What is management for febrile fit based on Malaysian guideline
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Malaysian clinical practice guideline febrile seizure management 2024
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Malaysia MOH CPG febrile seizures management site:moh.gov.my OR site:acadmed.org.my
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febrile seizure management treatment
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"Paediatric Protocols" Malaysia "febrile seizures" chapter 49 complex management diazepam midazolam phenobarbitone
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I now have comprehensive content from both the 4th and 5th editions of the Malaysian MOH Paediatric Protocols. Here is the full, structured answer based on Malaysian guidelines:
Management of Febrile Seizure - Malaysian Guidelines
Based on the Malaysian MOH Paediatric Protocols for Malaysian Hospitals (5th Edition) and the Malaysian Paediatric Association (MPA) Paediatric Protocols (4th Edition), Chapter 48/49: Febrile Seizures
Definition
A febrile seizure is a seizure occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or metabolic derangement.
Classification
| Feature | Simple Febrile Seizure | Complex Febrile Seizure |
|---|---|---|
| Duration | < 15 minutes | > 15 minutes |
| Type | Generalised only | May have focal features |
| Recurrence in same episode | Does not recur | > 1 seizure in same febrile episode |
| Post-ictal deficit | None | May have Todd's paralysis |
Management
1. Hospital Admission
Not all children require admission. Main indications are:
- To exclude intracranial pathology (especially infection)
- Fear of recurrent seizures
- To investigate and treat the cause of fever
- To allay parental anxiety (especially for families far from hospital)
2. Investigations
The need for investigations depends on clinical assessment of the individual case:
- Lumbar puncture (LP) - MUST be done (unless contraindicated) if:
- Any symptoms or signs of intracranial infection
- Persistent lethargy and not fully interactive
- LP - Should be considered if:
- Age < 12 months, especially if the child has not received Hib and pneumococcal immunisation
- Prior antibiotic therapy (may mask signs of meningitis)
- Serum calcium and electrolytes - rarely necessary
- EEG - NOT indicated, even for multiple recurrences or complex febrile seizures
- Blood counts, blood sugar, urinalysis, chest X-ray, blood culture - guided by clinical assessment of the fever source
3. Acute Seizure Management
- Most febrile seizures are brief and self-limiting
- If the seizure continues:
- Rectal Diazepam 0.5 mg/kg - first-line acute rescue medication if seizure lasts > 5 minutes
- For febrile status epilepticus, follow the Status Epilepticus protocol
4. Fever Control
- Avoid excessive clothing
- Paracetamol syrup or rectal: 15 mg/kg every 6 hours - for patient comfort
- Important: antipyretics do NOT reduce the risk of seizure recurrence - this should be communicated to parents
5. Long-term Prophylaxis
- Routine long-term anti-seizure medication is NOT recommended for simple febrile seizures
- Rectal diazepam (0.5 mg/kg) should be supplied to parents of children with high risk of recurrent febrile seizures, including those with febrile status epilepticus
- Parents should be taught to administer it if a seizure lasts > 5 minutes
Risk Factors for Recurrence
| Number of Risk Factors | Risk of Recurrence |
|---|---|
| 0 risk factors | < 15% |
| ≥ 2 risk factors | > 30% |
| ≥ 3 risk factors | > 60% |
Risk factors for recurrent febrile seizures:
- Family history of febrile seizures
- Age < 18 months at first seizure
- Low-grade fever (< 40°C) during first febrile seizure
- Brief interval (< 1 hour) between onset of fever and seizure
Risk Factors for Subsequent Epilepsy
- Neurodevelopmental abnormality
- Complex febrile seizures
- Family history of epilepsy
Prognosis
- Excellent - no neurological deficit, no effect on intelligence
- 3-4% of population experience febrile seizures
- 30% recurrence rate after first attack
- Risk of developing epilepsy: slightly higher than the general population only if risk factors present
Parental Education (First Aid Measures)
- Place child in lateral (recovery) position
- Wipe any vomitus or secretions from mouth
- Do NOT insert any object into the mouth (even if teeth are clenched)
- Do NOT give any fluids or drugs orally during a seizure
- Stay near the child until the seizure is over and comfort during recovery
- Counsel parents on the benign nature of the condition
Sources:
- Malaysian MOH Paediatric Protocols for Malaysian Hospitals, 5th Edition - Chapter 49: Febrile Seizures
- Malaysian Paediatric Association (MPA) Paediatric Protocols, 4th Edition - Chapter 48: Febrile Seizures
- The Harriet Lane Handbook, 23rd ed. - Section on Febrile Seizures, p. 739
What are the acute seizure management protocols (seizure termination drugs/doses)?
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status epilepticus acute seizure management drugs doses midazolam diazepam phenobarbitone phenytoin stepwise protocol
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Excellent - I have the full stepwise protocol from both editions. Here is the complete answer:
Acute Seizure / Convulsive Status Epilepticus Management
Malaysian MOH Paediatric Protocols (4th & 5th Edition) - Chapter 46/47
Timeline Definitions (ILAE 2015 - used in Malaysian protocol)
| Phase | Timepoint | Term |
|---|---|---|
| Seizure onset | T1 = 5 mins | Impending / Early SE |
| 5-30 mins | Established SE | |
| T2 = 30 mins | Established SE | |
| > 30-60 mins | Early Refractory SE | |
| > 60 mins | Established Refractory SE |
Step-by-Step Protocol
PHASE 1 - Pre-hospital / No IV Access (Seizure > 5 mins)
Option A - Rectal Diazepam (PR)
| Age | Dose |
|---|---|
| 2-5 years | 0.5 mg/kg (max 10 mg) |
| 6-11 years | 0.3 mg/kg |
| ≥ 12 years | 0.2 mg/kg |
Option B - Buccal Midazolam
- 0.2-0.5 mg/kg (max 10 mg)
Obtain IV access as soon as possible
PHASE 2 - IV Access Obtained (Seizure ongoing after Phase 1, or first presentation in hospital)
IV Diazepam
- 0.2 mg/kg slow IV bolus
- Rate: 2 mg/min
- Max: 10 mg
PHASE 3 - Seizure Continues > 5 mins after IV Diazepam (Established SE)
Choose one of the following second-line agents:
| Drug | Dose | Administration |
|---|---|---|
| IV Phenytoin | 20 mg/kg (max loading 1.25 g) | Dilute in 0.9% NaCl; max concentration 10 mg/mL; infuse over 20-30 mins; with cardiac monitoring |
| IV Phenobarbitone | 20 mg/kg (max loading 1 g) | Infuse at 25-50 mg/min |
| IV Sodium Valproate | 20 mg/kg (max loading 1.25 g) | Give over 1-5 mins at 20-50 mg/min; then infusion 1-5 mg/kg/hr |
| IV Midazolam | 0.2 mg/kg bolus (max 10 mg) at 2 mg/min, then infusion 3-5 mcg/kg/min (up to max 15 mcg/kg/min) | - |
Note: If using multiple drugs, choose agents with different mechanisms of action. Avoid combining phenytoin + phenobarbitone if possible.
PHASE 4 - Seizure Continues > 10 mins after Phenytoin (Early Refractory SE)
IV Phenobarbitone (if not already given)
- 10 mg/kg over 15 minutes
- Can repeat: additional 10-20 mg/kg if seizures persist
- Then further 10 mg/kg over 15 minutes if needed
- Watch for: hypotension, respiratory depression
PHASE 5 - Refractory SE (> 60 mins) / Anaesthetic Agents
Discuss with Paediatric Neurologist and Intensivist about inducing anaesthetic coma
| Drug | Dose |
|---|---|
| IV Midazolam infusion | Bolus 0.15 mg/kg, then infusion 1-2 mcg/kg/min, uptitrate to max 20 mcg/kg/min; begin weaning once 24-hour seizure-free |
Side effects to monitor: hypotension, respiratory depression, myoclonus
Additional agents to consider in refractory SE:
- IV Levetiracetam - 40 mg/kg/day loading, then 40 mg/kg/day in 2 divided doses
- Oral Topiramate - 4-10 mg/kg
Supportive / Concurrent Steps (All Phases)
- Maintain airway - position, suction
- Treat reversible causes - check glucose, electrolytes (calcium, sodium, magnesium), temperature
- Start antibiotics if clinical suspicion of meningitis
- Commence therapeutic hypothermia in infants meeting criteria
- Cardiac monitoring mandatory when using phenytoin
- Give adequate loading doses followed by maintenance; monitor drug levels for phenobarbitone and phenytoin
- Consider therapeutic hypothermia early in refractory SE cases
For Febrile Seizure Specifically (Home/Outpatient)
- Rectal Diazepam 0.5 mg/kg - supplied to parents of high-risk children
- Instruct parents to administer if seizure lasts > 5 minutes
- For febrile status epilepticus, escalate using the full SE protocol above
Important DON'Ts
- Avoid excessive time lag between doses/steps
- Do not avoid treatment out of fear of respiratory depression - have resuscitation equipment ready
- Do not combine phenytoin + phenobarbitone together if avoidable
Sources: Malaysian MOH Paediatric Protocols for Malaysian Hospitals, 5th Edition - Chapter 47: Status Epilepticus; Malaysian Paediatric Association (MPA) Paediatric Protocols, 4th Edition - Chapter 46: Status Epilepticus
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