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Three Part Question

In [children <5 years old presenting to the Emergency Department with a febrile convulsion] is [4 hours observation] adequate to [exclude serious infection]?

Clinical Scenario

An 18-month-old boy has been brought into the Emergency Department after having a febrile convulsion. His parents give a history of vomiting and being off his food that day, for approximately the last 12 hours. You wonder how long you should observe him for, or whether you need to admit him.

Search Strategy

OVID Medline <1966 – June Week 3 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$.mp.}]) AND (exp OBSERVATION/ OR observ$.mp. OR 4 hours observation.mp. OR four hours observation.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$.mp.}]) AND (exp OBSERVATION/ OR exp Clinical Observation/ OR observ$.mp. OR 4 hours observation.mp. OR four hours observation.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$.mp.}]) AND (OBSERVATION UNITS/ OR observ$.mp. OR 4 hours observation.mp. OR four hours observation.mp.) Limit to (English and (infant <1 to 23 months> or preschool child <2 to 5 years>))

Search Outcome

Medline: 216 papers found, 1 relevant.
Embase: 118 papers found, no new or relevant papers.
CINAHL: 7 papers found, no new or relevant papers.
Cochrane Library: no relevant papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mace SE. 2001. USA.	Paediatric patients in an Observation Unit (either paediatric or combined with adults).	Literature review.	Advantages of paediatric observation unit.	Better patient care, fewer missed diagnoses, better risk management, decreased malpractice liability, cost effective, increased patient and family satisfaction.	Data derived from abstract only. Does not mention the management of febrile convulsions specifically.
			Paediatric conditions treated in an observation unit.	Respiratory illnesses, gastrointestinal disorders, dehydration, infections, seizures and overdoses or poisonings.
			Differences between adult and paediatric care in an observation unit.	Children are more likely to have a specific diagnosis, they stay a shorter amount of time and have a highly variable admission rate.

Comment(s)

One relevant paper was found but was unable to be obtained in full. From the abstract it appears there are benefits from having an observation unit attached to an emergency department, which may be of use in the management of a child presenting with a febrile convulsion.

Clinical Bottom Line

Ther is insufficient evidence to establish the role of observation in the management of a child with a febrile convulsion.

References

1. Mace SE. Paediatric observation medicine. Emergency Medicine Clinics of North America. 2001; 19(1):239-54.