4 times increased but still reassuringly low.

For complex febrile seizures—those that are prolonged, focal, or recurrent within 24 hours—the risk is higher at 4-6%.

Additional factors that increase epilepsy risk include: family history of epilepsy, pre-existing neurodevelopmental abnormality, multiple recurrent febrile seizures, and particularly febrile status epilepticus.

The key message for parents is that even with a complex febrile seizure, more than 90% of children will NOT develop epilepsy. For simple febrile seizures, the prognosis is excellent with normal long-term development and cognition confirmed by large cohort studies."

Question 5: "When would you suspect Dravet syndrome and why is this important?"

Model Answer: "Dravet syndrome is a severe epileptic encephalopathy caused by SCN1A mutations that often presents with prolonged febrile seizures in infancy.

I would suspect Dravet syndrome if a child presents with prolonged febrile seizures lasting more than 15-30 minutes in the first year of life, particularly if seizures are hemiclonic or unilateral. Other red flags include seizures triggered by warm baths or warm weather, seizures that are refractory to initial benzodiazepine treatment, and any developmental plateau or regression after the first year.

Recognising Dravet syndrome is crucial for two reasons. First, certain anticonvulsants—specifically sodium channel blockers like carbamazepine, phenytoin, and lamotrigine—can paradoxically worsen seizures in Dravet syndrome and should be avoided. Second, these children require specialist paediatric neurology input and have a guarded prognosis for neurodevelopment.

If I suspected Dravet syndrome, I would arrange SCN1A gene testing and urgent paediatric neurology referral."

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12. Patient/Layperson Explanation

What is a Febrile Convulsion?

A febrile convulsion (also called a febrile seizure or "fever fit") is a seizure that happens when your child has a fever. It usually happens in children between 6 months and 5 years old. During the seizure, your child may become stiff, jerk their arms and legs, roll their eyes back, and become unresponsive. This typically lasts 1-5 minutes.

Is it serious?

Although febrile convulsions are extremely frightening to witness, they are usually completely harmless and do not cause any lasting damage to your child's brain. Research studies following children for many years have confirmed that children who have febrile convulsions have completely normal intelligence, learning, and behaviour.

About 2-5% of all children (1 in 20-50) will have at least one febrile convulsion. Most children grow out of them by age 5-6 and never have epilepsy.

What causes it?

Febrile convulsions happen because of how young children's brains react to a rapidly rising temperature. Common triggers include viral infections like colds, ear infections, or a viral illness called roseola.

The important point is that it's the speed of temperature rise, not how high the fever goes, that triggers the seizure. This is why seizures often happen early in an illness, sometimes before you even realise your child has a fever.

Does medicine prevent them?

No. Multiple medical studies have shown that giving paracetamol (Calpol) or ibuprofen (Nurofen) regularly does NOT prevent febrile seizures. These medicines are still useful for making your child more comfortable when they have a fever, but they cannot prevent seizures.

What should I do if it happens?

1. Stay calm — the seizure will usually stop on its own within a few minutes
2. Note the time — it's important to know how long it lasts
3. Lay your child on their side (recovery position) to keep their airway clear
4. Don't put anything in their mouth — they will not swallow their tongue
5. Don't try to stop the movements — this won't help
6. Move dangerous objects away from them
7. Call 999 if the seizure lasts more than 5 minutes

What to expect afterwards

After the seizure stops, your child will be sleepy and confused for 30-60 minutes. This is completely normal. Once they fully recover, they should be back to their normal self (although still unwell with the underlying infection).

Will it happen again?

About 1 in 3 children who have one febrile convulsion will have another one with a future fever. This is more likely if:

• Your child was under 12 months at their first seizure
• You have family members who had febrile convulsions
• The seizure happened very early in the illness

Even if it happens again, it's still usually harmless.

When to seek urgent medical help

Go to hospital or call 999 if:

• This is your child's first seizure
• The seizure lasts more than 5 minutes
• Your child doesn't wake up within an hour
• Your child has a rash that doesn't fade when pressed (use a glass)
• Your child has a stiff neck or is very unwell
• Another seizure happens within 24 hours
• You are worried about your child for any reason

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13. References

Primary Guidelines

1. Subcommittee on Febrile Seizures; American Academy of Pediatrics. Clinical practice guideline—neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. doi:10.1542/peds.2010-3318 [PMID: 21285335]

2. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures American Academy of Pediatrics. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121(6):1281-1286. doi:10.1542/peds.2008-0939 [PMID: 18519501]

Key Literature

3. Vestergaard M, Christensen J. Register-based studies on febrile seizures in Denmark. Brain Dev. 2009;31(5):372-377. doi:10.1016/j.braindev.2008.11.012 [PMID: 19168299]

4. Chung S. Febrile seizures. Korean J Pediatr. 2014;57(9):384-395. doi:10.3345/kjp.2014.57.9.384 [PMID: 25324864]

5. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics. 1978;61(5):720-727. [PMID: 662510]

6. Vestergaard M, Pedersen CB, Sidenius P, et al. The long-term risk of epilepsy after febrile seizures in susceptible subgroups. Am J Epidemiol. 2007;165(8):911-918. doi:10.1093/aje/kwk086 [PMID: 17267416]

7. Offringa M, Newton R, Cozijnsen MA, Nevitt SJ. Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev. 2017;2(2):CD003031. doi:10.1002/14651858.CD003031.pub3 [PMID: 28211911]

8. Rosenbloom E, Finkelstein Y, Adams-Webber T, Kozer E. Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis. Eur J Paediatr Neurol. 2013;17(6):585-588. doi:10.1016/j.ejpn.2013.04.008 [PMID: 23702315]

9. Hall CB, Long CE, Schnabel KC, et al. Human herpesvirus-6 infection in children: a prospective study of complications and reactivation. N Engl J Med. 1994;331(7):432-438. doi:10.1056/NEJM199408183310703 [PMID: 8035839]

10. Zerr DM, Meier AS, Selke SS, et al. A population-based study of primary human herpesvirus 6 infection. N Engl J Med. 2005;352(8):768-776. doi:10.1056/NEJMoa042207 [PMID: 15728809]

11. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures: a prospective cohort study. Arch Pediatr Adolesc Med. 1997;151(4):371-378. doi:10.1001/archpedi.1997.02170410045006 [PMID: 9111436]

12. Annegers JF, Hauser WA, Shirts SB, Kurland LT. Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med. 1987;316(9):493-498. doi:10.1056/NEJM198702263160901 [PMID: 3807992]

13. Verity CM, Golding J. Risk of epilepsy after febrile convulsions: a national cohort study. BMJ. 1991;303(6814):1373-1376. doi:10.1136/bmj.303.6814.1373 [PMID: 1760604]

14. Dravet C. The core Dravet syndrome phenotype. Epilepsia. 2011;52 Suppl 2:3-9. doi:10.1111/j.1528-1167.2011.02994.x [PMID: 21463272]

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16. Barlow WE, Davis RL, Glasser JW, et al. The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. N Engl J Med. 2001;345(9):656-661. doi:10.1056/NEJMoa003077 [PMID: 11547719]

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19. Shinnar S, Bello JA, Chan S, et al. MRI abnormalities following febrile status epilepticus in children: the FEBSTAT study. Neurology. 2012;79(9):871-877. doi:10.1212/WNL.0b013e318266fcc3 [PMID: 22843268]

20. National Institute for Health and Care Excellence. Feverish illness in children: assessment and initial management (CG160). NICE; 2021. https://www.nice.org.uk/guidance/cg160

Further Resources

• NHS Febrile Seizures: nhs.uk/conditions/febrile-seizures
• Epilepsy Action: epilepsy.org.uk
• Great Ormond Street Hospital Information: gosh.nhs.uk
• Advanced Paediatric Life Support (APLS): alsg.org

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14. Appendix: Quick Reference Cards

Simple vs Complex FC: Quick Differentiation

LP Decision Aid

Do LP if:

• Clinical signs of meningitis
• Age 6-12 months (lower threshold)
• Incomplete immunisations
• Pre-treated with antibiotics
• Incomplete recovery

LP not routine if:

• Age > 12 months
• Fully immunised
• Simple FC
• Clear fever source
• Complete recovery

Benzodiazepine Quick Reference

Parent Discharge Checklist

• Explained benign nature of simple FC
• Explained recurrence risk (30%)
• Clarified antipyretics don't prevent seizures
• Taught recovery position
• Explained when to call ambulance (> 5 min)
• Provided written information leaflet
• Arranged GP follow-up 24-48h
• Safety netted for return if concerns

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Any child with a seizure should be assessed by a healthcare professional to exclude serious underlying causes. Always follow local guidelines and protocols.