Febrile Seizure: Acute Presentation v2.

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Approval & Citation Summary of Version Changes Explanation of Evidence Ratings

If actively seizing,
! use Seizure Pathway
Inclusion Criteria Admit Criteria
· Patients age 6-60 months with seizure
· Prolonged post-ictal period OR
AND fever ≥38ºC or parental report of
fever within 24 hours · Severity of seizure or focality of
seizure OR
Exclusion Criteria · Disabling parental anxiety or
· Known epilepsy, probable intracranial · Lack of access to services OR
infection, intracranial shunt, · Consider if multiple seizures
immunodeficiency, cardiac right-to- left within 24 hours
shunt, or oncology patients

Signs or symptoms
Clinical judgement of
of intracranial infection significant risk
or meningitis?

Clinical judgement of low risk

Acute
Acute Evaluation
Evaluation
· Lab testing should focus on finding the cause of the patient’s Evaluate for Meningitis
fever or Intracranial Infection
· Routine analysis of serum electrolytes, calcium, phosphorus, · Consider CT if concern for increased intracranial
No
complete blood count and blood glucose are not meningitis pressure
recommended, unless they are indicated by a suspicious · Lumbar Puncture
history or physical findings. · Labs: CBC, blood culture, glucose
· Blood glucose level and urine drug screen may be · Treat with empiric antibiotics
considered useful if the child does not return to baseline
mental status or regain consciousness after the seizure.
· Consider neurology consultation if new prolonged focal Meningitis present
neurologic deficit with suspicion of subclinical status
epilepticus or seizure duration > 30 minutes
· EEG or neuroimaging not recommended for routine
evaluation Off
Pathway
Consider outpatient f/u

Consider Non-Urgent Outpatient Follow-up

· When to consider neuro consult, outpatient EEG, outpatient
MRI

Assess admit and discharge criteria

Discharge Criteria Parental Note: Antipyretics may be

· Patient appears non-toxic and returns to Education recommended for the acute
neurological baseline
Discharge · Seizures from a illness, but are not
· Parental anxiety addressed fever (PE265) recommended as
· Parental education provided · Follow-up with prophylaxis to decrease the
· Appropriate outpatient follow-up is identified primary MD incidence of febrile seizures

For questions concerning this pathway,

Last Updated: June 2019
contact: [email protected]
© 2019, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer Next Expected Review: June 2024
 Assess Risk of Meningitis or Intracranial Infection

History
· >3 days duration of illness
· Seen by primary MD in previous 24 hours
· Drowsiness or vomiting at home
· Infant 6-12 months old deficient in Hib or pneumococcal vaccines or immunization status cannot
be determined
· Pretreated with antibiotics

Physical Signs
· Petechiae
· Questionable nuchal rigidity
· Drowsiness
· Convulsing on examination
· Weakness or neurological deficit on examination
· Signs of infection of head or neck with potential for intracranial extension (such as mastoiditis,
sinusitis, etc.)
· Bulging fontanelle

Complex Features
· Focal seizures
· Seizure duration >15 minutes
· Multiple seizures in 24 hours

Meningitis Less Likely

· Prior febrile seizure
· Pre-existing neurological findings

[LOE: Expert opinion ]

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 Acute Evaluation

Risk of Intracranial Infection

There is no clear evidence that patients with complex febrile seizure are at higher risk for
intracranial infection than patients with a simple febrile seizure in the absence of additional
symptoms. [LOE: Guideline (Whelan 2017)] In children age 6 to 72 months of age with febrile
seizure in the absence of any other signs or symptoms, the prevalence of CNS infections was 0.2%
(range 0% to 1.4%, 4 studies, n=911 patients), and the risk of bacterial meningitis is 0.2% (range
0.0 to 1.0% in 5 studies, n=1109 patients). In children with compex febrile seizures, the overall
average prevalence of CNS infections was 2.2% (range 0.5% to 2.9%, 2 studies, n=718 patients),
and of bacterial meningitis was 0.6% (95% CI 0.25 to 1.5%). [LOE: Very low certainty (Najaf-Zadeh
2013)]

Lumbar Puncture
Perform a lumbar puncture in any child who presents with a seizure and a fever and has meningeal
signs and symptoms (e.g. neck stiffness, KIernig and/or Brudinski signs, altered consciousness >30
minutes or bulging anterior fontanelle. [LOE: Guideline (AAP 2011, Natsume 2017)] Consider risk
of intracranial infection in under-immunized patients or in those pretreated with antibiotics which can
mask signs and symptoms of meningitis [LOE: Guideline (AAP 2011, Whelan 2017)]

Labs
Incidence of bacteremia in children less than 24 months of age with or without seizures is the same
[LOE: Guideline (AAP 2011)]. The following tests are not routinely needed for children with FS:
serum electrolytes, calcium, phosphorus, magnesium, blood glucose, or complete CBC. Consider
labs in cases of poor general condition, prolonged altered consciousness, or signs of dehydration.
[LOE: Guideline (AAP 2011, Natsume 2017)]

Imaging
Head CT scan is not routinely recommended in evaluation or management of patients with simple or
complex febrile seizures. CT scans may have diagnostic scans may have diagnostic use if there is a
strong indication of an acute/subacute bleed or structural lesion based on a patient's exam and
history. [LOE: Guideline (AAP 2011, Whelan 2017)]

Non-urgent, outpatient MRI brain is recommended for patient with focal CFS, especially with
postictal neurologic deficit. There is no evidence to support routine use of neuroimaging in children
with simple or complex febrile seizure without interictal or postictal focality. Urgent brain MRI in the
emergency room is not recommended. [LOE: Guideline (Whelan 2017, AAP 2011)]

EEG
The impact of EEG after complex febrile seizure in patients who have returned to baseline has not
been evaluated in randomized-controlled trials [LOE: Guideline (Whelan 2017, Natsume 2017, AAP
2011, Shah 2017)]. Consider EEG for evaluation of complex febrile seizure. EEG is not necessary
after simple febrile seizure. [LOE: Guideline (AAP 2011)].

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 Outpatient Follow-up

Prevention with antipyretics

Prophylactic use of antipyretics during febrile current or future febrile illnesses does not affect the
incidence of febrile seizures [LOE: Guideline (Natsume 2017)].

When to consider Neuro consult and outpatient imaging

· There is no evidence to support routine use of neuroimaging in children with simple or complex
febrile seizure without interictal or postictal focality. [LOE: Guideline (Whelan 2017, AAP 2011)]
· Non-urgent, outpatient MRI brain is recommended for patients with focal complex febrile
seizures, especially if they continue to have a postictal focal deficit. [LOE: Guideline (Whelan
2017, AAP 2011)]
· Consider non-urgent outpatient neurology consultation, EEG, and MRI for patients with complex
febrile seizure AND other risk factors for epilepsy [Local expert opinion]
· Family history of epilepsy
· Previous traumatic brain injury or central nervous system infection
· Baseline neurodevelopmental or neurological deficits/abnormalities (cerebral palsy,
developmental delay, macro/microcephaly)
· Evidence of neurocutaneous syndrome (neurofibromatosis, tuberous sclerosis, etc)

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 Febrile Seizure Approval & Citation

Approved by the CSW Febrile Seizure team for June 13, 2019

CSW Febrile Seizure Team:

Neurology, Owner Lindsey Morgan, MD

Emergency Medicine Stanford Heath Ackley, MD
Clinical Nurse Specialist Sara Fenstermacher, MSN, RN, CPN

Clinical Effectiveness Team:

Consultant: Jennifer Hrachovec, PharmD MPH

Librarian Sue Groshong, MLIS
Program Coordinator: Kristyn Simmons

Clinical Effectiveness Leadership:

Medical Director: Darren Migita, MD

Operations Director: Karen Rancich Demmert, BS, MA

Retrieval Website: https://www.seattlechildrens.org/pdf/febrile-seizures-pathway.pdf

Please cite as:

Seattle Children’s Hospital, Morgan L, Ackley SH, Fenstermacher S, Hrachovec J, Migita, D, 2019
May. Febrile Seizure Pathway. Available from: https://www.seattlechildrens.org/pdf/febrile-seizures-
pathway.pdf

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 Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.

When possible, we used the GRADE method of rating evidence certainty. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the following
manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94, Hultcrantz M et al. J Clin Epidemiol.
2017;87:4-13.):

Certainty ratings are downgraded if studies:

· Have serious limitations
· Have inconsistent results
· If evidence does not directly address clinical questions
· If estimates are imprecise OR
· If it is felt that there is substantial publication bias

Certainty ratings are upgraded if it is felt that:

· The effect size is large
· If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
· If a dose-response gradient is evident

Certainty of Evidence:
High: The authors have a lot of confidence that the true effect is similar to the estimated effect
Moderate: The authors believe that the true effect is probably close to the estimated effect
Low: The true effect might be markedly different from the estimated effect
Very low: The true effect is probably markedly different from the estimated effect
Guideline: Recommendation is from a published guideline that used methodology deemed acceptable by the team
Expert Opinion: Based on available evidence that does not meet GRADE criteria (for example, case-control studies).

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 Summary of Version Changes
· Version 1 (11/15/2011): Go live
· Version 1.1 (3/3/2017): Updated email address and self-assessment
· Version 2.0 (6/13/2019): Updated literature review and discharge criteria, replaced ordering
guidance with reference to seizure pathway

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 Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they are not responsible for any errors or omissions or for the
results obtained from the use of such information.

Readers should confirm the information contained herein with other sources and are encouraged to
consult with their health care provider before making any health care decision.

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 Bibliography
Methods

A literature search was conducted in January 2019 to target synthesized literature on febrile
seizures for 2012 to current and limited to English and humans. The search was executed in Ovid
Medline, Embase, Cochrane Database of Systematic Reviews (CDSR) and Turning Research into
Practice (TRIP) databases.

Screening and data extraction were completed using DistillerSR (Evidence Partners, Ottawa,
Canada). Two reviewers independently screened abstracts and included guidelines and systematic
reviews that addressed optimal diagnosis, treatment, and prognosis of patients who meet pathway
inclusion/exclusion criteria. One reviewer extracted data and a second reviewer quality checked the
results. Differences were resolved by consensus.

Results

The searches of the 4 databases (see methods) retrieved 80 records. Once duplicates had been
removed, we had a total of 75 records. We excluded 64 records based on titles and abstracts. We
obtained the full text of the remaining 9 records and excluded 5. One article (the 2011 AAP
guideline), which was outside the current search dates and referenced in the 2011 version of this
pathway, was added to included articles. For this update we have included a total of 5 studies (4
new). The flow diagram summarizes the study selection process.

Identification
Records identified through Additional records identified
database searching (n=80) through other sources (n=0)

Screening
Records after duplicates removed (n=75)

Records screened (n=75) Records excluded (n=64)

Eligibility Articles excluded (n=5)

Did not answer clinical question (n=4)
Records assessed for eligibility (n=9) Did not meet quality threshold (n=1)

Included

New studies (n=4) Articles added from prior pathway version (n=1)

Studies included in pathway (n=5)

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

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 Bibliography
Included Studies

(AAP), Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic

evaluation of the child with a simple febrile seizure. (2011). Pediatrics, 127(2).
Abolfazl, N.-Z., Francois, D., Valerie, H., Pruvost, I., Bennour, A., & Martinot, A. (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), 55270. doi:10.1371/journal.pone.0055270
Natsume, J., Hamano, S.-I., Iyoda, K., Kanemura, H., Kubota, M., Mimaki, M., . . . Sugie, H. (2017).
New guidelines for management of febrile seizures in Japan. Brain & development, 39(1), 2-9.
doi:https://dx.doi.org/10.1016/j.braindev.2016.06.003
Shah, P. B., James, S., & Elayaraja, S. (2017). EEG for children with complex febrile seizures.
Cochrane Database of Systematic Reviews(10). doi:10.1002/14651858.CD009196.pub4
Whelan, H., Harmelink, M., Chou, E., Sallowm, D., Khan, N., Patil, R., . . . Greydanus, D. (2017).
Complex febrile seizures-A systematic review. Disease-A-Month, 63(1), 5-23. doi:https://
dx.doi.org/10.1016/j.disamonth.2016.12.001

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