05/05/2026
Que interesante 🧐
- Febrile Convulsion. The myths vs the truths.
Over the years, few of our topics have sparked as much interest as fever and its treatment. Fever in children seems to be a cesspool for cultivation of strong opinions in nurses. Well boy, are you gonna hate this post.
If you have experienced caring for a child with febrile convulsion, you will probably remember the fear, trepidation and shear anxiety in the eyes of the parents of that child at the time. In this post we explore this explosive onset presentation and dispel a few myths.
Myth 1
Febrile convulsion is caused by high fever in children. Wrong!
Truth: Febrile convulsion manifests when a temperature in a child aged 6 months- 3 years (rarely up to 6 years), changes rapidly. It relates to the speed of fluctuation not the height of a temp. A child with a temp of 41.6 is no more likely to fit than a child with a temp of 38.6.
Additionally, many febrile convulsions are induced during the rapid drop in temp seen post tepid sponging, and administration of antipyretic medication... Yes the ones on TV ads claiming "nothing works faster for pain and fever". Those ads are telling the truth, they cause RAPID drop in temperature. These drugs prevent the formation of prostaglandins which are those "healing" thermogenic chemicals released during infection and inflammation.
Myth 2
Febrile convulsion is dangerous.
Truth: a classic (or simple) febrile convulsion is one that follows three rules:
1- Short lived < 15 mins (92% less than 5 mins duration).
2- Convulsion onset is inside 24 hours from the onset of fever illness
3- Child will have only 1 convulsion during the illness.
The febrile convulsion that does not follow these rules is considered complex, and is therefore, sinister and neurologically suspicious.
These complex seizures need further investigation. Don’t send these ones home!
True febrile convulsions do not harm to the child, and do not cause brain damage. Whilst they are frightening to all who witness them, the hypoxic brain injuries associated with other convulsions and states of status epilepticus, are just not seen in children experiencing febrile convulsions.
It is therefore safe to allow a febrile convulsion to ride itself out. It is not the emergency that it looks like, and often by the time you’ve prepared the intranasal Midazolam, the child is a sleeping bundle of exhaustion. Just keep them safe from physical harm.
Myth 3
Giving antipyretic medication reduces the risk of febrile convulsion. Wrong!!!
Truth:
NO ANTIPYRETIC PREVENTS FEBRILE CONVILSIONS.
Antipyretic drugs (Ibuprofen and paracetamol) have been extensively studied for their prophylactic effects and found to be dismally ineffective. In fact this is not new. It is a fact we've known since 1995, and was first proposed before many of our readers were born (pre 70s).
There is an interesting claim that they may even risk contributing to a convulsion as they wear off without a follow-up dose being given on time.
Why do they fit?
It’s all about speed.
Two mechanisms that induce fits.
Think about what neutrophils and macrophages are doing here. Releasing chemicals to instruct the hypothalamus to raid the temperature. If paracetamol or ibuprofen is given and inhibits the prostaglandin message, more and more pyrogenic chemicals are being released by frustrated WBCs. Now the antipyretic drug starts to wear off, massive amounts of pyrogenic chemicals released by WBCs now induce a burst of fever inducing prostaglandins, and the temp rapidly shoots up.
The second mechanism is seen when a dose is given to a febrile child. The antipyretic shuts down prostaglandin production, resulting in a rapid fall of the fever. Very rarely, this in turn can induce the convulsion as they are caused by rapid fluctuation in temperature.
Myth 4
Febrile convulsions must be stopped.
Truth: they just don't.
While it is distressing to stand idle and do nothing, the only real benefit of stopping a febrile seizure is to alleviate the anxiety of the onlooker. So let's say you have a protocol or a mandate to treat, let's look at the standard management for convulsions. Jurisdictions differ in their approach but always use one of two benzodiazepine drugs. Both are given mucosally, an IV cannula is not needed.
Midazolam is the favourite this month. Given intra-nasally via a mucosal atomisation device (MAD) pictured, the dose is 0.5mg/kg up to max 5mg.
It is a strong short acting sedative that may cause profound ALOC postictally (after the fit stops). Therefore, lateral position, airway management, +/- oxygen if the kid's sats are below 95%
The other drug is Midazolam's older cousin, Diazepam. Hardly seen outside of complex seizure disorders; this is usually given PR- low re**al. 10mg seems to be standard. Don't be pushing that stuff too high or it won't work!!
As a drug is administered low in the re**um it absorbed into systemic blood vessels and exerts immediate effect. In fitting, this is desirable. If you ran it right up high in the re**um, the blood vessels drain first into the liver where diazepam is almost completely destroyed (read up on Hepatic First Pass).
Personally, I'm a fan of Midazolam, but that said, there is no evidence that a simple febrile convulsion needs to be stopped, and the irony here is that this family of drugs are also called anxiolytics, which is true when you think of the parents and nurses anxiety levels after the fit stops.
Summary:
Febrile convulsions are caused by Rapid fluctuation of temp, not height of fever.
They are rarely harmful or even need to be stopped.
We have known for at least 20 years that antipyretic medications are not preventative.
More reading on this RCH site.
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