Introduction

It is 04:00 in the morning; I awaken to the sound of my ten month old daughter crying. My husband and I quickly go to her crib, when my 4 year old begins calling at the same time. After helping my son fall back to sleep, I find my daughter fast asleep in her crib. I had a sudden urge to place my hand on her. She was boiling hot. I quickly woke my husband, and took a rectal temperature which read 104.9 degrees. After an unsuccessful attempt to decrease her fever with Tylenol and a sponge bath, we rushed to the closest emergency department for help.

My husband is a firefighter trained in emergency medicine, and I am a Master's prepared emergency room and cardiac nurse educator. We were greatly disappointed in the care provided our daughter that early morning in the emergency department. Upon arrival at the deserted emergency department, we waited almost 30 minutes to be seen by the attending emergency room physician. The doctor was unimpressed with our daughter’s symptoms, since the high fever was her only symptom. He gave her oral Motrin, and discharged her from the hospital with a temperature of 103 degrees. My husband and I were expecting at minimum some IV fluids to cool her temperature. We were accustomed to more aggressive emergency room protocol treatments. We were expecting some blood work, possible blood and urine cultures, or a lumbar puncture to rule out meningitis. At this point our daughter was lethargic and listless.

He instructed us to follow up with our pediatrician the next morning. When the nurse returned with our discharge papers, I requested to see the physician again, to request some IV fluids and at least a CBC since her temperature was so high, and the nurse replied that he had already gone home, and it would be a long time until the next shifts physician could speak with us. The nurse handed us our instructions to see our pediatrician the next morning and left the room.

Upon arrival home, while I was changing her diaper, I noticed her skin was turning purple, and mottled. The skin around her nose, and mouth looked almost jaundiced. She was also becoming more lethargic. Despite Motrin and Tylenol, her fever remained 103.8 degrees. At that point I decided we needed to follow up at the pediatrician now, and not in the morning. No sooner had we arrived at the pediatrician’s office, she began having febrile seizures as soon as we were taken into the exam room.

First I noticed the aura; she turned her head up, as though she was staring at something that was not there. Then her eyes began to roll in an upward motion. I recognized that she was about to have a seizure. That was when I became completely helpless. I screamed to call the pediatricians in the room for help. It was like I never went to nursing school. All I kept thinking and screaming was, “Oh God, not my baby, not her, is she breathing”. I was paralyzed with fright. Then all of the color drained from her body, she turned blue. I kept screaming for the pediatricians to come. What felt like an hour was only a second until a team of pediatricians, nurses, and a physician assistant whisked my daughter into the treatment room. The nurses quickly turned her on to her side, just in time for her to vomit.

It was not that I didn’t know what to do, I just couldn’t. I was scared and  paralyzed. I was no longer a nurse,  I was Mom. I cried and prayed. I kept yelling, “is she breathing”. It was then that my nursing knowledge worked against me when I caught a glimpse of the pulse oximeter. Her saturation had dropped to 70%. This was when panic set in. I kept screaming, “Give her oxygen… get the ambu bag… is she breathing”. All that registered was that my baby was blue, and had an oxygen saturation of 70%. I was so frightened, but the team of doctors and nurses had the situation well under control.

 What felt like a two hour seizure only lasted about five minutes. She didn’t even need rectal Valium to stop it, she stopped seizing on her own. After, it was over; the doctors informed us that the generalized seizure might have been related to her high fever. She remained post-ictal for about 15 minutes, she appeared dazed and her breathing was very shallow. Although it felt like eternity, she began to cry, I felt completely useless, whereas, my husband was calm the entire time, comforting me.

I have never lost control of any nursing situation until now. It feels so different when it’s your own child. This incidence has inspired me to review related literature about febrile seizures, and share it with other mothers as an easy to read guide.

Temperature and thermometer guide

What is the best method to take a temperature? There are several routes where a temperature can be taken: rectal, oral, axillary, tympanic, and across the forehead (Blais, Erb, Kozier &, Wilkinson, 1995).   For infants, rectal temperatures are closest to the body’s core temperature, but can be inaccurate if not inserted properly, or the infant has stool in rectum (Whaley & Wong, 1995). Oral temperatures are placed in the mouth sublingually; however, the child must be old enough to keep their mouth closed, and not bite the thermometer, otherwise a rectal temperature is the preferred method (Whaley & Wong, 1995). Oral temperatures can also be inaccurate if the child has ingested a cold or hot beverage, is a mouth breather, or the teen or pre-teen has recently smoked a cigarette (Whaley & Wong, 1995).

Axillary temperatures are convenient when your child is resisting an intrusive thermometer, however they have to be held close to the child’s skin, and are one of the least accurate (Whaley & Wong, 1995). Tympanic membrane sensor temperature readings are also less invasive and well received by infants and children (Whaley & Wong, 1995). However, for the most accurate reading, mothers must correctly straighten the ear canal prior to inserting the probe to ensure correct placement. The tympanic thermometer will give an accurate reading even in the presence of cerumen, or if the child has an ear infection such as Otitis  Media, as long as it is positioned correctly in the ear canal (Whaley & Wong, 1995). Plastic strip thermometers or thermographs are placed on the child’s forehead, and are variable in accuracy, measuring the furthest from the core temperature.

 There are several types of thermometers available to take an infant, toddler, or child’s temperature. Types of thermometers include the traditional mercury-in-glass thermometer, disposable thermometers, electric thermometers, chemical disposable thermometers, temperature sensitive-tape, and infrared thermometers (Blais, Erb, Kozier &, Wilkinson, 1995).

Although it is the most accurate, mercury-in -glass thermometers can break in the rectum if a child is restless, or if it is bitten in the child mouth (Blais et al., 1995). Some pediatricians do not recommend them at all. Mercury thermometers can also be disposable; they are generally color coded red for rectal, and blue for oral. Mercury-in glass thermometers take the longest to obtain a reading depending on the model: up to seven minutes for an oral temperature, up to four minutes for a rectal temperature, and up to five minutes for an axillary (Whaley & Wong, 1995).

These times vary widely among manufacturers. Electric/battery hand held thermometers can also be disposable, and dependent upon the model can measure temperatures from oral, or rectal routes in as fast as 2-6 seconds (Blais et al., 1995). Chemical disposable thermometers are one time use strips that can be placed in the child’s mouth, rectum, or axilla, with dots that change color for easy reading. These single use thermometers can take one minute in the mouth, three minutes via rectum, and three minutes via axilla to obtain a reading dependent upon the manufacturer (Whaley & Wong, 1995). Temperature–sensitive tape is used, ‘to obtain a general indication of body surface temperature”  (Blais et al., 1995, p. 432).

The tape is placed across the child’s forehead, and is easily used for screening (Whaley & Wong, 1995). This method is the least indicative of core temperature. Dependent upon the brand, some brands take 15 seconds to read. Infrared thermometers are utilized in the tympanic membrane (the ear canal) by measuring, “infrared energy given off by the heat source” (Blais et al., p. 432). Accuracy may be affected in  infants , “because of difficulty with correct placement” (Whaley & Wong, 1995, p. 228).

When could my child have a febrile seizure?

The exact causes of febrile seizures in children has yet to be certain (Whaley & Wong, p. 1728). Whaley & Wong further stated that, “fevers usually exceed 101.8 degrees F, and the seizure occurs during the temperatures rise rather than after a prolonged elevation” (Whaley & Wong, 1995, p. 1728). According to Berg, (1993), ‘In most children the height, but not rapidity, of the temperature elevation seems to be a factor” (Whaley & Wong, p. 1728).

When parents should call their pediatrician immediately?

Modified from Schmitt (1984):

If your child is less than 2 months old and has a fever

Fever is greater than or equal to 105 F

Child cries inconsolably

Child is difficult to arouse from sleep

Child becomes disoriented or confused

If a febrile seizure occurs

If your child complains of a stiff neck

If your child has a purple rash or spots on skin

If your child has difficulty breathing even after nose suctioned or blown

If your child appears very sick

If your child has underlying risk factors i.e.: asthma, HIV, or sickle cell disease

(Schmitt, 1984).

When should you call your pediatrician during regular office hours?

Schmitt (1984) also recommends:

Calling your pediatrician during regular office hours if your child is less than two years old with a fever greater than 104 F

 If there is burning during urination

A fever lasting longer than 72 hours

If the fever has been present for more than 24 hours with out an obvious sign of infection

If the fever disappears and returns longer than 24 hours after it subsided

If the child has a history of febrile seizures

If parents have questions for the pediatrician

(Schmitt, 1984).

Interesting facts about febrile seizures

According to the National Institute of Neurological Disorders and Stroke (NINDS), one in every 25 children has febrile seizures (NINDS, 2001). Of that 25, one third of children may have additional febrile seizures until they have outgrown them (NINDS, 2001). In general it is rare for a febrile seizure to occur in children younger than 6 months old, or older than 3 years old (NINDS, 2001). The NINDS states that, “the older a child is when the first febrile seizure occurs, the less likely that child is to have more” (NINDS 2001, Para. 3).  NINDS  illustrated risk factors for an increase in likelihood of additional febrile seizures if a child has their first febrile seizure at a young age, usually less than 15 months, if seizures begins when temperature is low, or if immediate family members also have a history of febrile seizures (NINDS, 2001).             

What can parents can do to prevent a febrile seizure?

Which ever is recommended by your pediatrician, fever lowering drugs such as Motrin or Tylenol can help to reduce fever, as well as make the child more comfortable. Keeping your child’s clothing light, can also help to lower the temperature, until you can get your child to the pediatrician. Parent’s should never cool your child’s temperature too rapidly, or use alcohol on their skin.  In the event that a high fever is detected prior to febrile seizure has occurred, a wash cloth or sponge with warm water to the child’s skin is recommended without submerging the child in water, in addition to fever lowering agents. The water temperature of the washcloth should be comfortable, to prevent shivering. According to Whaley & Wong, “shivering effect further increases metabolic output, and cooling causes discomfort in the child” (Whaley & Wong, 1995, p. 1729). Parent’s should never leave a young infant or child in a tub of water, if a seizure occurs, the child may inhale bath water (Parkview Health, 2004, Para. 10).

Occasionally, children who are especially prone to febrile seizures may be placed on anticonvulsants or oral or rectal valium during times when fever is present (NINDS, 2001). However, all medications have side affects, and it is up to your pediatrician to make these decisions. Parents should never administer any medications without your pediatrician’s advice.

Your child should be brought as soon as possible to the pediatrician, or emergency department if it is after hours. These steps may or may not prevent a febrile seizure. Every child is different, and has different seizure thresholds.

What to do during a febrile seizure?

I know from my experience that it is hard to keep calm. If  I had been at home when my baby’s first febrile seizure occurred, I would have called 911 immediately because like many mothers, I became hysterical and in shock. According to Parkview Health, seizures usually involve the whole body and may be accompanied by loss of consciousness for up to five minutes” (Parkview Health, 2004, Para. 8). During the seizure it is important to keep the child’s airway open, and maintain adequate ventilation. For children and infants, a side lying position is preferred in case the child vomits, and to increase perfusion. (Whaley & Wong, 1995, p. 1727). Should your child vomit during a seizure, a bulb syringe may be used gently to remove the vomitus. Never place anything in your child’s mouth during a seizure (Parkview Health, 2004). All pacifiers and bottles should be removed from the child’s mouth (Parkview Health, 2004).

 If the seizure lasts more than 5 minutes, or if the child is not breathing once the seizure has subsided call for help immediately by dialing 911, and begin rescue breathing, and CPR if indicated. It is very important to monitor the time the seizure began and ended (Parkview Health, 2004).  

When it’s over?

After the febrile seizure has subsided, and breathing has returned to normal, call your pediatrician immediately. It is normal for the child to fall into a deep sleep during the post-ictal period. If the febrile seizure lasts longer than five minutes, you should call 911 for emergency medical help to bring the child to the hospital immediately.

Only when your child is fully awake, a drink of water may be offered. If fever still persists, check with your pediatrician for directions to medicate with Motrin or Tylenol. A luke warm washcloth to aid in cooling is also recommended to decrease temperature, and prevent shivering. It is also common to have children appear slightly confused following the febrile seizure. It is important to inform your pediatrician how high the child’s temperature was just prior to the seizure, how long the febrile seizure lasted, and its characteristics. You should have your child evaluated by a physician as soon as possible to find the underlying cause of the fever.

 

References

Blais, K. Erb, G. Kozier, B. & Wilkinson, J. M. (1995). Fundamentals of nursing concepts, process, and practice (5th ed.). Redwood City, CA: Addison-Wesley Publishing Company, Inc.

National Institute of Neurological Disorders and Stroke (2001, July 1). Febrile seizures. Retrieved March 29, 2004, from: http://www.ninds.nih.gov

Parkview Health (2004, January). Children's Health. Retrieved March 28, 2004, from: http://www.parkview.com