What is the management plan for a 15-month-old child with a 1-week history of fever, influenza-like illness (ILI), a recent febrile seizure, and a confirmed COVID-19 infection?

Management of 15-Month-Old with COVID-19, Fever, and Recent Febrile Seizure

This child requires supportive care with antipyretics for fever management and close monitoring for signs of multisystem inflammatory syndrome in children (MIS-C), but does not require immunomodulatory therapy or specific COVID-19 treatment at this time. 1

Immediate Assessment Priorities

Distinguish Between Simple Febrile Seizure vs. Severe COVID-19 Complications

The vast majority of children with COVID-19 have mild symptoms, and febrile seizures occur in approximately 0.5% of pediatric COVID-19 cases. 1, 2 This child's presentation 4 days ago with a febrile seizure during acute COVID-19 infection is consistent with a typical febrile seizure rather than severe neurological COVID-19 complications. 3, 2

Key clinical distinctions to evaluate:

• Simple febrile seizure characteristics: Single episode, brief duration (<15 minutes), no focal features, occurring in children under 6 years with fever 3, 2
• Complex febrile seizures: Prolonged (>15 minutes), multiple episodes within 24 hours, or focal features 2
• Status epilepticus: Requires immediate intervention and may indicate severe COVID-19 neurological involvement 4, 5

Rule Out MIS-C

MIS-C typically presents 2-6 weeks after SARS-CoV-2 infection with persistent fever, multiorgan dysfunction, and elevated inflammatory markers—not during the acute infectious phase. 1 This child is only 1 week into illness, making MIS-C unlikely at this stage.

Monitor for MIS-C warning signs over the next 2-4 weeks:

• Persistent fever beyond 3-5 days 1
• Gastrointestinal symptoms (abdominal pain, vomiting, diarrhea) 1
• Rash or conjunctivitis 1
• Cardiovascular symptoms (chest pain, tachycardia out of proportion to fever) 1

Fever Management

Antipyretic Therapy

Administer paracetamol (acetaminophen) 10-15 mg/kg every 4-6 hours as first-line therapy for fever and discomfort. 6, 7

Importantly, antipyretics do NOT prevent recurrence of febrile seizures according to the American Academy of Pediatrics, so the goal is symptom relief rather than seizure prevention. 6

If fever persists above 38.5°C (101°F) after paracetamol:

• Add ibuprofen 10 mg/kg every 6-8 hours as second-line therapy 7
• Consider tepid sponging as adjunctive physical cooling 7
• Ensure adequate hydration (up to 2 liters per day for this age/weight) 6, 7

Common Pitfall to Avoid

Do not use antipyretics with the expectation of preventing further febrile seizures—this is ineffective and not evidence-based. 6 Parents should be counseled that fever control does not reduce seizure recurrence risk.

Monitoring and Follow-Up

Home Monitoring (If Child Appears Well)

Most children with COVID-19 and simple febrile seizures can be managed at home with close outpatient follow-up. 1, 3

Instruct caregivers to monitor for:

• Persistent fever beyond 5-7 days (may indicate MIS-C development) 1
• Recurrent seizures, especially if afebrile or prolonged 3, 8
• Signs of respiratory distress (increased work of breathing, hypoxia) 1
• Altered mental status, severe headache, or neck stiffness 7, 3
• Cardiovascular symptoms (chest pain, syncope, severe fatigue) 1

When to Escalate Care

Immediate medical evaluation is required if:

• Seizure recurs, especially if afebrile or lasting >5 minutes 3, 8
• Development of status epilepticus 4, 5
• Signs of severe respiratory illness (ARDS, shock, significant hypoxia) 1
• Persistent fever with multiorgan symptoms suggesting MIS-C 1
• Altered mental status or focal neurological deficits 3, 8

No Immunomodulatory Therapy Indicated

This child does NOT meet criteria for immunomodulatory treatment. 1

Immunomodulation is reserved for:

• Children with severe COVID-19 and hyperinflammation (ARDS, shock, substantially elevated inflammatory markers including LDH, d-dimer, IL-6, ferritin, CRP) 1
• Confirmed MIS-C with cardiac involvement or multiorgan dysfunction 1

Children with mild-to-moderate COVID-19 symptoms, even with febrile seizures, should receive supportive care only. 1

Seizure-Specific Considerations

No Prophylactic Antiepileptic Drugs Needed

Antiepileptic prophylaxis is not indicated for simple febrile seizures, even in the context of COVID-19. 6, 3 The seizure 4 days ago was likely a typical febrile seizure triggered by acute viral infection.

Neurological Red Flags

Approximately 9% of children with COVID-19 and febrile seizures may require critical care services, particularly those with complex features. 2

Concerning features requiring neuroimaging and possible hospitalization:

• Multiple seizures within 24 hours 2
• Focal seizure activity or prolonged postictal state 3, 8
• Afebrile seizures in this age group 3, 8
• Persistent altered mental status 8, 4

Prognosis and Parental Counseling

The overall prognosis for children with COVID-19 and simple febrile seizures is excellent, with most recovering completely without sequelae. 1, 3, 2 Febrile seizures, while alarming, are not commonly associated with severe neurological complications in COVID-19. 2

Parents should be reassured that febrile seizures occur in 0.5% of pediatric COVID-19 cases and typically represent benign events rather than severe disease. 2 However, vigilance for MIS-C development over the subsequent 2-6 weeks is essential. 1