Pre-referral guidelines for primary care providers

Seizures are common presentations in childhood and can occur at any age. The following definitions need to be considered when dealing with seizures:

  • Afebrile seizure is an undifferentiated convulsion in the absence of fever, which may be generalised or partial (focal).
  • Febrile convulsion is a convulsion in the presence of fever (> 38 degrees) - refer to the febrile convulsion pre-referral page
  • Epilepsy is the term given to recurrent afebrile seizures that are not explained by another cause (e.g. hypoglycaemia, electrolyte abnormality, seizure 'mimics')

For the diagnosis and management of afebrile seizures, please refer to the Royal Children’s Hospital clinical practice guidelines.

Practice Points

  • Afebrile seizures do not represent an emergency if they stop within 5-10 minutes.
  • Defining the type and character of afebrile seizures is important for triaging urgency of referral to paediatric services
    • focal vs. generalised, timeframe, frequency of episodes, associated features, triggers
  • Blank staring episodes are a very common presentation in children, especially those with autism spectrum disorders, and often do not represent absence ('petit mal') epilepsy
  • Consider seizure 'mimics' when presented with a possible afebrile seizure, e.g.:
    • breath-holding episodes ('blue' or 'pallid', often emotional trigger)
    • syncope (esp. adolescents, often a trigger, may have atypical movements, no post-ictal phase)
    • infantile masturbation (esp. <3yo, repetitive stereotypies, no LOC)
    • pseudoseizures (esp. adolescents, not usu. loss of continence, normal pupils)
  • Neuroimaging is not generally required in well children who have generalised seizures with a normal clinical examination.
  • Clinical history is often more valuable than an EEG, and a normal EEG does not preclude epilepsy.

Referral pathways

  • Paediatrician
    • Refer any acute seizures requiring immediate management (i.e. persistent convulsion or prolonged altered consciousness) to the Emergency Department.
    • Referral to paediatric outpatient services is recommended for any children with an unexplained afebrile seizure
    • Early discussion with paediatric services is encouraged for the following:
      • infants
      • developmental delay
      • persistent neurological findings or incomplete recovery
  • EEG
    • Referral for EEG is generally undertaken after discussion with or review by paediatric services.
  • Neurologist
    • Onward referral to neurology services can be considered after consultation with a general paediatric service.
  • Other resources