What is the most appropriate next step for a previously healthy child who develops a febrile seizure (fever-induced seizure) with generalized tonic-clonic movements after a high fever (hyperthermia)?

Most Appropriate Next Step for Simple Febrile Seizure

The most appropriate next step is to give rectal diazepam (for future episodes) and evaluate the fever source (option d). This child has experienced a simple febrile seizure—brief, generalized, with full recovery—and requires identification of the underlying infection causing the fever, not neuroimaging, antiepileptic prophylaxis, or an epilepsy diagnosis 1, 2.

Immediate Management Priorities

The primary objective is identifying the source of fever, particularly ruling out serious bacterial infections like meningitis and urinary tract infections 2. This takes precedence over any seizure-specific interventions because:

• The seizure itself was brief (2 minutes), generalized, and followed by complete recovery—classic features of a simple febrile seizure 1, 3
• The child is now acting normally, indicating no ongoing neurological emergency 2
• Fever evaluation is essential to detect potentially serious infections that require specific treatment 2

Fever Source Evaluation Should Include:

• Assessment for meningeal signs (altered mental status, neck stiffness, excessive drowsiness, irritability), which would mandate lumbar puncture regardless of age 2
• Urinalysis, as urinary tract infection is the most common serious bacterial infection in febrile children (5-7% prevalence) 2
• Chest radiography if respiratory signs present (tachypnea, retractions, crackles) 2
• General appearance assessment—toxic appearance, poor feeding, or incomplete recovery after one hour requires more aggressive evaluation 2

Why Other Options Are Incorrect

Daily Anticonvulsants (Option a) and Antiepileptic Prophylaxis (Option b):

The American Academy of Pediatrics explicitly recommends against both continuous and intermittent anticonvulsant therapy for simple febrile seizures 1. The evidence is unequivocal:

• Potential harms outweigh benefits, including valproic acid's rare fatal hepatotoxicity, phenobarbital's hyperactivity and irritability, and diazepam's lethargy 1
• Prophylaxis does not prevent the rare cases of later epilepsy or improve long-term outcomes 1, 4
• The prognosis is excellent regardless, with only 2.5% risk of subsequent epilepsy after a simple febrile seizure 1, 2

Immediate CT Scan (Option c):

Routine neuroimaging is not indicated for simple febrile seizures in well-appearing children 1, 3. Brain imaging would only be considered if:

• The child remains comatose or has not completely recovered within one hour 5
• There are focal neurological findings suggesting a structural lesion 3
• The seizure was complex (>15 minutes, focal features, or multiple within 24 hours) 1

Epilepsy Diagnosis (Option e):

This is definitively not epilepsy—epilepsy requires recurrent unprovoked seizures, whereas this was a single provoked seizure in the context of fever 1. The risk of developing epilepsy is extremely low (2.5%) and likely due to genetic predisposition rather than the febrile seizure itself 1, 2.

Role of Rectal Diazepam

Many pediatricians advise providing rectal diazepam for parents to administer at home during future febrile episodes or at seizure onset 5. This approach:

• Moves first-line anticonvulsant defense close to the child, preventing prolonged recurrent seizures 6, 4
• Is effective, inexpensive, feasible for non-professionals, has few side effects, and is well-accepted by parents 6
• Should be given when IV access is not available for ongoing seizures 1
• Does not prevent initial seizure recurrence but can abort prolonged seizures if they occur 6, 4

Additional Management Considerations

Administer paracetamol (acetaminophen) for comfort, not seizure prevention, as antipyretics improve comfort but do not prevent febrile seizure recurrence 1, 2, 3. Physical cooling methods (fanning, cold bathing, tepid sponging) should be avoided as they cause discomfort without benefit 5, 2.

Ensure adequate hydration to prevent dehydration during the febrile illness 5, 2.

Parent Education and Follow-Up

Provide comprehensive education about the benign nature and excellent prognosis 1, 2:

• Recurrence risk is approximately 30% overall, higher (50%) in children under 2 years of age 1, 2
• Home management instructions: position child on side during seizure, do not place anything in mouth, seek emergency care if seizure lasts >5 minutes 2
• Signs requiring immediate return: worsening condition, skin rash/petechiae, respiratory distress, feeding refusal, excessive irritability, or somnolence 2

Reevaluate the child within 24 hours if managed as an outpatient 2.

Critical Pitfall to Avoid

The most common error is over-investigation and over-treatment of simple febrile seizures 5. Electroencephalography, routine blood tests (urea, electrolytes, calcium), and neuroimaging should not be performed on more than a small minority of patients with simple febrile seizures 5, 1. The focus must remain on fever source identification and parent reassurance about the benign prognosis 1, 2.