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 Active Seizure

• Position the child on their side (recovery position) to maintain airway patency and prevent aspiration of secretions 1
• Remove nearby objects that could cause injury during the convulsive movements 1
• Never attempt to restrain the child or hold them down during the seizure 1
• Never place anything in the child's mouth, including fingers, spoons, or bite blocks—this can cause injury and does not prevent tongue biting 1
• Time the seizure duration from onset, as this determines subsequent management decisions 1

When to Administer Emergency Medication

• For seizures lasting more than 5 minutes, administer a benzodiazepine to terminate the seizure 2
• Most febrile seizures are brief and self-limiting, resolving within 1-2 minutes without intervention 1

When to Activate Emergency Services

Call emergency services immediately if: 1

• This is a first-time seizure in the child
• The child is under 6 months of age
• The seizure lasts more than 5 minutes
• Repeated seizures occur without the child returning to baseline consciousness between episodes
• The seizure is associated with traumatic injury or respiratory difficulty

Post-Seizure Assessment

• After the seizure stops, assess the child's level of consciousness and neurological status 3
• Look for signs of meningitis: neck stiffness, altered behavior, bulging fontanelle, septic appearance 3
• Identify the source of fever to guide appropriate treatment 2
• Observe for focal neurological findings that would classify this as a complex febrile seizure 4

Lumbar Puncture Indications

A lumbar puncture is required when: 3

• The child has meningitis symptoms (neck stiffness, bulging fontanelle)
• Septic signs are present
• Behavior disturbance or altered consciousness persists

A lumbar puncture should be discussed based on clinical progression when: 3

• The seizure was focal in nature
• Repetitive seizures occurred within 24 hours
• Clinical symptoms are evolving, particularly in infants under 12 months

A lumbar puncture is NOT necessary for: 3

• Simple febrile seizures (generalized, lasting <15 minutes, single episode in 24 hours) without meningeal signs
• This applies even to infants between 6-12 months of age with simple febrile seizures 3

Common Pitfalls to Avoid

• Do not delay antibiotics if bacterial meningitis is suspected—administer IV ceftriaxone immediately without waiting for lumbar puncture or imaging 5
• Do not assume the seizure is benign in children under 6 months—this falls outside the typical age range for febrile seizures and requires thorough evaluation 1
• Do not routinely order laboratory tests, neuroimaging, or EEG for well-appearing children with simple febrile seizures 2
• Consider early re-evaluation (at least 4 hours after initial assessment), particularly in infants younger than 12 months, to monitor for evolving signs of serious infection 3

Parent Education and Reassurance

• Reassure parents that simple febrile seizures are benign, affect 2-5% of children, and do not cause brain damage, affect intelligence, or lead to learning disabilities 1
• The risk of recurrence is approximately 30% overall, increasing to 50% in children under 12 months of age 1
• Simple febrile seizures do not increase the risk of epilepsy beyond the general population risk of approximately 1% 4
• Teach parents home seizure management and when to seek emergency care 2