What is the immediate management for a child experiencing a febrile seizure?

Immediate Management of Febrile Seizures

Place the child in a recovery position to prevent aspiration, clear the surrounding area to prevent injury, and do not restrain the child or place anything in their mouth—most febrile seizures are self-limiting and will resolve spontaneously. 1

During the Seizure

• Position the child on their side (recovery position) to maintain airway patency and prevent aspiration of secretions 1
• Clear the immediate environment of hard objects or furniture that could cause injury during the convulsive episode 1
• Do not attempt to restrain the child's movements or hold them down, as this provides no benefit and may cause injury 1
• Never place anything in the child's mouth (fingers, spoons, tongue depressors), as this can cause airway obstruction or dental trauma 1
• Time the seizure duration carefully, as management changes significantly if the seizure exceeds 5 minutes 1, 2

When to Activate Emergency Services

Call emergency services immediately if: 1

• This is a first-time seizure (requires evaluation to confirm diagnosis)
• The child is under 6 months of age (febrile seizures are not typical in this age group)
• The seizure lasts more than 5 minutes (requires benzodiazepine administration) 2
• Repeated seizures occur without the child returning to baseline consciousness between episodes
• The seizure is associated with traumatic injury or respiratory difficulty 1

Acute Seizure Termination (If Seizure >5 Minutes)

• Administer a benzodiazepine for any seizure lasting more than 5 minutes to prevent progression to status epilepticus 2
• This represents a medical emergency requiring immediate intervention, as prolonged seizures carry higher risk of complications

Post-Seizure Assessment

After the seizure terminates, focus on identifying the fever source and determining if further evaluation is needed:

• Assess for signs of meningitis or sepsis: meningismus, altered mental status beyond expected post-ictal period, petechial rash, hemodynamic instability 3
• Evaluate seizure characteristics: Was it generalized or focal? Duration? Single episode or multiple within 24 hours? 4
• Consider lumbar puncture indications (see below)

Lumbar Puncture Decision-Making

The decision for lumbar puncture should be based on clinical presentation, not age alone:

• Mandatory lumbar puncture: Any child with meningeal signs, septic appearance, or persistent behavioral disturbance 3
• Consider lumbar puncture: Focal seizure or repetitive seizures within 24 hours WITHOUT clear meningitis signs—decision based on clinical judgment and evolution over time 3
• Lumbar puncture NOT necessary: Simple febrile seizure (generalized, <15 minutes, single episode) without meningeal signs, even in infants 6-12 months old 3
• Early reassessment (at least 4 hours after initial evaluation) is particularly helpful in infants under 12 months to monitor clinical evolution 3

This represents an important shift from older guidelines that routinely recommended lumbar puncture in all infants under 12 months—current evidence supports clinical judgment over age-based protocols 3.

Fever Management

• Treat fever with acetaminophen to promote comfort and prevent dehydration 5
• Note that antipyretics do not prevent febrile seizure recurrence in general, though rectal acetaminophen may reduce short-term recurrence risk immediately following a seizure 2

What NOT to Do

• Do not initiate continuous anticonvulsant therapy (phenobarbital, valproic acid) for simple febrile seizures—the American Academy of Pediatrics strongly recommends against this due to potential adverse effects including fatal hepatotoxicity and thrombocytopenia without improvement in long-term outcomes 4, 1
• Do not perform routine diagnostic testing (EEG, neuroimaging, laboratory studies) in well-appearing children with simple febrile seizures 2

Parent Education and Reassurance

Provide immediate counseling to address parental anxiety:

• Febrile seizures are benign and do not cause brain damage, affect intelligence, or lead to learning disabilities 1
• Recurrence risk is approximately 30% overall (50% if first seizure occurs before 12 months of age) 1, 5
• Risk of developing epilepsy is only 1% by age 7, similar to the general population 4
• No long-term cognitive or behavioral effects occur from simple febrile seizures 4