What are the recent guidelines for managing febrile seizures in infants?

Management of Febrile Seizures in Infants

For infants under 12 months presenting with a febrile seizure, lumbar puncture should almost always be performed to exclude meningitis, as clinical signs may be unreliable in this age group. 1, 2, 3

Immediate Assessment and Acute Management

During the Seizure

• Place the child in a recovery position to prevent aspiration and clear the surrounding area to prevent injury 4
• Do not restrain the child or place anything in their mouth 4
• Measure blood glucose immediately if the child is actively convulsing or unrousable 3

When to Activate Emergency Services

• First-time seizure, seizure in a child under 6 months, seizure lasting more than 5 minutes, repeated seizures without return to baseline, or seizure with traumatic injury or respiratory difficulty 4

Diagnostic Evaluation: The Critical Decision About Lumbar Puncture

Age-Based Approach

Infants < 12 months:

• Lumbar puncture is almost always indicated to rule out meningitis 1, 2, 3
• The risk of bacterial meningitis presenting as febrile seizure is approximately 1.9%, which is clinically significant in this vulnerable age group 5
• Clinical signs of meningitis are unreliable and often absent in this age group 5, 6

Children 12-18 months:

• Lumbar puncture should probably be performed, though the indication is less absolute than in younger infants 1
• Recent evidence suggests the risk of bacterial meningitis is very low (approaching zero) in this age group with simple febrile seizures 7

Additional Indications for Lumbar Puncture (Any Age)

• Clinical signs of meningism (neck stiffness, bulging fontanel) 1, 3
• Complex febrile seizure (prolonged >15 minutes, focal features, or multiple seizures in 24 hours) 1, 5
• Child is excessively drowsy, irritable, or systemically ill 1, 3
• Prolonged symptoms or incomplete recovery after one hour 1, 3
• Prior antibiotic treatment (may mask meningitis symptoms) 5, 8
• Incomplete vaccination status for Haemophilus influenzae type b or Streptococcus pneumoniae 8

Important Caveat About Lumbar Puncture

• A comatose child must be examined by an experienced physician before lumbar puncture due to risk of herniation 1
• Brain imaging may be necessary before lumbar puncture in such cases 1
• If deciding not to perform lumbar puncture, the physician must be prepared to reassess within a few hours 1

What NOT to Do: Avoiding Unnecessary Testing

The following tests should NOT be routinely performed for simple febrile seizures: 1, 3

• Electroencephalography (EEG) - not a guide to treatment or prognosis 1
• Blood urea and serum electrolyte estimations 1
• Serum calcium estimation 1
• Neuroimaging (CT or MRI) - only indicated for complex seizures or if structural abnormality suspected 1

Fever Management

• Treat fever with paracetamol (acetaminophen) to promote comfort and prevent dehydration 1, 2
• Physical methods such as fanning, cold bathing, and tepid sponging are not recommended as they cause discomfort 1
• Ensure adequate fluid intake 1
• Important limitation: No evidence exists that antipyretic treatment prevents recurrence of febrile seizures 1

Long-Term Management and Anticonvulsant Therapy

Continuous or intermittent anticonvulsant therapy is NOT recommended for children with simple febrile seizures. 1, 2, 4

The rationale is straightforward:

• The risks of anticonvulsant medications (behavioral effects, sedation, hepatotoxicity) outweigh any potential benefits 1
• No study has demonstrated that treating simple febrile seizures prevents later development of epilepsy 1
• Simple febrile seizures do not cause structural brain damage 1

Exception: Rectal Diazepam

• Some pediatricians advise rectal diazepam for use at seizure onset, though this is not universally recommended 1
• Parents should receive clear instructions if this approach is chosen 1

Prognosis and Parent Counseling

Excellent Overall Prognosis

• The prognosis for developmental and neurological impairment is excellent 1, 3
• Simple febrile seizures do not cause brain damage, affect intelligence, or lead to learning disabilities 1, 4

Risk of Epilepsy

• After a single simple febrile seizure, the risk of developing epilepsy by age 7 is approximately 1% (same as general population) 1, 2, 3
• Risk increases to 2.4% by age 25 in children with multiple risk factors: multiple simple febrile seizures, age <12 months at first seizure, and family history of epilepsy 1

Risk of Recurrence

• Infants <12 months: approximately 50% probability of recurrent febrile seizures 1, 2, 4
• Children >12 months: approximately 30% probability of second febrile seizure 1, 2, 4
• Of those with a second seizure, 50% will have at least one additional recurrence 1
• Family history of febrile seizures in first-degree relative increases recurrence risk to nearly 50% 1

Critical Pitfalls to Avoid

• Do not dismiss the need for lumbar puncture in infants <12 months based solely on a "simple" seizure presentation - meningitis can present with seizures as the only sign in one-sixth of cases, and one-third of these lack meningeal signs 6
• Do not delay lumbar puncture if clinically indicated - bacterial meningitis can result in serious neurologic morbidity and death if diagnosis is delayed 5, 6
• Do not perform unnecessary investigations (EEG, extensive metabolic panels) in straightforward simple febrile seizure cases 1, 3
• Do not prescribe continuous anticonvulsant therapy - the risks outweigh benefits for simple febrile seizures 1, 2, 4

Documentation Requirements

The medical record should contain: 1

• Accurate description of the convulsion (duration, focal vs. generalized, number of episodes)
• Family history of febrile and non-febrile seizures
• Age at first seizure
• Temperature on presentation
• Presence or absence of meningeal signs
• Assessment of fever source
• Child's neurodevelopmental state when recovered
• Blood glucose concentration if measured during seizure
• Clear documentation of decision-making regarding lumbar puncture