What is the management and prescription for febrile seizures in Indian clinical practice for Emergency, ICU, IPD (In-Patient Department), and OPD (Out-Patient Department) settings?

Management of Febrile Seizures in Indian Clinical Practice

Emergency Department Management

For febrile seizures lasting >5 minutes, administer IV lorazepam 0.1 mg/kg (maximum 4 mg) slowly at 2 mg/min, or rectal diazepam 0.5 mg/kg if IV access is unavailable. 1, 2, 3

Acute Seizure Termination

• IV lorazepam is the preferred first-line agent when IV access is available, given at 0.1 mg/kg (maximum 4 mg) slowly over 2 minutes 1, 2
• Rectal diazepam 0.5 mg/kg should be used when IV access is not immediately available, as WHO guidelines specifically advise against IM diazepam due to erratic absorption 1
• If seizures continue after 10-15 minutes of observation following the first dose, repeat the same benzodiazepine dose once 2, 3
• Airway patency must be assured and respiratory support equipment kept ready, as respiratory depression is the most important risk with benzodiazepine use 2, 3

Initial Assessment in Emergency

• For children <12 months with febrile seizure, lumbar puncture is almost always indicated to exclude meningitis 4
• For children >12 months, perform LP if signs of meningism, excessive somnolence, systemic illness, complex features, or incomplete recovery after 1 hour 4
• Obtain urine testing in all cases to identify urinary tract infection, the most common serious bacterial infection (5-7% prevalence) 4
• No routine neuroimaging, EEG, or other laboratory tests are needed for simple febrile seizures in well-appearing children 1, 5

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ICU Admission Criteria & Management

Admit to ICU for febrile status epilepticus (seizures >30 minutes), recurrent seizures without return to baseline, or respiratory compromise requiring ventilatory support. 2, 6

ICU Prescription

• Continue IV lorazepam 0.1 mg/kg every 10-15 minutes up to maximum 0.3 mg/kg total if seizures persist 2
• If seizures continue despite adequate benzodiazepine dosing, load with IV phenobarbital 15-20 mg/kg to achieve therapeutic levels of 20 µg/mL 7
• Maintain continuous cardiorespiratory monitoring with pulse oximetry and capnography 2, 6
• Keep intubation equipment at bedside as benzodiazepines and phenobarbital cause cumulative respiratory depression 2, 7
• Identify and treat fever source aggressively with appropriate antibiotics if bacterial infection suspected 1, 4

Supportive Care in ICU

• Paracetamol 10-15 mg/kg IV/PO every 4-6 hours (maximum 5 doses/24 hours) for fever control and comfort 8, 4
• Maintain IV fluids to prevent dehydration 4
• Monitor for post-ictal sedation, which may be prolonged with multiple benzodiazepine doses 2

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In-Patient Department (IPD) Management

Children admitted for observation after complex febrile seizures or prolonged seizures require fever source identification, supportive care, and parental education—not prophylactic anticonvulsants. 9, 1

IPD Prescription (First 24-48 Hours)

• Paracetamol 10-15 mg/kg PO/IV every 4-6 hours as needed for fever (maximum 5 doses/24 hours) 8, 4
• Ibuprofen 5-10 mg/kg PO every 6-8 hours as alternative or adjunct antipyretic if >6 months age 8
• Appropriate antibiotics if bacterial infection identified (e.g., UTI, pneumonia) 4
• IV fluids if oral intake inadequate to maintain hydration 4
• No prophylactic anticonvulsants (phenobarbital, valproate, or diazepam) should be prescribed 9, 1

Monitoring in IPD

• Vital signs every 4 hours including temperature 1
• Neurological examination every 6-8 hours to ensure return to baseline 1, 4
• Observe for seizure recurrence within 24 hours (defines complex febrile seizure) 9, 1

Critical Pitfall to Avoid

• Do not prescribe continuous or intermittent anticonvulsant prophylaxis (phenobarbital, valproate, or intermittent diazepam) as the AAP explicitly recommends against this—the toxicities outweigh benefits 9, 1
• The potential harms include valproate's fatal hepatotoxicity, phenobarbital's hyperactivity/irritability, and diazepam's lethargy and risk of masking evolving CNS infection 1

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Out-Patient Department (OPD) Follow-Up

Provide parents with rectal diazepam 0.5 mg/kg for home rescue use if seizures last >5 minutes, along with comprehensive education about the benign prognosis. 1, 10, 6

OPD Prescription (Discharge/Follow-up)

• Rectal diazepam solution 0.5 mg/kg (5 mg for <12 kg, 10 mg for >12 kg) to be kept at home for rescue use if seizure lasts >5 minutes 1, 10, 6
• Paracetamol 10-15 mg/kg PO every 4-6 hours PRN for future febrile illnesses (for comfort, not seizure prevention) 8, 4
• No continuous or intermittent prophylactic anticonvulsants should be prescribed 9, 1

Parental Education (Essential Component)

• Recurrence risk is ~30% overall (50% if age <12 months, higher with family history) 1, 4, 5
• Risk of developing epilepsy is extremely low (2-2.5%), only slightly higher than general population 9, 1, 4
• Antipyretics do not prevent febrile seizures, though they improve comfort and prevent dehydration 9, 1, 8
• Home management instructions: position child on side, do not restrain, never put anything in mouth, call emergency if seizure >5 minutes or child doesn't return to baseline 1, 4

Follow-Up Schedule

• Routine follow-up in 1-2 weeks to reassess and reinforce education 1, 5
• No routine EEG or neuroimaging needed for simple febrile seizures 1, 5
• Refer to pediatric neurology only if: complex features, developmental concerns, or failure to return to neurological baseline 1, 6

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Key Algorithmic Approach Summary

Simple Febrile Seizure (Brief, Generalized, Single in 24h):

• Emergency: Supportive care, identify fever source, no routine LP if >12 months and well-appearing 1, 4
• IPD: Observation if needed, antipyretics for comfort, no prophylaxis 9, 1
• OPD: Parental education, home rectal diazepam rescue kit, no prophylaxis 1, 10

Complex Febrile Seizure (>15 min, Focal, or Recurrent in 24h):

• Emergency: Benzodiazepine if active, LP strongly considered, identify fever source 1, 4
• ICU: If status epilepticus or respiratory compromise 2, 6
• IPD: Extended observation, still no prophylaxis 9, 1
• OPD: Home rectal diazepam, close follow-up, consider neurology referral 1, 6

The evidence is unequivocal: prophylactic anticonvulsants have no role in febrile seizure management in routine Indian clinical practice. 9, 1