A BNF case study in which a 14-month old boy has been crying frequently and has vomited twice. He is not feeding and sleeping as well as he normally does. He appears flushed, his head feels hot, he is coryzal, and there is abdominal tenderness.
Based on a case study from the BNF/BNFC e-newsletter, July 2010
Over the last 24 hours, a 14-month old boy has been crying frequently and has vomited twice. He is not feeding and sleeping as well as he normally does. He appears flushed, his head feels hot, he is coryzal, and there is abdominal tenderness.
- His body temperature (measured with a tympanic thermometer) = 39.5oC
- Heart rate = 150 beats/minute
- Respiratory rate = 40 breaths/minute
- Body-weight = 12kg.
A urine sample is sent to the laboratory for urgent microscopy and culture. A blood culture is also sent.
His history is otherwise unremarkable and there is no family history of neurological abnormalities. He received his first dose of MMR vaccine and a booster dose of pneumococcal polysaccharide conjugate vaccine (adsorbed) 7 days ago.
During the examination, he has a generalised tonic-clonic convulsion lasting 2 minutes and he is sleepy for some minutes afterwards. On further examination he is co-ordinated for his age, able to say ‘mama’, and is appropriately alert and orientated. He has no rash and there is no neck stiffness.
How should this boy’s febrile convulsion be treated?
The prescribing notes on Febrile Convulsions in section 4.8.3, BNFC 2010−2011, advise that brief febrile convulsions need no specific treatment. However, after a first febrile convulsion, it is usual practice to observe the child overnight in hospital. Antipyretic medication (e.g. paracetamol) is commonly used to reduce fever and prevent further convulsions, but evidence to support this practice is lacking. However, antipyretic medication can be used to make this child, who is distressed with marked fever, more comfortable. Diazepam by slow intravenous injection or preferably rectally in solution is used for prolonged febrile convulsions (those lasting 5 minutes or longer), recurrent convulsions, or those occurring in a child at known risk; according to Medical Emergencies in the Community, midazolam by the buccal route is an alternative. Neither midazolam nor diazepam is currently indicated for this child.
The boy is prescribed paracetamol oral suspension 360mg as a single dose then 250mg every 6hours. The parents are concerned that the first dose of paracetamol is much higher than the dosethey usually give him at home. Has the boy been prescribed an appropriate dose of paracetamol?
According to the paracetamol monograph in BNFC 2010−2011, the dose of paracetamol for severe pyrexia in a child of this age is 20−30mg/kg as a single dose then 15−20mg/kg every 6−8 hours; max. 90mg/kg daily in divided doses. In less severe pyrexia or when paracetamol is initiated by the parents or carers for a child of this age, the standard dose of paracetamol is 120−250mg every 4−6 hours (max. 4 doses in 24 hours). As the boy has marked fever with discomfort, he has been prescribed an appropriate dose of paracetamol based on his body-weight.
Can ibuprofen be given at the same time as paracetamol for fever?
Paracetamol and ibuprofen should not be administered at the same time to children with fever. However, use of the alternative antipyretic may be considered if the child does not respond to the first antipyretic.
Does this boy require long-term anticonvulsant prophylaxis for febrile convulsions?
The prescribing notes on Febrile Convulsions in section 4.8.3, BNFC 2010−2011, advise that long-term anticonvulsant prophylaxis is rarely indicated for febrile convulsions. The boy does not require long-term prophylaxis because he had a single, simple febrile convulsion, and he has no history of afebrile seizures.
The parents remember reading that the MMR vaccine can be associated with febrile seizures.Could the MMR vaccine be responsible for this boy’s febrile convulsion?
According to the prescribing notes on MMR Vaccine in section 14.4, BNFC 2010−2011, febrile seizures may occur 6 to 11 days after MMR vaccination in 1 in 1000 children and the incidence is lower than that following measles infection. Adverse reactions are considerably less frequent after the second dose of MMR vaccine than after the first dose.
Although the time at which the febrile convulsion occurred in this child is closely related to the time from when the MMR vaccine was administered, the urinary-tract infection is much more likely to be responsible for the boy’s fever and febrile convulsion.
Are further vaccinations contra-indicated in this child?
According to the prescribing notes on Active Immunity in section 14.1, BNFC 2010−2011, when there is a personal history of febrile convulsions, there is an increased risk of these occurring during fever from any cause, including vaccination, but this is not a contra-indication to vaccination. In this child who had a febrile convulsion without neurological deterioration, further vaccinations can be given at the appropriate age.
Microscopy of the urine sample shows greater than 100 leucocytes mm3 and the presence of numerous Gram-negative bacilli. The boy is commenced on intravenous fluids and cefotaxime. He improves within 48 hours of starting the antibiotic and the cefotaxime is switched to cefalexin to complete 7 days’ treatment.
Does this child require imaging tests or antibiotic prophylaxis for the urinary-tract infection?
Imaging tests of the urinary tract are not indicated for children of this age with a first-time urinary-tract infection that responds to antibiotic treatment within 48 hours.
The prescribing notes on Urinary-tract Infections in section 5.1.13, BNFC 2010−2011, recommend considering antibiotic prophylaxis for children with recurrent infection, significant urinary-tract anomalies, or significant kidney damage. Although antibiotic prophylaxis is not recommended for this child, general advice should be provided on preventing UTIs, such as maintaining an adequate intake of fluid.