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Management of Pediatric Febrile Seizures
Management of Pediatric Febrile Seizures Lilly Ma, DNP, CPNP-PC, and Sabrina Opiola McCauley, DNP, CPNP, NNP-BC ABSTRACT
Febrile seizures are the most common seizure disorder. Febrile seizures are frightening to witness, and therefore caregiver education is paramount to help relieve anxiety levels. Acknowledgment of this concern by pediatric health care providers is needed to understand the importance of education, reassurance, and anticipatory guidance for caregivers. This article aims to discuss the assessment, diagnosis, and management of febrile seizures for the nurse practitioner based on the most current literature. Through appropriate clinical interventions, anticipatory guidance, and caregiver education, the nurse practitioner can substantially increase the comfort of the patients and their caregivers. Keywords: anticipatory guidance, febrile seizure, fever, pediatric/child, primary care Ó 2017 Elsevier Inc. All rights reserved.
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ebrile seizures are the most common seizure disorder in childhood, and children with this condition may present to the primary care provider’s office or the emergency department. Febrile seizures have a peak incidence in the second year of life,1 occurring in 2% to 5% of the pediatric population.2 According to the most recent guidelines from the American Academy of Pediatrics (AAP),3 a febrile seizure is a seizure accompanied by fever (temperature 100.4 F or 38 C by any method) and without central nervous system infection that occurs in infants and children aged 6 through 60 months. Most febrile seizures are benign but are nonetheless frightening for caregivers to witness; therefore caregiver education is important to help relieve anxiety levels. Febrile seizures are emotionally traumatic for caregivers. Many caregivers may think that their child is dying during the seizure event and have a persistent fear of recurrence.4 Acknowledgment of this concern by nurse practitioners (NPs) is needed to understand the importance of education, reassurance, and anticipatory guidance for pediatric caregivers. This article will discuss the assessment, diagnosis, and management of febrile seizures, review current literature, and address strategies to implement key education points into current practice. 74
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PATHOPHYSIOLOGY
The mechanism through which a fever can cause a febrile seizure is still unclear. However, the cause of febrile seizures is known to be multifactorial, with genetic and environmental factors.5 An increase in brain temperature alters neuronal functions and ion channels, which influences neuronal firing and excitability, resulting in seizures.6 Genetics comes into play with neurodevelopmental vulnerability, alterations in sodium channel expression, hypothalamic dysregulation, and cortical and hippocampal excitability.7 Environmental triggers are believed to be involved through metabolic dysregulatory pathways.7 The secretion of cytokine, an inflammatory mediator, is also known to be part of the mechanism of febrile seizures.6 RISK FACTORS
A febrile seizure is generally a benign condition, related to various causative and risk factors (Table 1). Febrile seizures are an age-dependent phenomenon, occurring between 6 months and 5 years of age, attributed to the vulnerability of the child’s developing nervous system. Family history of febrile seizures, specifically in a first-degree relative, also plays a role. The degree of the fever (103 F or 39 C), rather than the rate of the temperature rise, is Volume 14, Issue 2, February 2018
Table 1. Causative and Risk Factors of Febrile Seizures Factors Associated With Febrile Seizures Individual
Age Degree of fever History of febrile seizure
Familial
First-degree relative with history of febrile seizures
Environmental Positive illness contact at home, day care, or school Virus
Bacteria
Respiratory: influenza virus, parainfluenza, respiratory syncytial virus, adenovirus Enteric: enterovirus, Coxsackie virus, rotavirus Herpesviruses: human herpesvirus, cytomegalovirus, herpes simplex virus Respiratory: Streptococcus pneumoniae Enteric: Shigella dysenteriae, Salmonella enteritidis Urinary: Escherichia coli
Vaccination
Measles, mumps, and rubella (MMR) Pertussis
Others
Channelopathies, pH, water and electrolyte imbalance, cytokines
Adapted from Mohebbi, Holden, and Butler IJ.19 Copyright 2008 by Sage Publications.
another risk factor in children.6 Although viral and bacterial infections are identified risk factors in febrile seizures, there is a higher association with viral infections because they tend to cause high fevers. Finding the causative factor of the febrile seizure event may help aid in diagnosis, management, and prevention of recurrent episodes, as well as provide comfort to the child’s parents and caregivers.
defined as primary generalized seizures that last for less than 15 minutes and do not recur within 24 hours.2 This is the most common type of febrile seizure, occurring in 70%e75% of children with febrile seizures.9 Complex febrile seizure is defined as focal, prolonged (duration longer than 15 minutes but less than 30 minutes), and/or recurrent within 24 hours. Approximately 20%e25% of febrile seizures are complex.9 Febrile status epilepticus is defined as generalized or focal seizures lasting more than 30 minutes.2 The seizure can be continuous or intermittent, without return to neurologic baseline during the period. EVALUATION History
A thorough history should be taken on all children after an episode of febrile seizure, including past medical history, medications, allergies, vaccination history, a full review of systems, onset and characteristic of the fever, events leading up to the febrile seizure, characteristics of the seizure episode (duration, body movements, and recurrence), and potential sick contacts or exposures. A developmental history and family medical history is also important to assess for risk factors. The NP must be able to use the history to distinguish whether the child had a simple, complex, or status epilepticus episode and develop a list of differential diagnoses. It is important for the NP to understand that a febrile seizure is a diagnosis of exclusion, and therefore a detailed history to determine the need for further evaluation with diagnostic testing is necessary. Meningitis, encephalitis, or a space-occupying brain lesion should be considered in any child presenting with a fever and seizure.
CLINICAL PRESENTATION
Signs and symptoms of febrile seizures include loss of consciousness, generalized or focal twitching or jerking of arms and legs, eye deviation or rolling back, pallor or cyanosis, and difficulty breathing. After the seizure, the child appears drowsy, lethargic, disoriented, and confused. This postictal state may last up to 30 minutes, after which the child should return to baseline.8 Febrile seizures are classified as simple, complex, or status epilepticus depending on characteristics, duration, and recurrence. Simple febrile seizure is www.npjournal.org
Physical Examination
After a complete history has been conducted, a comprehensive examination should be performed to identify the cause of the fever. The NP must determine whether the child is clinically stable and his or her hydration status. It is important to assess the patient’s airway patency, ventilation and oxygen adequacy, and circulatory status.10 A comprehensive neurologic examination should be conducted to ensure that the child is neurologically healthy. The neurologic assessment should The Journal for Nurse Practitioners - JNP
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include any changes in mental status, drowsiness, arousability, hallucinations, headache, irritability, and neck stiffness or pain. These signs and symptoms may indicate sepsis or meningitis and warrant further evaluation. It is important to note that children with febrile seizures are generally well appearing and return to baseline within 30 minutes.8 Therefore, any abnormality noted on examination after this time period should prompt suspicion for possible systemic infection. Diagnostic Tests
NPs assessing children after a febrile seizure should focus their evaluation on identifying the cause of the child’s fever. According to the AAP,3 simple febrile seizures do not usually require further evaluation, specifically neuroimaging, electroencephalogram (EEG), or blood tests. Most children with complex
febrile seizures do not need routine work-up or neuroimaging.11 In fact, an epileptiform EEG is not a sensitive measure and has a poor positive predictive value for the development of epilepsy among neurologically healthy or mildly delayed children with a first complex febrile seizure.12 A head computed tomography scan is not routinely recommended in the evaluation or management of children with complex febrile seizures unless there is indication of an intracranial hemorrhage or structural lesion based on history and physical examination.9 In some patients with complex febrile seizures or with a high index of suspicion of a more serious cause of fever and seizure (Table 2), diagnostic tests may be considered. In a child with a fever and seizure, a lumbar puncture may be considered if there is a suspicion for intracranial infection or meningitis based on history and physical examination,
Table 2. Diagnostic Tests for Febrile Seizures Diagnostic Tests Neuroimaging
Indications CT or MRI should not be performed in the routine evaluation of the child with a simple febrile seizure If focal or prolonged seizure, obtain outpatient brain MRI without contrast
EEG
Space-occupying lesion Herniation Mesial temporal sclerosis
Should not be performed in the evaluation of a neurologically healthy child with a simple febrile seizure
Lumbar puncture
Blood tests
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Differential Diagnoses
If abnormal neurodevelopmental state or more than one complex feature of family history of epilepsy, may obtain outpatient EEG
Febrile status epilepticus
Any child who presents with a seizure and a fever and has meningeal signs and symptoms (neck stiffness, Kernig and/or Brudzinski signs); or in any child whose history or examination suggests the presence of meningitis or intracranial infection
Meningitis Intracranial infection
In any infant between 6 and 12 months of age who presents with a seizure and fever, and is considered deficient (immunizations not complete or status cannot be determined) in Haemophilus influenza type b (Hib) or Streptococcus pneumoniae immunizations
Bacterial meningitis
Any child who presents with seizure and fever and is pretreated with antibiotics, because antibiotics can mask the signs and symptoms of meningitis
Meningitis
The following tests should not be performed routinely for the sole purpose of identifying the cause of a simple febrile seizure: measurement of serum electrolytes, calcium, phosphorus, magnesium, or blood glucose, or complete blood cell count
Blood abnormalities
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immunization status, or the recent or current use of antibiotics, which may mask meningitis. However, the risk of bacterial meningitis is extremely low, with an estimated risk of 0% among children aged between 6 and 11 months with a first simple febrile seizure.13 A nonurgent, outpatient magnetic resonance imaging scan of the brain may be considered for children with focal complex seizures and postictal neurologic deficit to evaluate for an underlying structural brain abnormality.9 Refer to Table 2 for indications of diagnostic tests and a list of differential diagnoses to be considered. TREATMENT
The AAP3 reports febrile seizures to be common and benign in children, with excellent prognosis and no long-term complications. There is no specific treatment for febrile seizures; rather, the aim is to treat the underlying cause. Depending on the NP’s assessment and the child’s clinical status, care may include oxygen supplementation, pulse oximetry, cardiac monitoring, and intravenous fluids. It is important to assess and maintain the child’s oxygenation and hydration status, transferring to an appropriate facility as needed. Antipyretics
Although antipyretics may improve the child’s comfort, it will not prevent a febrile seizure or reduce the recurrence of febrile seizures. A systematic review14 of randomized controlled trials and a metaanalysis aimed at determining the effectiveness of antipyretic use in prevention of subsequent febrile seizures assessed a sample of 540 children. Among the sample, 348 children received antipyretics, including acetaminophen, ibuprofen, and diclofenac, and 192 received a placebo. No statistically significant difference was found between the antipyretics and the placebo groups in the recurrence rate of febrile seizures. Many caregivers administer antipyretics even when there is a mild elevation in temperature because they are concerned that the child must maintain a “normal” temperature.15 Generally, acetaminophen and ibuprofen are considered safe and effective antipyretics for children, but education to prevent overdose is important to avoid adverse events such as www.npjournal.org
hepatotoxicity, gastrointestinal upset, respiratory failure, metabolic acidosis, renal failure, and coma.8 Combination therapy of alternating acetaminophen and ibuprofen may place children at increased risk of toxicity because of administration errors and should be carefully considered by the NP. Antiepileptic Drugs
Febrile seizures are a benign condition and do not cause long-term complications; therefore, the use of antiepileptic drugs are not typically recommended. Immediate management includes the use of a rescue seizure medication such as rectal diazepam or intranasal midazolam to stop an ongoing seizure when the febrile seizure lasts longer than 5 minutes and respiration becomes a concern.6 Continuous antiepileptic therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with oral diazepam have shown to be effective in reducing the risk of recurrence.8 However, NPs must consider the potential toxicities associated with these antiepileptic drugs. The adverse effects likely outweigh the relatively minor risks associated with febrile seizures. If antiepileptic therapy is considered, a pediatric neurology referral should be initiated. Ultimately, the most effective treatment of febrile seizures is aimed toward treating the febrile illness rather than the seizure. Neurology Referral
A nonurgent neurologic consult can be obtained if there is clinical suspicion for an underlying neurologic or developmental disorder.6 It should be considered in children with persistent neurologic deficits after a complex febrile seizure, recurrent complex febrile seizure, febrile status epilepticus, abnormalities on evaluation, or seizures not clearly related to fever.9 Dravet syndrome, previously known as severe myoclonic epilepsy of infancy, is characterized by intractable epilepsy and poor neurodevelopmental outcomes. This rare, catastrophic, lifelong form of epilepsy manifests as frequent or prolonged seizures in the first year of life, and therefore neurologic evaluation and genetic testing should be considered in children with 2 prolonged febrile seizures by 1 year of age.16 The Journal for Nurse Practitioners - JNP
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POTENTIAL RISKS
Children with simple febrile seizures have a high rate of recurrence. A prospective cohort study17 aimed at identifying the risks and predictors of single and multiple recurrent febrile seizures included a total sample of 428 children with their first febrile seizures. The study suggested that the risk of the recurrence of febrile seizures decreased with older age at onset of first episode. Children younger than 12 months at the time of their first simple febrile seizure have an approximately 50% probability of having recurrent febrile seizures, children older than 12 months at the time of their first event have an approximately 30% probability of a second febrile seizure. Additionally, 50% of those who do have a second febrile seizure can have at least 1 additional recurrence.17 The risk of epilepsy depends on several factors (Table 3), including age at onset of first febrile seizure, number of recurrent episodes of febrile seizures, and family history of epilepsy. The risk of developing epilepsy by age 7 in children who have experienced a simple febrile seizure is 1%, which is the same as the general population.18 Children who have had multiple simple febrile seizures, are younger than 12 months at the time of their first febrile seizure, and have a family history of epilepsy are at higher risk for epilepsy, with generalized afebrile seizures developing by 25 years of age in 2.4%.18
Table 3. Risk Factors for Recurrent Febrile Seizures and Subsequent Epilepsy Recurrent febrile seizures Family history of febrile seizures Age < 18 months Lower peak fever with previous febrile seizure(s) Shorter duration of fever with previous febrile seizure(s) Subsequent epilepsy
Neurodevelopmental abnormality Complex febrile seizure Family history of epilepsy Shorter duration of fever with prior febrile seizure(s)
Adapted from Shinnar and Glauser.18 Copyright 2002 by Sage Publications.
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ROLE OF THE NP Clinical Practice
NPs will encounter febrile seizures at some point in their careers and will most likely manage them in the outpatient setting. The assessment and evaluation of children who present with febrile seizures should be directed toward determining the specific cause for the fever using history and physical examination findings along with appropriate diagnostic tests to reduce the period of morbidity and hospitalization, decrease the need for neurologic studies, relieve the anxiety of the child’s caregivers, and reduce the administration of anticonvulsants.19 The NP caring for the child should focus on making sure the child is clinically stable, monitoring for signs and symptoms of serious illness, improving the child’s comfort by maintaining hydration, and educating caregivers on the appropriate use of antipyretics. Education
In addition to the evaluation and management of the child’s health, a major role of the NP is educating the child’s family. The NP is often the main source of information for the child’s caregivers on febrile seizures. Anticipatory guidance, as outlined in Table 4, should be provided at each visit because fevers are common and can result in febrile seizures in any child. The NP should counsel caregivers on what they should do if a febrile seizure occurs. First, lay the child on the floor in the side-lying position to prevent aspiration; remove objects in the surrounding area that may injure the child. With the caregiver at the child’s back, caregiver should put her fingers under the chin. Straighten the airway by pushing chin upward. DO NOT place anything in the child’s mouth. The caregiver should also be educated to time the duration of the seizure and to note what is occurring during the seizure episode. Recommending that caregivers take a cardiopulmonary resuscitation class can also be beneficial in reducing their anxiety. Fever is a frequent cause of concern; it is important to help the caregivers understand that fever itself is not a danger to a generally healthy individual. The NP should educate and reassure caregivers that fever is not the primary illness, but is the immune system’s physiologic mechanism to fight infection.15 Caregivers Volume 14, Issue 2, February 2018
Table 4. Anticipatory Guidance and Education on Febrile Seizures for Caregivers
Febrile seizures occur in 2%e5% of all children between the ages of 6 months and 5 years. Febrile seizures tend to run in families. Febrile seizures often occur in the first 24 hours of the febrile illness. A febrile seizure might present with body stiffening; twitching of the face, arms and legs, or both; eye rolling; jerking of the arms and legs; staring; or loss of consciousness. These seizures might appear frightening to observers but are generally harmless. Your child might appear not to be breathing and the skin color might become darker. Call 911 or emergency personnel. Caregivers should consider taking a CPR class. First, lay the child on the floor in the side-lying position to prevent aspiration; remove objects in the surrounding area that may injure the child. With the caregiver at the child’s back, caregiver should put her fingers under the chin. Straighten the airway by pushing chin upward. DO NOT place anything in the child’s mouth. You should time the duration of the seizure and note what is occurring during the seizure episode. Febrile seizures do not cause brain damage or paralysis. A child who has febrile seizures has only a slightly increased risk of having a seizure disorder compared with that of a child who has never had a febrile seizure. Febrile seizures can recur with subsequent febrile illnesses. Your child should be seen by a health care provider for an evaluation after every episode. Medicines are generally not given to prevent simple febrile seizures. Use of medicines such as acetaminophen or ibuprofen for fevers has not been shown to prevent febrile seizures. Although immunizations are associated with febrile seizures, this is not a reason not to immunize your child.
Adapted from Warden, Zibulewsky, Mace, Gold, and Gausche-Hill.10
should be reassured that the fever does not worsen the course of the illness, nor will it cause neurologic complications. They should also be educated to monitor the child for any changes in activity level and observe for signs or symptoms of illness. The NP should inform caregivers that although febrile seizures are dramatic events, they do not indicate future neurologic dysfunction or disease. It is also important to address concerns of the correlation between vaccinations and febrile seizures. Vaccines associated with febrile seizures include measles, mumps, rubella, and varicella (MMRV) and diphtheria, tetanus toxoid, and pertussis (DTP).2 Postvaccination febrile seizures are rare and often occur within the first 3 days after administration of a live attenuated vaccine, with increased risk when multiple vaccines are given.2 However, febrile seizures due to vaccination are no different from those of other causes and should not discourage caregivers from vaccinating their children. When counseling caregivers on the management of fever, it is important to emphasize that the goal of antipyretic therapy is not to “normalize” body temperature; rather, it is part of supportive care to improve the child’s comfort in addition to hydration and rest. Approximately half of caregivers consider a temperature of < 100.4 F or 38 C to be a fever, and www.npjournal.org
25% of caregivers would give antipyretics when their temperature does not indicate fever.20 Additionally, caregivers have reported awakening their child from sleep to give them antipyretics.20 It is critically important that all caregivers be given clear instructions on the appropriate administration of antipyretics because of the risk of overdose and its fatal complications. The accurate formulation, dose, dosing interval, and daily maximum dosage of each type of antipyretic must be discussed. All medications should be labeled clearly with dosing instructions and include an appropriate dosing device. Child safety, including proper handling and storage of antipyretics, should also be encouraged. Parents should be reassured that febrile seizures do not cause brain damage or paralysis, nor do they place the child at risk for developmental or behavioral consequences.21 It is also important to educate parents that a child with history of febrile seizure has a low risk of developing epilepsy.18 Although febrile seizures are benign, the child should still be evaluated, whether in the primary care setting or in the emergency department, after every episode. The need for a follow-up should be determined on the basis of the underlying cause of the fever and the clinical presentation of the child. The caregiver should note the onset of fever, The Journal for Nurse Practitioners - JNP
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characteristics and duration of the seizures, and postictal state. Future Research
There are still gaps in knowledge revolving around febrile seizures, indicating the need for further research. Future studies should determine the appropriate use of neuroimaging studies, the timing of administration of antiviral and antibacterial drugs, and the acute and chronic administration of anticonvulsants in simple and complex febrile seizures. CONCLUSION
Although most febrile seizures are benign, their careful assessment and management is important. NPs evaluating children after a febrile seizure should focus on identifying the cause of the child’s fever and treating the febrile illness rather than the seizure. Febrile seizures are frightening for caregivers to witness, and therefore education is necessary to help relieve their anxiety levels. Acknowledgment of this concern by NPs is needed to understand the importance of education, reassurance, and anticipatory guidance for their pediatric patients and their caregivers. References 1. Wilmshurst JM, Gaillard WD, Vinayan K, Tsuchida TN, Plouin P, Van Bogaert P, et al. Summary of recommendations for the management of infantile seizures: task force reports for the ILAE Commission of Pediatrics. Epilepsia. 2015;56(8):1185-1197. https://doi.org/10.1111/epi.13057. 2. Khair AM, Elmagrabi D. Febrile seizures and febrile seizure syndromes: An updated overview of old and current knowledge. Neurol Res Int. 2015;2015:1-7. https://doi.org/10.1155/2015/849341. 3. American Academy of Pediatrics. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. https://doi.org/10.1542/peds.2010-3318. 4. Gordon KE, Dooley JM, Wood E, Brna P, Bethune P. Which characteristics of children with a febrile seizure are associated with subsequent physician visits? Pediatrics. 2004;114(4):962-964. https://doi.org/10.1542/peds.2003-0650-F. 5. Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:1-7. https://doi.org/10.1136/bmj.h4240. 6. Chung S. Febrile seizures. Korean J Pediatr. 2014;57(9):384-395. https:// doi.org/10.3345/kjp.2014.57.9.384. 7. Sisodiya S. Feverish prospects for seizure genetics. Nat Genet. 2014;46(12):1255-1256. https://doi.org/10.1038/ng.3150. 8. 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. https://doi.org/10.1542/peds.2008-0939.
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9. Whelan H, Harmelink M, Chou E, Sallowm D, Khan N, Patil R, et al. Complex febrile seizures—a systematic review. Dis Mon. 2017;63(1):5-23. https://doi.org/10.1016/j.disamonth.2016.12.001. 10. Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-222. https://doi.org/10 .1067/mem.2003.48. 11. Hardasmalani MD, Saber M. Yield of diagnostic studies in children presenting with complex febrile seizures. Pediatr Emerg Care. 2012;28(8):789-791. https:// doi.org/10.1097/PEC.0b013e3182627ed2. 12. Harini C, Nagarajan E, Kimia AA, de Carvalho RM, An S, Bergin AM, et al. Utility of initial EEG in first complex febrile seizure. Epilepsy Behav. 2015;52:200-204. https://doi.org/10.1016/j.yebeh.2015.09.003. 13. Guedj R, Chappuy H, Titomanlio L, Trieu TV, Biscardi S, Nissack-Obiketeki G, et al. Risk of bacterial meningitis in children 6 to 11 months of age with a first simple febrile seizure: a retrospective, cross-sectional, observational study. Acad Emerg Med. 2015;22(11):1290-1297. https://doi.org/10.1111/ acem.12798. 14. 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;17:585-588. https://doi.org/10.1016/j.ejpn.2013.04.008. 15. Sullivan JE, Farrar HC, the Section on Clinical Pharmacology and Therapeutics, Committee on Drugs. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587. https://doi.org/10.1542/peds.2010-3852. 16. Wu YW, Sullivan J, McDaniel SS, Meisler MH, Walsh EM, Li SX, Kuzniewicz MW. Incidence of Dravet syndrome in a US population. Pediatrics. 2015;136(5):e1310-e1315. https://doi.org/10.1542/peds.2015-1807. 17. Berg AT, Shinnar S, Darefsky AS, Holford TR, Shapiro ED, Salomon ME, et al. Predictors of recurrent febrile seizures: a prospective cohort study. Arch Pediatr Adolesc Med. 1997;151(4):371-378. http://www.ncbi.nlm.nih.gov/ pubmed/9111436. Accessed February 1, 2017. 18. Shinnar S, Glauser TA. Febrile seizures. J Child Neurol. 2002;17:S44-S52. https://doi.org/10.1177/08830738020170010601. 19. Mohebbi MR, Holden KR, Butler IJ. FIRST: A practical approach to the causes and management of febrile seizures. J Child Neurol. 2008;23(12):1484-1488. https://doi.org/10.1177/0883073808319317. 20. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years. Pediatrics. 2001;107(6):1241-1246. 21. Leaffer EB, Hinton VJ, Hesdorffer DC. Longitudinal assessment of skill development in children with first febrile seizure. Epilepsy Behav. 2013;28(1):83-87.
Lilly Ma, DNP, CPNP-PC, is a pediatric nurse practitioner in the Department of Pediatric Neurology, NYU Langone Medical Center, New York, NY. She can be reached at LillyMa89@ gmail.com. Sabrina Opiola McCauley, DNP, CPNP, NNP-BC, is an assistant professor of nursing at the Columbia University School of Nursing, New York, NY. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.09.021
Volume 14, Issue 2, February 2018
Febrile seizures are the most common seizure disorder. Febrile seizures are frightening to witness, and therefore caregiver education is paramount to help relieve anxiety levels. Acknowledgment of this concern by pediatric health care providers is needed to understand the importance of education, reassurance, and anticipatory guidance for caregivers. This article aims to discuss the assessment, diagnosis, and management of febrile seizures for the nurse practitioner based on the most current literature. Through appropriate clinical interventions, anticipatory guidance, and caregiver education, the nurse practitioner can substantially increase the comfort of the patients and their caregivers. Keywords: anticipatory guidance, febrile seizure, fever, pediatric/child, primary care Ó 2017 Elsevier Inc. All rights reserved.
F
ebrile seizures are the most common seizure disorder in childhood, and children with this condition may present to the primary care provider’s office or the emergency department. Febrile seizures have a peak incidence in the second year of life,1 occurring in 2% to 5% of the pediatric population.2 According to the most recent guidelines from the American Academy of Pediatrics (AAP),3 a febrile seizure is a seizure accompanied by fever (temperature 100.4 F or 38 C by any method) and without central nervous system infection that occurs in infants and children aged 6 through 60 months. Most febrile seizures are benign but are nonetheless frightening for caregivers to witness; therefore caregiver education is important to help relieve anxiety levels. Febrile seizures are emotionally traumatic for caregivers. Many caregivers may think that their child is dying during the seizure event and have a persistent fear of recurrence.4 Acknowledgment of this concern by nurse practitioners (NPs) is needed to understand the importance of education, reassurance, and anticipatory guidance for pediatric caregivers. This article will discuss the assessment, diagnosis, and management of febrile seizures, review current literature, and address strategies to implement key education points into current practice. 74
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PATHOPHYSIOLOGY
The mechanism through which a fever can cause a febrile seizure is still unclear. However, the cause of febrile seizures is known to be multifactorial, with genetic and environmental factors.5 An increase in brain temperature alters neuronal functions and ion channels, which influences neuronal firing and excitability, resulting in seizures.6 Genetics comes into play with neurodevelopmental vulnerability, alterations in sodium channel expression, hypothalamic dysregulation, and cortical and hippocampal excitability.7 Environmental triggers are believed to be involved through metabolic dysregulatory pathways.7 The secretion of cytokine, an inflammatory mediator, is also known to be part of the mechanism of febrile seizures.6 RISK FACTORS
A febrile seizure is generally a benign condition, related to various causative and risk factors (Table 1). Febrile seizures are an age-dependent phenomenon, occurring between 6 months and 5 years of age, attributed to the vulnerability of the child’s developing nervous system. Family history of febrile seizures, specifically in a first-degree relative, also plays a role. The degree of the fever (103 F or 39 C), rather than the rate of the temperature rise, is Volume 14, Issue 2, February 2018
Table 1. Causative and Risk Factors of Febrile Seizures Factors Associated With Febrile Seizures Individual
Age Degree of fever History of febrile seizure
Familial
First-degree relative with history of febrile seizures
Environmental Positive illness contact at home, day care, or school Virus
Bacteria
Respiratory: influenza virus, parainfluenza, respiratory syncytial virus, adenovirus Enteric: enterovirus, Coxsackie virus, rotavirus Herpesviruses: human herpesvirus, cytomegalovirus, herpes simplex virus Respiratory: Streptococcus pneumoniae Enteric: Shigella dysenteriae, Salmonella enteritidis Urinary: Escherichia coli
Vaccination
Measles, mumps, and rubella (MMR) Pertussis
Others
Channelopathies, pH, water and electrolyte imbalance, cytokines
Adapted from Mohebbi, Holden, and Butler IJ.19 Copyright 2008 by Sage Publications.
another risk factor in children.6 Although viral and bacterial infections are identified risk factors in febrile seizures, there is a higher association with viral infections because they tend to cause high fevers. Finding the causative factor of the febrile seizure event may help aid in diagnosis, management, and prevention of recurrent episodes, as well as provide comfort to the child’s parents and caregivers.
defined as primary generalized seizures that last for less than 15 minutes and do not recur within 24 hours.2 This is the most common type of febrile seizure, occurring in 70%e75% of children with febrile seizures.9 Complex febrile seizure is defined as focal, prolonged (duration longer than 15 minutes but less than 30 minutes), and/or recurrent within 24 hours. Approximately 20%e25% of febrile seizures are complex.9 Febrile status epilepticus is defined as generalized or focal seizures lasting more than 30 minutes.2 The seizure can be continuous or intermittent, without return to neurologic baseline during the period. EVALUATION History
A thorough history should be taken on all children after an episode of febrile seizure, including past medical history, medications, allergies, vaccination history, a full review of systems, onset and characteristic of the fever, events leading up to the febrile seizure, characteristics of the seizure episode (duration, body movements, and recurrence), and potential sick contacts or exposures. A developmental history and family medical history is also important to assess for risk factors. The NP must be able to use the history to distinguish whether the child had a simple, complex, or status epilepticus episode and develop a list of differential diagnoses. It is important for the NP to understand that a febrile seizure is a diagnosis of exclusion, and therefore a detailed history to determine the need for further evaluation with diagnostic testing is necessary. Meningitis, encephalitis, or a space-occupying brain lesion should be considered in any child presenting with a fever and seizure.
CLINICAL PRESENTATION
Signs and symptoms of febrile seizures include loss of consciousness, generalized or focal twitching or jerking of arms and legs, eye deviation or rolling back, pallor or cyanosis, and difficulty breathing. After the seizure, the child appears drowsy, lethargic, disoriented, and confused. This postictal state may last up to 30 minutes, after which the child should return to baseline.8 Febrile seizures are classified as simple, complex, or status epilepticus depending on characteristics, duration, and recurrence. Simple febrile seizure is www.npjournal.org
Physical Examination
After a complete history has been conducted, a comprehensive examination should be performed to identify the cause of the fever. The NP must determine whether the child is clinically stable and his or her hydration status. It is important to assess the patient’s airway patency, ventilation and oxygen adequacy, and circulatory status.10 A comprehensive neurologic examination should be conducted to ensure that the child is neurologically healthy. The neurologic assessment should The Journal for Nurse Practitioners - JNP
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include any changes in mental status, drowsiness, arousability, hallucinations, headache, irritability, and neck stiffness or pain. These signs and symptoms may indicate sepsis or meningitis and warrant further evaluation. It is important to note that children with febrile seizures are generally well appearing and return to baseline within 30 minutes.8 Therefore, any abnormality noted on examination after this time period should prompt suspicion for possible systemic infection. Diagnostic Tests
NPs assessing children after a febrile seizure should focus their evaluation on identifying the cause of the child’s fever. According to the AAP,3 simple febrile seizures do not usually require further evaluation, specifically neuroimaging, electroencephalogram (EEG), or blood tests. Most children with complex
febrile seizures do not need routine work-up or neuroimaging.11 In fact, an epileptiform EEG is not a sensitive measure and has a poor positive predictive value for the development of epilepsy among neurologically healthy or mildly delayed children with a first complex febrile seizure.12 A head computed tomography scan is not routinely recommended in the evaluation or management of children with complex febrile seizures unless there is indication of an intracranial hemorrhage or structural lesion based on history and physical examination.9 In some patients with complex febrile seizures or with a high index of suspicion of a more serious cause of fever and seizure (Table 2), diagnostic tests may be considered. In a child with a fever and seizure, a lumbar puncture may be considered if there is a suspicion for intracranial infection or meningitis based on history and physical examination,
Table 2. Diagnostic Tests for Febrile Seizures Diagnostic Tests Neuroimaging
Indications CT or MRI should not be performed in the routine evaluation of the child with a simple febrile seizure If focal or prolonged seizure, obtain outpatient brain MRI without contrast
EEG
Space-occupying lesion Herniation Mesial temporal sclerosis
Should not be performed in the evaluation of a neurologically healthy child with a simple febrile seizure
Lumbar puncture
Blood tests
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Differential Diagnoses
If abnormal neurodevelopmental state or more than one complex feature of family history of epilepsy, may obtain outpatient EEG
Febrile status epilepticus
Any child who presents with a seizure and a fever and has meningeal signs and symptoms (neck stiffness, Kernig and/or Brudzinski signs); or in any child whose history or examination suggests the presence of meningitis or intracranial infection
Meningitis Intracranial infection
In any infant between 6 and 12 months of age who presents with a seizure and fever, and is considered deficient (immunizations not complete or status cannot be determined) in Haemophilus influenza type b (Hib) or Streptococcus pneumoniae immunizations
Bacterial meningitis
Any child who presents with seizure and fever and is pretreated with antibiotics, because antibiotics can mask the signs and symptoms of meningitis
Meningitis
The following tests should not be performed routinely for the sole purpose of identifying the cause of a simple febrile seizure: measurement of serum electrolytes, calcium, phosphorus, magnesium, or blood glucose, or complete blood cell count
Blood abnormalities
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immunization status, or the recent or current use of antibiotics, which may mask meningitis. However, the risk of bacterial meningitis is extremely low, with an estimated risk of 0% among children aged between 6 and 11 months with a first simple febrile seizure.13 A nonurgent, outpatient magnetic resonance imaging scan of the brain may be considered for children with focal complex seizures and postictal neurologic deficit to evaluate for an underlying structural brain abnormality.9 Refer to Table 2 for indications of diagnostic tests and a list of differential diagnoses to be considered. TREATMENT
The AAP3 reports febrile seizures to be common and benign in children, with excellent prognosis and no long-term complications. There is no specific treatment for febrile seizures; rather, the aim is to treat the underlying cause. Depending on the NP’s assessment and the child’s clinical status, care may include oxygen supplementation, pulse oximetry, cardiac monitoring, and intravenous fluids. It is important to assess and maintain the child’s oxygenation and hydration status, transferring to an appropriate facility as needed. Antipyretics
Although antipyretics may improve the child’s comfort, it will not prevent a febrile seizure or reduce the recurrence of febrile seizures. A systematic review14 of randomized controlled trials and a metaanalysis aimed at determining the effectiveness of antipyretic use in prevention of subsequent febrile seizures assessed a sample of 540 children. Among the sample, 348 children received antipyretics, including acetaminophen, ibuprofen, and diclofenac, and 192 received a placebo. No statistically significant difference was found between the antipyretics and the placebo groups in the recurrence rate of febrile seizures. Many caregivers administer antipyretics even when there is a mild elevation in temperature because they are concerned that the child must maintain a “normal” temperature.15 Generally, acetaminophen and ibuprofen are considered safe and effective antipyretics for children, but education to prevent overdose is important to avoid adverse events such as www.npjournal.org
hepatotoxicity, gastrointestinal upset, respiratory failure, metabolic acidosis, renal failure, and coma.8 Combination therapy of alternating acetaminophen and ibuprofen may place children at increased risk of toxicity because of administration errors and should be carefully considered by the NP. Antiepileptic Drugs
Febrile seizures are a benign condition and do not cause long-term complications; therefore, the use of antiepileptic drugs are not typically recommended. Immediate management includes the use of a rescue seizure medication such as rectal diazepam or intranasal midazolam to stop an ongoing seizure when the febrile seizure lasts longer than 5 minutes and respiration becomes a concern.6 Continuous antiepileptic therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with oral diazepam have shown to be effective in reducing the risk of recurrence.8 However, NPs must consider the potential toxicities associated with these antiepileptic drugs. The adverse effects likely outweigh the relatively minor risks associated with febrile seizures. If antiepileptic therapy is considered, a pediatric neurology referral should be initiated. Ultimately, the most effective treatment of febrile seizures is aimed toward treating the febrile illness rather than the seizure. Neurology Referral
A nonurgent neurologic consult can be obtained if there is clinical suspicion for an underlying neurologic or developmental disorder.6 It should be considered in children with persistent neurologic deficits after a complex febrile seizure, recurrent complex febrile seizure, febrile status epilepticus, abnormalities on evaluation, or seizures not clearly related to fever.9 Dravet syndrome, previously known as severe myoclonic epilepsy of infancy, is characterized by intractable epilepsy and poor neurodevelopmental outcomes. This rare, catastrophic, lifelong form of epilepsy manifests as frequent or prolonged seizures in the first year of life, and therefore neurologic evaluation and genetic testing should be considered in children with 2 prolonged febrile seizures by 1 year of age.16 The Journal for Nurse Practitioners - JNP
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POTENTIAL RISKS
Children with simple febrile seizures have a high rate of recurrence. A prospective cohort study17 aimed at identifying the risks and predictors of single and multiple recurrent febrile seizures included a total sample of 428 children with their first febrile seizures. The study suggested that the risk of the recurrence of febrile seizures decreased with older age at onset of first episode. Children younger than 12 months at the time of their first simple febrile seizure have an approximately 50% probability of having recurrent febrile seizures, children older than 12 months at the time of their first event have an approximately 30% probability of a second febrile seizure. Additionally, 50% of those who do have a second febrile seizure can have at least 1 additional recurrence.17 The risk of epilepsy depends on several factors (Table 3), including age at onset of first febrile seizure, number of recurrent episodes of febrile seizures, and family history of epilepsy. The risk of developing epilepsy by age 7 in children who have experienced a simple febrile seizure is 1%, which is the same as the general population.18 Children who have had multiple simple febrile seizures, are younger than 12 months at the time of their first febrile seizure, and have a family history of epilepsy are at higher risk for epilepsy, with generalized afebrile seizures developing by 25 years of age in 2.4%.18
Table 3. Risk Factors for Recurrent Febrile Seizures and Subsequent Epilepsy Recurrent febrile seizures Family history of febrile seizures Age < 18 months Lower peak fever with previous febrile seizure(s) Shorter duration of fever with previous febrile seizure(s) Subsequent epilepsy
Neurodevelopmental abnormality Complex febrile seizure Family history of epilepsy Shorter duration of fever with prior febrile seizure(s)
Adapted from Shinnar and Glauser.18 Copyright 2002 by Sage Publications.
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ROLE OF THE NP Clinical Practice
NPs will encounter febrile seizures at some point in their careers and will most likely manage them in the outpatient setting. The assessment and evaluation of children who present with febrile seizures should be directed toward determining the specific cause for the fever using history and physical examination findings along with appropriate diagnostic tests to reduce the period of morbidity and hospitalization, decrease the need for neurologic studies, relieve the anxiety of the child’s caregivers, and reduce the administration of anticonvulsants.19 The NP caring for the child should focus on making sure the child is clinically stable, monitoring for signs and symptoms of serious illness, improving the child’s comfort by maintaining hydration, and educating caregivers on the appropriate use of antipyretics. Education
In addition to the evaluation and management of the child’s health, a major role of the NP is educating the child’s family. The NP is often the main source of information for the child’s caregivers on febrile seizures. Anticipatory guidance, as outlined in Table 4, should be provided at each visit because fevers are common and can result in febrile seizures in any child. The NP should counsel caregivers on what they should do if a febrile seizure occurs. First, lay the child on the floor in the side-lying position to prevent aspiration; remove objects in the surrounding area that may injure the child. With the caregiver at the child’s back, caregiver should put her fingers under the chin. Straighten the airway by pushing chin upward. DO NOT place anything in the child’s mouth. The caregiver should also be educated to time the duration of the seizure and to note what is occurring during the seizure episode. Recommending that caregivers take a cardiopulmonary resuscitation class can also be beneficial in reducing their anxiety. Fever is a frequent cause of concern; it is important to help the caregivers understand that fever itself is not a danger to a generally healthy individual. The NP should educate and reassure caregivers that fever is not the primary illness, but is the immune system’s physiologic mechanism to fight infection.15 Caregivers Volume 14, Issue 2, February 2018
Table 4. Anticipatory Guidance and Education on Febrile Seizures for Caregivers
Febrile seizures occur in 2%e5% of all children between the ages of 6 months and 5 years. Febrile seizures tend to run in families. Febrile seizures often occur in the first 24 hours of the febrile illness. A febrile seizure might present with body stiffening; twitching of the face, arms and legs, or both; eye rolling; jerking of the arms and legs; staring; or loss of consciousness. These seizures might appear frightening to observers but are generally harmless. Your child might appear not to be breathing and the skin color might become darker. Call 911 or emergency personnel. Caregivers should consider taking a CPR class. First, lay the child on the floor in the side-lying position to prevent aspiration; remove objects in the surrounding area that may injure the child. With the caregiver at the child’s back, caregiver should put her fingers under the chin. Straighten the airway by pushing chin upward. DO NOT place anything in the child’s mouth. You should time the duration of the seizure and note what is occurring during the seizure episode. Febrile seizures do not cause brain damage or paralysis. A child who has febrile seizures has only a slightly increased risk of having a seizure disorder compared with that of a child who has never had a febrile seizure. Febrile seizures can recur with subsequent febrile illnesses. Your child should be seen by a health care provider for an evaluation after every episode. Medicines are generally not given to prevent simple febrile seizures. Use of medicines such as acetaminophen or ibuprofen for fevers has not been shown to prevent febrile seizures. Although immunizations are associated with febrile seizures, this is not a reason not to immunize your child.
Adapted from Warden, Zibulewsky, Mace, Gold, and Gausche-Hill.10
should be reassured that the fever does not worsen the course of the illness, nor will it cause neurologic complications. They should also be educated to monitor the child for any changes in activity level and observe for signs or symptoms of illness. The NP should inform caregivers that although febrile seizures are dramatic events, they do not indicate future neurologic dysfunction or disease. It is also important to address concerns of the correlation between vaccinations and febrile seizures. Vaccines associated with febrile seizures include measles, mumps, rubella, and varicella (MMRV) and diphtheria, tetanus toxoid, and pertussis (DTP).2 Postvaccination febrile seizures are rare and often occur within the first 3 days after administration of a live attenuated vaccine, with increased risk when multiple vaccines are given.2 However, febrile seizures due to vaccination are no different from those of other causes and should not discourage caregivers from vaccinating their children. When counseling caregivers on the management of fever, it is important to emphasize that the goal of antipyretic therapy is not to “normalize” body temperature; rather, it is part of supportive care to improve the child’s comfort in addition to hydration and rest. Approximately half of caregivers consider a temperature of < 100.4 F or 38 C to be a fever, and www.npjournal.org
25% of caregivers would give antipyretics when their temperature does not indicate fever.20 Additionally, caregivers have reported awakening their child from sleep to give them antipyretics.20 It is critically important that all caregivers be given clear instructions on the appropriate administration of antipyretics because of the risk of overdose and its fatal complications. The accurate formulation, dose, dosing interval, and daily maximum dosage of each type of antipyretic must be discussed. All medications should be labeled clearly with dosing instructions and include an appropriate dosing device. Child safety, including proper handling and storage of antipyretics, should also be encouraged. Parents should be reassured that febrile seizures do not cause brain damage or paralysis, nor do they place the child at risk for developmental or behavioral consequences.21 It is also important to educate parents that a child with history of febrile seizure has a low risk of developing epilepsy.18 Although febrile seizures are benign, the child should still be evaluated, whether in the primary care setting or in the emergency department, after every episode. The need for a follow-up should be determined on the basis of the underlying cause of the fever and the clinical presentation of the child. The caregiver should note the onset of fever, The Journal for Nurse Practitioners - JNP
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characteristics and duration of the seizures, and postictal state. Future Research
There are still gaps in knowledge revolving around febrile seizures, indicating the need for further research. Future studies should determine the appropriate use of neuroimaging studies, the timing of administration of antiviral and antibacterial drugs, and the acute and chronic administration of anticonvulsants in simple and complex febrile seizures. CONCLUSION
Although most febrile seizures are benign, their careful assessment and management is important. NPs evaluating children after a febrile seizure should focus on identifying the cause of the child’s fever and treating the febrile illness rather than the seizure. Febrile seizures are frightening for caregivers to witness, and therefore education is necessary to help relieve their anxiety levels. Acknowledgment of this concern by NPs is needed to understand the importance of education, reassurance, and anticipatory guidance for their pediatric patients and their caregivers. References 1. Wilmshurst JM, Gaillard WD, Vinayan K, Tsuchida TN, Plouin P, Van Bogaert P, et al. Summary of recommendations for the management of infantile seizures: task force reports for the ILAE Commission of Pediatrics. Epilepsia. 2015;56(8):1185-1197. https://doi.org/10.1111/epi.13057. 2. Khair AM, Elmagrabi D. Febrile seizures and febrile seizure syndromes: An updated overview of old and current knowledge. Neurol Res Int. 2015;2015:1-7. https://doi.org/10.1155/2015/849341. 3. American Academy of Pediatrics. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. https://doi.org/10.1542/peds.2010-3318. 4. Gordon KE, Dooley JM, Wood E, Brna P, Bethune P. Which characteristics of children with a febrile seizure are associated with subsequent physician visits? Pediatrics. 2004;114(4):962-964. https://doi.org/10.1542/peds.2003-0650-F. 5. Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;351:1-7. https://doi.org/10.1136/bmj.h4240. 6. Chung S. Febrile seizures. Korean J Pediatr. 2014;57(9):384-395. https:// doi.org/10.3345/kjp.2014.57.9.384. 7. Sisodiya S. Feverish prospects for seizure genetics. Nat Genet. 2014;46(12):1255-1256. https://doi.org/10.1038/ng.3150. 8. 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. https://doi.org/10.1542/peds.2008-0939.
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9. Whelan H, Harmelink M, Chou E, Sallowm D, Khan N, Patil R, et al. Complex febrile seizures—a systematic review. Dis Mon. 2017;63(1):5-23. https://doi.org/10.1016/j.disamonth.2016.12.001. 10. Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-222. https://doi.org/10 .1067/mem.2003.48. 11. Hardasmalani MD, Saber M. Yield of diagnostic studies in children presenting with complex febrile seizures. Pediatr Emerg Care. 2012;28(8):789-791. https:// doi.org/10.1097/PEC.0b013e3182627ed2. 12. Harini C, Nagarajan E, Kimia AA, de Carvalho RM, An S, Bergin AM, et al. Utility of initial EEG in first complex febrile seizure. Epilepsy Behav. 2015;52:200-204. https://doi.org/10.1016/j.yebeh.2015.09.003. 13. Guedj R, Chappuy H, Titomanlio L, Trieu TV, Biscardi S, Nissack-Obiketeki G, et al. Risk of bacterial meningitis in children 6 to 11 months of age with a first simple febrile seizure: a retrospective, cross-sectional, observational study. Acad Emerg Med. 2015;22(11):1290-1297. https://doi.org/10.1111/ acem.12798. 14. 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;17:585-588. https://doi.org/10.1016/j.ejpn.2013.04.008. 15. Sullivan JE, Farrar HC, the Section on Clinical Pharmacology and Therapeutics, Committee on Drugs. Fever and antipyretic use in children. Pediatrics. 2011;127(3):580-587. https://doi.org/10.1542/peds.2010-3852. 16. Wu YW, Sullivan J, McDaniel SS, Meisler MH, Walsh EM, Li SX, Kuzniewicz MW. Incidence of Dravet syndrome in a US population. Pediatrics. 2015;136(5):e1310-e1315. https://doi.org/10.1542/peds.2015-1807. 17. Berg AT, Shinnar S, Darefsky AS, Holford TR, Shapiro ED, Salomon ME, et al. Predictors of recurrent febrile seizures: a prospective cohort study. Arch Pediatr Adolesc Med. 1997;151(4):371-378. http://www.ncbi.nlm.nih.gov/ pubmed/9111436. Accessed February 1, 2017. 18. Shinnar S, Glauser TA. Febrile seizures. J Child Neurol. 2002;17:S44-S52. https://doi.org/10.1177/08830738020170010601. 19. Mohebbi MR, Holden KR, Butler IJ. FIRST: A practical approach to the causes and management of febrile seizures. J Child Neurol. 2008;23(12):1484-1488. https://doi.org/10.1177/0883073808319317. 20. Crocetti M, Moghbeli N, Serwint J. Fever phobia revisited: have parental misconceptions about fever changed in 20 years. Pediatrics. 2001;107(6):1241-1246. 21. Leaffer EB, Hinton VJ, Hesdorffer DC. Longitudinal assessment of skill development in children with first febrile seizure. Epilepsy Behav. 2013;28(1):83-87.
Lilly Ma, DNP, CPNP-PC, is a pediatric nurse practitioner in the Department of Pediatric Neurology, NYU Langone Medical Center, New York, NY. She can be reached at LillyMa89@ gmail.com. Sabrina Opiola McCauley, DNP, CPNP, NNP-BC, is an assistant professor of nursing at the Columbia University School of Nursing, New York, NY. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.nurpra.2017.09.021
Volume 14, Issue 2, February 2018