What is the treatment for febrile seizures?

Treatment of Febrile Seizures

Long-term anticonvulsant prophylaxis is NOT recommended for simple febrile seizures—the risks of medication toxicity clearly outweigh the benign nature of these seizures. 1, 2, 3

Acute Management During a Seizure

For seizures in progress:

• Help the child to the ground and place in recovery position to prevent injury 2
• Clear the area around the child and never restrain or place anything in the mouth 2
• Call emergency services if this is a first-time seizure, the seizure lasts >5 minutes, multiple seizures occur without return to baseline, or if there are traumatic injuries, breathing difficulties, or choking 2, 3

For prolonged seizures (>5 minutes):

• IV lorazepam is preferred over diazepam due to longer duration of action 3
• When IV access is unavailable, rectal diazepam should be administered 2
• IM diazepam should be avoided due to erratic absorption 2

Long-Term Management: Why No Prophylaxis?

The American Academy of Pediatrics explicitly recommends against both continuous and intermittent anticonvulsant therapy based on high-quality randomized controlled trials. 2, 3 This recommendation applies to children with one or more simple febrile seizures and is based on a clear harm-benefit analysis:

Risks of Anticonvulsant Prophylaxis Outweigh Benefits:

• Valproic acid: Rare but fatal hepatotoxicity (especially in children <2 years who are at greatest risk of febrile seizures), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis 1
• Phenobarbital: Hyperactivity, irritability, and behavioral disturbances 2
• Intermittent diazepam: Lethargy and risk of masking an evolving CNS infection 2
• Carbamazepine and phenytoin: Not effective in preventing febrile seizure recurrence 1

Why Treatment Isn't Necessary:

• Simple febrile seizures are benign events with excellent prognosis 1, 2, 3
• Nearly all children have normal neurological, motor, intellectual, and cognitive long-term outcomes 4
• The risk of developing epilepsy is extremely low and likely due to genetic predisposition rather than the febrile seizures themselves 2

Role of Antipyretics

Antipyretics (acetaminophen and ibuprofen) do NOT prevent febrile seizures or reduce recurrence risk, though they may improve comfort during febrile illness. 1, 2, 3, 5

This has been demonstrated in multiple randomized controlled trials:

• Acetaminophen given every 4 hours versus sporadically showed no difference in febrile seizure recurrence 1, 6
• Ibuprofen versus placebo showed no reduction in seizure recurrence despite significant temperature reduction 7
• Acetaminophen combined with low-dose oral diazepam did not reduce febrile seizure recurrence compared to controls 1

Standard antipyretic dosing for comfort:

• Acetaminophen: 10-15 mg/kg every 4-6 hours, not to exceed 5 doses in 24 hours 5
• Ibuprofen may be used as an alternative 5

Special Considerations

Intermittent oral diazepam at fever onset may be considered only when parental anxiety is severe, but this is not a routine recommendation. 3 An alternative approach is providing parents with rectal diazepam solution to administer at home at seizure onset to prevent prolonged recurrent seizures, which is effective, inexpensive, has few side effects, and is well-accepted by parents. 4

For complex febrile seizures (prolonged >15 minutes, focal features, or multiple within 24 hours), prophylactic intermittent diazepam during febrile illness may be considered, though this represents a different clinical scenario than simple febrile seizures. 2

Critical Pitfalls to Avoid

• Do not prescribe prophylactic anticonvulsants for simple febrile seizures—this is unequivocal in the guidelines 1, 2, 3
• Do not tell parents that antipyretics will prevent seizures—they improve comfort but do not reduce recurrence risk 1, 2, 3, 5
• Do not overlook parent education—emphasize the benign nature, excellent prognosis, and low risk of epilepsy 2
• A seizure could occur before fever is noticed, so intermittent medication strategies may fail due to method rather than agent efficacy 1

Parent Education Priorities

Focus counseling on:

• The benign nature of simple febrile seizures and excellent prognosis 2
• Recurrence risk is approximately 30% overall, higher in younger children and those with family history 2
• Practical home management including seizure first aid 2
• When to call emergency services 2, 3