What is the management for children with febrile seizures?

Management of Children with Febrile Seizures

Neither continuous nor intermittent anticonvulsant prophylaxis should be used for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 1, 2

Immediate Management During Active Seizure

• Position the child on their side to prevent aspiration and clear the area of harmful objects to prevent injury 3
• Never restrain the child or place anything in their mouth during the seizure 3
• For seizures lasting more than 5 minutes, administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 1
• Activate emergency services for first-time seizures, seizures in children under 6 months, seizures lasting more than 5 minutes, repeated seizures without return to baseline, or seizures with traumatic injury or respiratory difficulty 3

Diagnostic Evaluation

• Routine neuroimaging is NOT indicated for simple febrile seizures 1
• Laboratory tests, neuroimaging, and electroencephalography are not routinely required for well-appearing children with simple febrile seizures, except as needed to identify the source of fever 4
• For complex febrile seizures (lasting >15 minutes, focal features, or recurring within 24 hours), the neurologic examination should guide further evaluation 4

Long-Term Management and Prophylaxis

The harm-benefit analysis clearly favors no prophylactic treatment for simple febrile seizures. 1

Why Prophylaxis is NOT Recommended:

• Continuous anticonvulsant therapy with phenobarbital or valproic acid is effective in reducing recurrence but carries unacceptable risks including rare fatal hepatotoxicity (especially in children younger than 2 years), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis with valproic acid 5
• Phenobarbital causes hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions 5
• Intermittent diazepam prophylaxis may reduce recurrence rates but does not improve long-term outcomes and causes lethargy, drowsiness, and ataxia 5, 6
• Antipyretics do not prevent febrile seizures or reduce recurrence risk 1

Alternative Approach for Select Cases:

• For families with severe anxiety or children with multiple complex febrile seizures, an alternative strategy is providing rectal diazepam gel (Diastat) for parents to administer at home at seizure onset to prevent febrile status epilepticus 6, 7
• This approach focuses on acute seizure termination rather than prophylaxis 6

Prognosis and Parent Education

Excellent Long-Term Outcomes:

• Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or behavioral abnormalities 5, 1, 2
• No evidence exists that simple febrile seizures cause structural brain damage 5, 8
• The risk of developing epilepsy by age 7 is approximately 1%, identical to the general population 5, 2
• Even children with multiple simple febrile seizures, first seizure before 12 months, and family history of epilepsy have only 2.4% risk of developing epilepsy by age 25 years 5, 2
• There is no evidence that treating simple febrile seizures can prevent the rare cases of later epilepsy 5, 6

Recurrence Risk:

• Children younger than 12 months at first seizure have approximately 50% probability of recurrent febrile seizures 5, 3, 2
• Children older than 12 months at first seizure have approximately 30% probability of a second febrile seizure 5, 3, 2
• Of those who have a second febrile seizure, 50% have at least one additional recurrence 5

Key Counseling Points:

• Reassure parents about the benign nature and excellent prognosis of simple febrile seizures 1, 3, 4
• Educate on practical home management: positioning during seizures, when to call emergency services, and that antipyretics will not prevent future seizures 1, 3
• Emphasize that febrile seizures do not cause brain damage, affect intelligence, or lead to learning disabilities 3, 4

Common Pitfalls to Avoid

• Do not prescribe daily prophylactic anticonvulsants for simple febrile seizures—the risks far outweigh any potential benefits 1, 2, 8
• Do not order routine neuroimaging, EEG, or extensive laboratory testing for well-appearing children with simple febrile seizures 1, 4
• Do not recommend antipyretics as a strategy to prevent febrile seizures, as they are ineffective for this purpose 1
• Avoid creating unnecessary parental anxiety by overemphasizing the minimal epilepsy risk, which is essentially the same as the general population 5, 2