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infection. If the child presents in a convulsion the situation should be reassessed when it has
stopped. Even when there is evidence of an infection outside the nervous system it may be
important to exclude an intracranial infection by performing a lumbar puncture.

Admission to hospital
Febrile convulsions that last for more than a few minutes should be stopped and if the
convulsion cannot be stopped the child should be admitted to hospital. If the convulsion has
stopped it must then be decided whether or not to admit. According to the RCP/BPA Joint
Working Group61 the following factors would favour admission after a first convulsion:

 Complex convulsion
 Child aged less than 18 months
 Early review by a doctor at home not possible
 Home circumstances inadequate, or unusual parental anxiety, or parents’ inability to cope.

Investigations
‘No investigations are routinely necessary in all children after a febrile convulsion’,
according to the RCP/BPA Joint Working Group61. This statement seems to be representative
of the views of most commentators. It may be appropriate to check the blood glucose
concentration or the electrolytes in some children with continuing convulsions.

Lumbar puncture
This is still a controversial subject. Rosman59 recommends an active approach  lumbar
puncture for all children less than two years old with febrile convulsions – and he suggests
the need for a second lumbar puncture in some children with suspected meningitis, quoting
evidence from Lorber and Sunderland64 who reported that the CSF is sometimes normal early
in the course of meningitis, although their general advice was that ‘lumbar puncture should
not be carried out as a routine procedure’. Rutter and Smales65 also reported that two children
in their series developed meningitis within one or two days of a negative lumbar puncture, so
false reassurance can be derived from a lumbar puncture. Clinical vigilance seems to be all-
important.

The RCP/BPA Joint Working Group61 recommended a lumbar puncture if:

 There are clinical signs of meningism
 After a complex convulsion
 If the child is unduly drowsy or irritable or systemically ill
 If the child is less than 18 months old (probably) and almost certainly if the child is aged

less than 12 months.

The group considered that ideally a decision should be made by an experienced doctor. If the
decision is taken not to perform a lumbar puncture it should be reviewed within a few hours.
The risk of coning in a comatose child should be borne in mind and so should the fact that
clinical signs of meningism are much less likely to be found in younger children.

Camfield and Camfield57 recommend a lumbar puncture for the majority of children under
one year of age with a first febrile seizure because at that age meningitis may be accompanied
by very little nuchal rigidity or other findings of meningeal irritation. Lumbar puncture is
indicated when there is the possibility of a partially treated meningitis in a child who has
already been given antibiotics. The American Academy of Pediatrics reached similar
conclusions62. In a retrospective cohort review Kimia et al found that the risk of bacterial
meningitis presenting as first simple febrile seizures at ages 618 months was very low66.