What is the management for a 2-year-old experiencing a febrile seizure?

Management of Febrile Seizures in a 2-Year-Old

For a 2-year-old experiencing a febrile seizure, immediately place the child in the recovery position to prevent aspiration, clear the surrounding area to prevent injury, and do not restrain the child or place anything in their mouth. 1, 2

Immediate Acute Management

During the Seizure

• Position the child on their side (recovery position) to maintain airway patency and prevent aspiration 1, 2
• Remove nearby objects that could cause injury during the convulsive movements 1
• Never attempt to restrain the child or insert anything into their mouth during the seizure 1, 2
• Most febrile seizures are self-limited and resolve spontaneously within 1-2 minutes without intervention 1

When to Call Emergency Services

• Activate emergency medical services if this is the child's first seizure, the seizure lasts more than 5 minutes, multiple seizures occur without return to baseline consciousness, or if there is traumatic injury, breathing difficulty, or choking 1, 2
• For seizures lasting more than 5 minutes, benzodiazepine administration is indicated 3
• When IV access is available, administer IV lorazepam (preferred) or IV diazepam; when IV access is unavailable, use rectal diazepam 1

Post-Seizure Evaluation

Diagnostic Workup

• For well-appearing children with simple febrile seizures (brief, generalized, single episode in 24 hours), routine diagnostic testing including lumbar puncture, neuroimaging, or EEG is NOT required 1, 4, 3
• Diagnostic evaluation should focus solely on identifying the source of fever (e.g., otitis media, viral illness) 1, 3
• Lumbar puncture is mandatory only if meningitis symptoms are present (altered mental status, meningeal signs, septic appearance) 5
• For complex febrile seizures (>15 minutes, focal features, or multiple within 24 hours), the neurological examination should guide further evaluation 3

Critical Pitfall to Avoid

• Do not perform routine lumbar puncture in well-appearing children with simple febrile seizures, even in infants 6-12 months old, unless clinical signs suggest meningitis 5
• Early clinical reassessment (at least 4 hours after initial evaluation) can be helpful, particularly in infants under 12 months 5

Long-Term Management

Anticonvulsant Prophylaxis

• The American Academy of Pediatrics explicitly recommends AGAINST both continuous and intermittent anticonvulsant therapy for children with simple febrile seizures 1, 2, 4
• This recommendation is based on high-quality evidence showing that potential harms (valproic acid's fatal hepatotoxicity, phenobarbital's hyperactivity and irritability, diazepam's lethargy and risk of masking evolving CNS infection) clearly outweigh benefits 1
• Even for recurrent simple febrile seizures, prophylactic anticonvulsants are not indicated 1, 4

Antipyretic Use

• Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizures or reduce recurrence risk 1, 2, 3
• They may be used for comfort during febrile illness but should not be prescribed with the expectation of seizure prevention 1

Rescue Medication Consideration

• Rescue benzodiazepines might be prescribed only when there is a high risk (>20%) of prolonged febrile seizure, specifically: age at first seizure <12 months OR history of previous febrile status epilepticus OR first seizure was focal OR abnormal neurological development/examination OR family history of nonfebrile seizures 5
• For complex febrile seizures, prophylactic intermittent diazepam during febrile illness may be considered per WHO guidelines 1

Parent Education and Prognosis

Reassurance Points

• Febrile seizures affect 2-5% of children and are the most common childhood seizure disorder 1, 4
• Simple febrile seizures do not cause brain damage, do not affect intelligence or learning, and do not lead to academic difficulties 2, 4
• The risk of developing epilepsy by age 7 is approximately 1%, similar to the general population 4
• Overall recurrence risk is approximately 30%, increasing to 50% in children under 12 months at first seizure 2, 4

When to Request Neurology Consultation

• Refer for neurological consultation if: prolonged febrile seizure before age 1 year, prolonged AND focal seizure, repetitive focal seizures within 24 hours, multiple complex febrile seizures, or abnormal neurological examination/development 5