Management of Febrile Convulsions in Pediatric Patients
Treat the acute seizure with rectal diazepam, manage fever with paracetamol for comfort, perform lumbar puncture in children under 12 months or with complex features to exclude meningitis, and provide parents with rectal diazepam for home use to prevent prolonged recurrent seizures. 1, 2, 3
Acute Seizure Management
During an active seizure, immediately administer rectal diazepam or lorazepam after ensuring airway patency and placing the child in a semi-prone position to prevent aspiration. 3, 4
- Monitor vital signs continuously during the convulsion 4
- Check blood glucose if the child is seen during the seizure 1
- Most febrile seizures are self-terminating and brief 5
Critical Assessment: Exclude Serious Bacterial Infections
Immediate Lumbar Puncture Indications
Perform lumbar puncture if the child is under 12 months of age (almost certainly) or under 18 months (probably), as meningitis can present with fever and seizure without obvious meningeal signs in this age group. 1, 2
Additional indications for lumbar puncture include: 1
- Clinical signs of meningism (neck stiffness, bulging fontanelle, altered mental status) 2
- Complex convulsion (prolonged >15-20 minutes, focal features, or multiple seizures in 24 hours) 1
- Child is unduly drowsy, irritable, or systemically ill 1, 2
- Incomplete recovery within one hour 1
A comatose child must be examined by an experienced physician before lumbar puncture due to risk of herniation; brain imaging may be necessary first. 1
When to Admit vs. Discharge
Admit if: 2
- Toxic or ill appearance
- Age under 3 months 2
- Complex convulsion lasting >20 minutes 1
- Abnormal cerebrospinal fluid if lumbar puncture performed 2
- Difficulty feeding, vomiting, or decreased urine output 2
Discharge if: 2
- Good general condition
- Simple febrile seizure (brief, generalized, single episode in 24 hours)
- Normal examination after recovery
- Parents can monitor and return if deterioration occurs
Fever Management
Use paracetamol (acetaminophen) as the preferred antipyretic to promote child comfort and prevent dehydration, not to normalize temperature. 1, 2
- Ensure adequate fluid intake 1
- Do not use physical cooling methods (fanning, cold bathing, tepid sponging) as they cause discomfort without proven benefit. 1
- Antipyretic treatment does not prevent febrile seizure recurrence 1
Investigations to Avoid
Do not routinely perform: 1
- Electroencephalography (not a guide to treatment or prognosis) 1
- Serum electrolytes or calcium (unless specific clinical indication) 1
- Chest radiography (unless respiratory signs present) 2
Prophylaxis and Recurrence Prevention
Provide parents with rectal diazepam solution for home administration at seizure onset to prevent prolonged recurrent seizures. 1, 3
- Recurrence risk is approximately 30% overall, higher with younger age at first convulsion and positive family history (up to 50%) 1, 2
- Chronic daily anticonvulsant prophylaxis is not recommended as it does not improve long-term outcomes and has significant side effects 3
- Intermittent diazepam during febrile episodes may reduce recurrence but reserve for selected high-risk cases 3
Parent Education and Reassurance
Counsel parents that febrile convulsions are benign with excellent prognosis for normal development and neurological outcome. 1, 4
Provide specific information on: 1, 2
- Nature and prevalence of febrile seizures
- Risk of subsequent epilepsy is only 2.5% after simple febrile convulsion 1
- Instructions for fever management and rectal diazepam use
- Warning signs requiring immediate return: worsening general condition, skin rash, respiratory distress, feeding refusal, excessive irritability or somnolence 2
Follow-up
Reevaluate within 24 hours if managed as outpatient. 2