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Three Part Question

In [children 2-5 years old presenting to the Emergency Department with their first febrile convulsion] is [hospital admission] necessary due to the [risk of recurrence or serious infection]?

Clinical Scenario

A 2-year-old girl has been brought to the Emergency Department having had her first febrile convulsion, which has now resolved. On examination she has a runny nose and a cough and she has been off her food. You suspect she has a viral URTI. She is her parent's first child and they are very concerned and anxious to know whether she has anything serious and whether this will happen again. You wonder whether you should admit her, or give the parents advice and discharge her.

Search Strategy

OVID Medline <1966 – June 2005>
EMBASE <1980 – 2005 Week 26>
CINAHL <1982 – June Week 3 2005>
The Cochrane Library 2005 Issue 2.
Medline
(exp Seizures, Febrile/ OR [seizure$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [convulsion$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [fit$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}]) AND (first.mp. OR primary.mp. OR initial$.mp.) AND (exp Patient Admission/ OR admission.mp. OR admit$.mp. OR exp HOSPITALIZATION OR hospitalisation.mp.) Limit to (humans and English language and ("infant (1 to 23 months)" or "preschool child (2 to 5 years)")).
EMBASE
(exp Febrile Convulsion/ OR [seizure$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [exp SEIZURE/ AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [convulsion$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [exp CONVULSION/ AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [exp "SEIZURE, EPILEPSY AND CONVULSION"/ AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [fit$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}]) AND (first.mp. OR primary.mp. OR initial$.mp.) AND (exp Hospital Admission/ OR patient admission.mp. OR admission.mp. OR admit$.mp. OR exp Hospitalization/ OR hospitalisation.mp.) Limit to (human and English language and (infant or preschool child <1 to 6 years>)).
CINAHL
(exp Convulsions, Febrile/ OR [exp Seizures/ AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [seizure$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [convulsion$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [exp CONVULSIONs/ AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}] OR [fit$.mp. AND {exp FEVER/ OR fever$.mp. OR febrile.mp. OR pyrexia$.mp.}]) AND (first.mp. OR primary.mp. OR initial$.mp.) AND (exp Patient Admission/ OR exp Hospitalization/ OR hospitalisation.mp. OR admission.mp. OR admit$.mp.) Limit to (English and (infant <1 to 23 months> or preschool child <2 to 5 years>)).

Search Outcome

Medline: 86 papers found, 1 relevant.
Embase: 51 papers found, no new or relevant papers.
CINAHL: 4 papers found, no new or relevant papers.
Cochrane Library: no relevant papers.
2 found by hand searching.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Green AL, MacFaul R. 1985. UK.	199 children aged 5-71 months admitted with simple febrile convulsion between 1980 and 1983, with no persistent underlying neurological abnormality, no history of afebrile seizures and no evidence of meningitis or encephalitis.	Retrospective cohort study.	Number of children admitted.	199/199 (100%)	No follow up.
			Number of recurrences.	32/199 (16.1%)
			Number of recurrences before admission.	13/32 (40.6%)
			Number of recurrences after admission.	19/32
			Mean duration of admission.	55.8hours (range 12-188 hours)
			Mean duration of fever.	24.8 hours (range 0-106 hours)
			Number of children with fever after 24 hours of admission.	78/199 (39.2%)
			Number of children with recurrence after 24 hours of admission.	0/199
Chong LA, Lee WS and Goh AYT. 2003. Malaysia.	428 paediatric acute and elective admissions to a tertiary referral hospital during a six-week period (July-August 2001), excluding children with a major chronic illness requiring frequent admissions.	Cohort study	Number of children admitted.	428/428 (100%)	Data for elective and emergency admissions is combined. Only 6 of the 93 patients discharged within 24 hours were admitted with febrile convulsion.
			Number of children discharged within 24 hours.	93/428 (22%)
			Number of children discharged within 12 hours.	56/93 (60.2%)
			Mean duration of stay.	12 hours
			Number of readmissions after discharge.	0%
Hampers LC et al 2000 USA	At 7 emergency departments, records of all patients aged 6 months-5 years of age during a 30 month period (July 1995 – December 1997) with a discharge diagnosis including the term 'seizure' were reviewed to identify the 455 children with simple, first time febrile convulsions.	Retrospective cohort study.	Number of children presenting to general emergency department (GED).	330	Relied on patient's notes for information, which may be incomplete. Hospitals not chosen randomly. Does not compare GEDs to GEDs or PEDs to PEDs.
			Number of children presenting to a tertiary academic paediatric emergency department (PED).	125
			Percentage of children admitted.	GED-18%, PED-4% (p<0.01, odds ratio 5.2, 95%CI 2.0%-15%)
			Number of abnormal test results (lumbar puncture, serum sodium, serum glucose, urine culture).	GED- 0%,PED-0%

Comment(s)

Two of the studies found suggest that after 24 hours admission it is safe to discharge a child who has had a febrile convulsion, if the cause of the fever has been identified, as recurrence after this time is rare, even if the fever persists. One study suggests that children are significantly more likely to be admitted in a general emergency department compared to a paediatric emergency department, but the clinical outcomes are the same.

Clinical Bottom Line

It appears to be safe to discharge a child who has presented with a simple, first time febrile convulsion after 24 hours admission, even if still febrile, as the risk of a recurrent febrile convulsion after this time is very low.

References

1. Green AL, MacFaul R Duration of admission for febrile convulsions? Archives of Disease in Childhood. 1985;60(12):1182-4
2. Chong LA, Lee WS and Goh AYT. Paediatric admissions at a tertiary hospital in Kuala Lumpur - a case for a short stay ward. Medical Journal of Malaysia. 2003; 58(1):89-93.
3. Hampers LC, Trainor JL, Listernick R, Eddy JJ, Thompson DA, Sloan EP, Chrisler OP, Gatewood LM, McNulty B and Krug SE. Setting based variation in management of simple febrile seizure. Academic Emergency Medicine. 2000; 7(1):21-7.