What is the treatment and management of neonatal and pediatric febrile seizures?

Treatment and Management of Neonatal and Pediatric Febrile Seizures

Neither continuous nor intermittent anticonvulsant therapy is recommended for children with simple febrile seizures, as the potential toxicities of these medications outweigh the minimal risks associated with febrile seizures. 1, 2

Definition and Classification

• Febrile seizures: Most common seizure disorder in childhood, affecting 2-5% of children
  • Peak age: 14-18 months
  • 97% occur in children under 4 years of age 2
  • Classified as:
    • Simple febrile seizures (~70%): Generalized, lasting <15 minutes, no recurrence within 24 hours
    • Complex febrile seizures (~30%): Focal, prolonged (≥15 minutes), or recurrent within 24 hours 2, 3

Acute Management of Febrile Seizures

1. For ongoing seizures:

   • Position child on their side in recovery position
   • Clear area to prevent injury
   • Do not restrain or put anything in the child's mouth
   • Monitor until fully recovered 2

2. For prolonged seizures (>5 minutes):

   • Administer benzodiazepine (lorazepam IV is commonly used) 4, 3
   • Ensure patent airway and monitor respiration closely
   • Be prepared for potential respiratory depression with lorazepam 4
   • Have ventilatory support equipment available 4

3. Emergency situations requiring immediate medical attention:

   • Seizures lasting >5 minutes
   • Seizures in infants <6 months
   • Multiple seizures without return to baseline
   • Seizures with respiratory distress 2

Diagnostic Evaluation

• For simple febrile seizures in well-appearing children:

  • No routine diagnostic testing (laboratory tests, neuroimaging, or electroencephalography) is recommended 2, 3
  • Focus on identifying the source of fever

• For complex febrile seizures:

  • Neurological examination should guide further evaluation
  • Consider lumbar puncture if meningitis is suspected, especially in:
    • Children <12 months
    • Children with persistent altered mental status
    • Children with meningeal signs 5, 3
  • Neuroimaging may be considered in selected cases of complex febrile seizures 2

Long-term Management

1. Prophylactic treatment:

   • Antipyretics (acetaminophen, ibuprofen) are ineffective in preventing recurrence of febrile seizures 2, 5, 3
   • Continuous anticonvulsant therapy with phenobarbital or valproic acid is not recommended despite effectiveness in reducing recurrence risk 1, 6
   • Intermittent diazepam therapy is not recommended despite some effectiveness 1, 6
   • Rectal acetaminophen may reduce short-term recurrence following a febrile seizure 3

2. Parent education:

   • Explain the benign nature and excellent prognosis
   • Provide guidance on home management of seizures
   • Reassure that febrile seizures do not cause brain damage, learning problems, or developmental delays 2, 3

Prognosis

• Risk of recurrence:

  • 30-50% chance of recurrence after first simple febrile seizure 1, 2
  • Higher risk if first seizure occurs at <12 months of age 1

• Risk of epilepsy:

  • Children with simple febrile seizures: ~1% (similar to general population) 2, 6
  • Children with complex febrile seizures: Up to 22% depending on complex features present 2

• Long-term outcomes:

  • No evidence of decline in IQ, academic performance, or neurocognitive function
  • No evidence that febrile seizures produce structural CNS damage 2, 6

Common Pitfalls and Caveats

1. Overtreatment: Avoid routine use of anticonvulsants due to adverse effects that outweigh the minimal risks of febrile seizures 1, 2

2. Overlooking meningitis: Always consider meningitis in the differential diagnosis, especially in infants or those with atypical presentations 5

3. Parental anxiety: Failure to adequately educate and reassure parents about the benign nature of febrile seizures can lead to unnecessary anxiety and healthcare utilization 3

4. Respiratory depression: When using benzodiazepines for prolonged seizures, be vigilant for respiratory depression, especially in heavily sedated patients 4

5. Overinvestigation: Children with simple febrile seizures are often over-investigated and over-treated 5