What is the management of febrile seizures in children?

Management of Febrile Seizures in Children

Neither continuous nor intermittent anticonvulsant therapy is recommended for children with simple febrile seizures due to the potential toxicities outweighing the relatively minor risks associated with these seizures. 1

Definition and Classification

• Febrile seizures are seizures occurring in children between 6 and 60 months of age with fever (≥38.0°C), without intracranial infection, metabolic disturbance, or history of afebrile seizures 1, 2
• They are classified into two types:
  • Simple febrile seizures: last <15 minutes, generalized, occur once in 24 hours 1, 2
  • Complex febrile seizures: last >15 minutes, focal, or occur more than once in 24 hours 1, 2

Epidemiology and Risk Factors

• Febrile seizures affect 2-5% of children, with peak incidence around 18 months of age 1, 3
• Risk factors for recurrence include:
  • Age <12 months at first seizure (50% recurrence risk) 1, 2
  • Children >12 months have approximately 30% recurrence risk 1
  • Family history of epilepsy 1
  • Multiple febrile seizures 1

Evaluation

• For simple febrile seizures in well-appearing children, routine diagnostic testing (laboratory tests, neuroimaging, or EEG) is not required 4
• Lumbar puncture is indicated in:
  • Children <12 months of age to rule out meningitis 2
  • Presence of meningeal signs 2
  • Complex febrile seizures 2
  • Children who are excessively somnolent, irritable, or systemically ill 2
  • Prolonged seizures or incomplete recovery after one hour 2

Acute Management

• For seizures lasting >5 minutes, administer a benzodiazepine 4
• For home management of prolonged seizures, rectal diazepam solution can be effective when administered by parents 5

Long-term Management

• Antipyretics (preferably acetaminophen) should be used to promote comfort and prevent dehydration, but they do not prevent recurrent febrile seizures 2, 4
• Continuous anticonvulsant therapy with phenobarbital, primidone, or valproic acid is effective in reducing recurrence but is NOT recommended due to:
  • Potential adverse effects including fatal hepatotoxicity (especially in children <2 years), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis with valproic acid 1
  • Hyperactivity, irritability, lethargy, sleep disturbances with phenobarbital 1
  • The benign nature of febrile seizures does not justify these risks 1
• Intermittent diazepam therapy can reduce recurrence but is also NOT recommended due to:
  • Side effects including lethargy, drowsiness, and ataxia 1
  • Risk of masking evolving central nervous system infections 1

Prognosis

• Simple febrile seizures have excellent long-term outcomes with:
  • No decline in IQ, academic performance, or behavior 1
  • No evidence of structural brain damage 1
  • Risk of developing epilepsy by age 7 is approximately 1% (similar to general population) 1
  • Children with multiple simple febrile seizures, first seizure <12 months, and family history of epilepsy have slightly higher risk (2.4%) of developing epilepsy by age 25 1
• No reported cases of death from simple febrile seizures 1

Parent Education

• Reassure parents about the benign nature and excellent prognosis of febrile seizures 4, 3
• Educate on seizure first aid and when to seek emergency care 4
• Explain that prophylactic treatment does not improve long-term outcomes 1, 5

Key Recommendations

• The American Academy of Pediatrics strongly recommends against continuous or intermittent anticonvulsant therapy for children with one or more simple febrile seizures 1
• Treatment should focus on the underlying cause of fever rather than seizure prevention 3
• The benefits of preventing recurrence with anticonvulsants do not outweigh the risks of medication side effects 1, 5