What is the approach to managing a second febrile seizure in an 18-month-old child?

Management of a Second Febrile Seizure in an 18-Month-Old Child

For an 18-month-old child with a second febrile seizure, a lumbar puncture should be performed to rule out meningitis, as children under 18 months are at higher risk for central nervous system infections that may present with seizures and fever. 1

Initial Evaluation

When evaluating a child with a second febrile seizure, follow this approach:

1. Assess for signs of meningitis or encephalitis:

   • Look for neck stiffness, excessive irritability, lethargy, or altered mental status
   • If present, immediate lumbar puncture is indicated

2. Determine if the seizure was simple or complex:

   • Simple: <15 minutes, generalized, single episode in 24 hours
   • Complex: >15 minutes, focal features, or multiple episodes within 24 hours

3. Check vital signs and assess hydration status:

   • Ensure adequate fluid intake to prevent dehydration
   • Measure temperature and treat fever for comfort

4. Measure blood glucose with glucose oxidase strip if the child is still convulsing or unrousable 1

Diagnostic Testing

• Lumbar puncture: Indicated for 18-month-old children with febrile seizures 1
• Neuroimaging: Not routinely indicated for simple febrile seizures 1
• Electroencephalography (EEG): Not recommended after simple febrile seizures as it does not guide treatment or prognosis 1
• Blood tests: Not routinely necessary beyond glucose measurement if indicated 1

Treatment Approach

Acute Management

• If seizure is ongoing and lasts more than 5 minutes, administer a benzodiazepine 2
• Rectal diazepam solution is effective for acute treatment of prolonged seizures 3

Long-term Management

• Antipyretic therapy:

  • Use paracetamol (acetaminophen) for fever control and comfort 1
  • Avoid physical cooling methods like cold bathing or tepid sponging 1
  • Note that antipyretics alone do not prevent recurrence of febrile seizures 1, 4

• Anticonvulsant therapy:

  • Continuous anticonvulsant therapy is not recommended for simple febrile seizures due to potential toxicities that outweigh the relatively minor risks of recurrent seizures 1
  • Intermittent diazepam may be considered only in highly selected cases with multiple risk factors 3

Parent Education

Provide parents with:

• Explanation of febrile seizures and their benign nature
• Instructions on fever management
• Reassurance about excellent long-term prognosis 1, 2
• Information about the risk of recurrence (approximately 30-50% in children under 12 months at first seizure) 1

Prognosis

• Febrile seizures have an excellent prognosis with no long-term effects on development, intellect, or behavior 1, 2
• Risk of developing epilepsy is approximately 2.5% after simple febrile seizures (compared to 1% in general population) 1
• Risk of recurrence is higher in children who had their first seizure before 12 months of age (50%) compared to those who had it after 12 months (30%) 1

Follow-up

• Schedule follow-up to assess neurological development
• Consider referral to pediatric neurology if:
  • Complex febrile seizures occur
  • Multiple recurrences happen
  • There is family history of epilepsy
  • Developmental concerns arise

Common Pitfalls to Avoid

• Overinvestigation: Avoid unnecessary neuroimaging and EEG for simple febrile seizures
• Overtreatment: Avoid routine use of anticonvulsants for prophylaxis
• Underdiagnosis of meningitis: Remember that children under 18 months require careful evaluation for meningitis
• Inadequate parent education: Failure to provide clear instructions about home management and when to seek emergency care