American Academy of Pediatrics Guidelines for Febrile Seizures
The AAP strongly recommends against routine anticonvulsant prophylaxis (neither continuous nor intermittent therapy) for children with simple febrile seizures, as the potential toxicities of these medications outweigh the minimal risks associated with these benign, self-limited events. 1
Definition and Classification
Simple febrile seizures are defined by the AAP as brief (<15 minutes), generalized seizures occurring once in a 24-hour period in febrile children aged 6-60 months without intracranial infection, metabolic disturbance, or history of afebrile seizures. 1
Complex febrile seizures are prolonged (>15 minutes), focal, or occur more than once within 24 hours. 1
Key Epidemiologic Facts
- Febrile seizures affect 2-5% of children, making them the most common childhood seizure disorder. 1, 2
- Recurrence rate is approximately 30% overall, with higher rates (up to 50%) in children under 12 months of age. 2, 3
- The risk of developing epilepsy is extremely low, though slightly higher than the general population, and is likely due to genetic predisposition rather than structural brain damage from febrile seizures. 1
Acute Management Recommendations
During the Seizure
- Place the child in the recovery position to prevent aspiration and clear the surrounding area to prevent injury. 2, 3
- Never restrain the child or place anything in their mouth. 2, 3
- Most febrile seizures are self-limited and resolve spontaneously within 1-2 minutes. 2
When to Activate Emergency Services
Emergency medical services should be called for: 2, 3
- First-time seizures
- Seizures in children under 6 months of age
- Seizures lasting >5 minutes
- Multiple seizures without return to baseline consciousness
- Seizures with traumatic injury, breathing difficulties, or choking
Pharmacologic Intervention for Prolonged Seizures
For seizures lasting more than 5 minutes, benzodiazepines should be administered: 2
- IV lorazepam or diazepam (lorazepam preferred) when IV access is available
- Rectal diazepam when IV access is not available
- IM diazepam should be avoided due to erratic absorption 2
Long-Term Management: The Core AAP Recommendation
Anticonvulsant Prophylaxis: NOT Recommended
The AAP explicitly recommends against both continuous and intermittent anticonvulsant therapy for children with one or more simple febrile seizures. 1 This recommendation is based on aggregate evidence quality B (randomized controlled trials with minor limitations). 1
Why Prophylaxis Is Not Recommended
The harm-benefit analysis clearly favors no treatment: 1
Benefits of anticonvulsant therapy:
- Prevention of recurrent febrile seizures, which themselves are not harmful and do not significantly increase the risk of future epilepsy 1
Harms of anticonvulsant therapy:
- Valproic acid: Rare fatal hepatotoxicity (especially in children <2 years who are at greatest risk of febrile seizures), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis 1
- Phenobarbital: Hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions 1
- Intermittent diazepam: Lethargy, drowsiness, ataxia, and risk of masking an evolving CNS infection 1
Evidence for Efficacy (But Still Not Recommended)
While continuous therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with diazepam are effective in reducing febrile seizure recurrence, the AAP determined that this benefit does not justify the risks. 1 Phenobarbital reduced recurrence from 25 per 100 subjects per year to 5 per 100 subjects per year in controlled trials, but only when therapeutic levels were maintained with good compliance. 1
Antipyretic Therapy: Ineffective for Prevention
Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they may improve comfort during febrile illness. 1, 2, 3 The AAP reviewed this specifically and found no evidence supporting antipyretics for seizure prevention. 1
Diagnostic Evaluation
For children with simple febrile seizures who are well-appearing, routine diagnostic testing is not required (no laboratory tests, neuroimaging, or electroencephalography), except as indicated to identify the source of fever. 4
For complex febrile seizures, the neurologic examination should guide further evaluation. 4
Parent Education and Counseling
The AAP emphasizes the importance of educating caregivers about: 1, 3
- The benign nature of simple febrile seizures: They do not cause brain damage, affect intelligence, or lead to learning disabilities 3
- Excellent prognosis: No long-term adverse effects have been identified except for recurrence risk 1
- Recurrence risk: Approximately 30% overall, higher in younger children and those with family history 2, 3
- Practical home management: Recovery position, clearing the area, when to call emergency services 2, 3
Critical Pitfalls to Avoid
Do not prescribe prophylactic anticonvulsants for simple febrile seizures – the AAP guideline is unequivocal on this point, as the risks outweigh benefits. 1
Do not recommend antipyretics for seizure prevention – while they may provide comfort, they have no effect on seizure recurrence. 1, 2
Do not use IM diazepam for acute seizure management – absorption is erratic; use IV or rectal routes instead. 2
Do not confuse simple with complex febrile seizures – the AAP guidelines apply specifically to simple febrile seizures in neurologically normal children. 1
Expected Outcomes of Following AAP Guidelines
The AAP identified four key outcomes: 1
- Optimizing practitioner understanding of the scientific basis for avoiding proposed treatments
- Improving child health by avoiding therapies with high potential for adverse effects and no demonstrated ability to improve long-term outcomes
- Reducing costs by avoiding ineffective therapies
- Helping practitioners educate caregivers about the low risks associated with simple febrile seizures