What is the management approach for a 2-year-old child presenting with hyperthermia (fever) and a seizure, with no neurological deficits?

Management of a 2-Year-Old with Fever and Seizure

Reassure the parents and identify the source of fever—this is a simple febrile seizure requiring no EEG, no head CT, and no antiepileptic drugs. 1, 2

Immediate Assessment Priorities

The primary objective is to identify the source of fever, particularly ruling out serious bacterial infections like meningitis and urinary tract infection. 2, 3

Critical Exclusion Criteria

• Assess for meningeal signs: Check for altered mental status, neck stiffness, excessive drowsiness, or irritability—any of these mandate lumbar puncture regardless of age 2, 4
• Evaluate general appearance: A child with toxic appearance, poor feeding, or incomplete recovery after one hour requires more aggressive evaluation 2, 3
• At 2 years of age with no neurological deficits and presumed simple febrile seizure, lumbar puncture is not routinely indicated unless clinical suspicion for CNS infection exists 2, 3

Essential Diagnostic Workup

• Obtain urinalysis: Urinary tract infection is the most common serious bacterial infection in febrile children, with 5-7% prevalence 3
• Assess for respiratory signs: If tachypnea, retractions, or crackles are present, obtain chest radiography 2
• Blood glucose if seen during seizure 1

What NOT to Do

Do not order routine EEG—it is explicitly listed as inappropriate investigation for simple febrile seizures. 1

Do not order head CT—neuroimaging is not indicated for simple febrile seizures without focal neurological deficits. 1

Do not start maintenance antiepileptic drugs—the potential toxicities outweigh the relatively minor risks of simple febrile seizures. 1

Fever Management

• Administer paracetamol (acetaminophen) for comfort, not seizure prevention: Antipyretics improve comfort but do not prevent febrile seizure recurrence 1, 2
• Avoid physical cooling methods: Fanning, cold bathing, and tepid sponging cause discomfort and are not recommended 1, 2
• Ensure adequate hydration to prevent dehydration 1

Prognosis and Parent Education

The prognosis is excellent—risk of subsequent epilepsy after a simple febrile seizure is only 2.5%. 1

Key Points for Parents

• Recurrence risk is approximately 30% overall, but increases to 50% in children under 2 years of age 1, 2, 3
• Provide home management instructions: Position child on side during seizure, do not place anything in mouth, seek emergency care if seizure lasts >5 minutes 3
• Warning signs requiring immediate return: Worsening general condition, skin rash/petechiae, respiratory distress, feeding refusal, excessive irritability or somnolence 2

Common Pitfalls to Avoid

• Do not assume all febrile seizures are benign without proper assessment: Up to 1 in 6 children with meningitis present with seizures, and one-third may lack meningeal signs 4
• Do not overlook urinary tract infection: This is easily missed without urinalysis 3
• Do not prescribe prophylactic anticonvulsants: Evidence shows no benefit for simple febrile seizures, and toxicity risks are significant 1

Follow-Up

• Reevaluate within 24 hours if managed as outpatient 2
• Document key elements: Accurate seizure description, family history of seizures, temperature on presentation, presence/absence of meningeal signs, neurodevelopmental state when recovered 1