From the Guidelines
Referral to a pediatric neurologist and consideration of antiepileptic medications for febrile seizures in 3-4 year olds should be based on specific risk factors rather than routine practice, as most febrile seizures do not require neurological referral or antiepileptic treatment. The decision to refer or initiate antiepileptics should prioritize the child's morbidity, mortality, and quality of life outcomes. According to the most recent and highest quality study 1, emergent neuroimaging is not recommended for simple febrile seizures, and advanced imaging may often be deferred to outpatient or nonurgent settings in the absence of high-risk historical or clinical examination findings.
Some key factors to consider when deciding to refer to pediatric neurology include:
- Complex febrile seizures (lasting >15 minutes, focal features, or multiple seizures within 24 hours)
- More than 2-3 febrile seizures total
- Seizures occurring less than 6 months apart
- Developmental delays
- Abnormal neurological exam
- Family history of epilepsy
Continuous antiepileptic therapy is rarely indicated for simple febrile seizures due to the benign nature of the condition and potential medication side effects. For children with frequent or prolonged febrile seizures, intermittent rescue therapy with rectal diazepam (0.5 mg/kg) or buccal midazolam (0.2-0.5 mg/kg) may be prescribed for seizures lasting more than 5 minutes, as suggested by previous guidelines 1. Parent education about febrile seizure management, including first aid measures and when to seek emergency care, is essential regardless of seizure frequency or characteristics.
From the Research
Referral to Pediatric Neurology
- A child with febrile seizures should be referred to pediatric neurology if there is a suspicion of epilepsy, as indicated by a complex febrile seizure or a history of afebrile seizures 2.
- Referral to pediatric neurology is also recommended if the child has a history of central nervous system infection or abnormality, or if the seizure is accompanied by other concerning symptoms such as meningitis 3.
Initiation of Antiepileptics
- Antiepileptic medication is usually initiated after the second epileptic seizure, and the choice of medication depends on the type of seizure and epilepsy classification 2.
- Continuous preventative antiepileptic therapy is not recommended for the prevention of recurrent febrile seizures, as the risks and potential side effects of these medications outweigh the benefits 4, 5.
- Intermittent anticonvulsant therapy, such as diazepam, may be considered in some cases, but the decision to use these medications should be made on a case-by-case basis, taking into account the potential benefits and risks 5.
Factors to Consider
- The risk of recurrence of febrile seizures is high, with approximately 30-40% of children experiencing a recurrence during early childhood 3.
- The prognosis for children with febrile seizures is generally favorable, as the condition is usually benign and self-limiting 3.
- Antipyretics, such as acetaminophen or ibuprofen, have no role in the prevention of febrile seizures, and their use should be limited to treating fever and discomfort 4, 5.