How to manage an 18-month-old with fever and focal seizure?

Management of an 18-Month-Old with Fever and Focal Seizure

The immediate management of this 18-month-old with a focal febrile seizure should include antipyretic therapy with acetaminophen, assessment for signs of meningitis or serious infection, and consideration for lumbar puncture given the focal nature of the seizure. 1, 2

Initial Assessment and Stabilization

1. Airway, Breathing, Circulation

   • Ensure patent airway
   • Monitor oxygen saturation with continuous pulse oximetry
   • Check vital signs including temperature, heart rate, respiratory rate, and blood pressure

2. Seizure Management

   • If seizure is ongoing (>5 minutes):
     • Administer IV lorazepam 0.1 mg/kg (maximum 4 mg) 2, 3
     • Have equipment for airway management immediately available 3
   • If seizure persists after initial benzodiazepine:
     • Consider second-line agents such as phenytoin/fosphenytoin (18-20 mg/kg IV) or phenobarbital (10-20 mg/kg IV) 2

3. Fever Management

   • Administer acetaminophen for fever control
   • Ensure adequate hydration
   • Avoid physical cooling methods like cold bathing or tepid sponging 1, 2

Diagnostic Evaluation

This patient has a complex febrile seizure (focal seizure with impaired awareness), which requires more thorough evaluation:

1. Laboratory Studies

   • Blood glucose measurement (immediate if still seizing or unresponsive) 1, 2
   • Consider CBC, electrolytes, and blood culture if clinically indicated to identify source of fever

2. Infection Assessment

   • Thorough examination for source of infection
   • Lumbar puncture consideration: Given the focal nature of the seizure, a lumbar puncture should be strongly considered to rule out meningitis, especially if there are any signs of meningitis, sepsis, or altered behavior 1, 2, 4

3. Neuroimaging

   • Consider neuroimaging (CT or MRI) if:
     • Persistent altered mental status
     • Focal neurological deficits
     • Concern for increased intracranial pressure 1, 2

4. EEG

   • Routine EEG is not recommended after a first febrile seizure 1, 5

Hospitalization Criteria

Consider hospital admission if:

• First complex febrile seizure
• Age <18 months with focal seizure
• Incomplete recovery after 1 hour
• Signs of serious infection or dehydration
• Parental anxiety that cannot be adequately addressed 1, 2

Discharge Planning and Follow-up

If the child recovers completely and diagnostic evaluation is reassuring:

1. Parent Education

   • Explain the nature of febrile seizures and their generally benign prognosis
   • Discuss the risk of recurrence (approximately 30-50% with risk factors including young age at first seizure and family history) 1, 2
   • Provide instructions on fever management and seizure first aid

2. Rescue Medication Consideration

   • Consider prescribing rectal diazepam for home use if high risk of recurrent prolonged seizures (age <12 months, previous prolonged seizure, or focal seizure) 2, 4

3. Follow-up

   • Arrange follow-up with primary care physician
   • Consider neurology referral given the focal nature of the seizure 4

Prognosis

• The risk of developing epilepsy after a complex febrile seizure is higher than with simple febrile seizures but still relatively low (approximately 2.5-10%) 1
• Focal seizures are associated with a slightly higher risk of subsequent epilepsy, but most children will not develop epilepsy 6, 5
• Long-term anticonvulsant therapy is not recommended as the potential toxicities outweigh the risks associated with febrile seizures 1

Common Pitfalls to Avoid

• Failing to recognize a complex febrile seizure (focal, prolonged, or multiple seizures within 24 hours)
• Missing signs of meningitis or encephalitis
• Overuse of diagnostic tests in well-appearing children with simple febrile seizures
• Prescribing long-term anticonvulsant therapy, which is not recommended for febrile seizures 1, 2
• Underestimating parental anxiety and need for education about febrile seizures