What is the immediate management for a child experiencing a febrile seizure?

Immediate Management of Febrile Seizures in Children

During the Active Seizure

Place the child in a recovery position (on their side) to prevent aspiration, clear the surrounding area of harmful objects, and protect the head from injury—most febrile seizures are self-limiting and require only supportive care. 1, 2

Critical Safety Measures

• Never restrain the child or place anything in their mouth during active seizure activity. 1, 2
• Position the patient on their side and remove environmental hazards. 1
• Assess airway, breathing, and circulation immediately. 1

When to Administer Medication

• For seizures lasting more than 5 minutes, administer benzodiazepines as first-line treatment. 1, 3
• Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min is the recommended first-line agent per the American Academy of Pediatrics. 1
• Alternatively, rectal diazepam can be administered by parents at home for prolonged seizures. 4

When to Activate Emergency Services

Call emergency services for: 2

• First-time seizure
• Child under 6 months of age
• Seizure lasting more than 5 minutes
• Repeated seizures without return to baseline consciousness
• Seizure with traumatic injury or respiratory difficulty

Post-Seizure Assessment

Lumbar Puncture Indications

The decision to perform lumbar puncture should be based on clinical presentation, not simply on the occurrence of a febrile seizure:

• Required: Any child with meningitis symptoms, septic signs, or behavior disturbance. 5
• Consider: Focal febrile seizures or repetitive seizures without clear meningeal signs—clinical judgment based on symptoms and progression over time. 5
• Not necessary: Simple febrile seizures (generalized, <15 minutes, single episode in 24 hours) without signs of meningitis, even in infants 6-12 months old. 5
• Early re-evaluation (at least 4 hours after initial assessment) is helpful, particularly in infants younger than 12 months. 5

Routine Testing NOT Indicated

• Neuroimaging is NOT indicated for simple febrile seizures. 1
• Routine laboratory tests and electroencephalography are not required for well-appearing children with simple febrile seizures. 3
• Diagnostic workup should focus on identifying the source of fever. 3, 6

Common Pitfalls to Avoid

• Do not prescribe continuous or intermittent anticonvulsant prophylaxis for simple febrile seizures—the American Academy of Pediatrics strongly recommends against this due to potential toxicities (fatal hepatotoxicity with valproic acid, behavioral changes with phenobarbital) that clearly outweigh minimal benefits. 7, 1, 2
• Antipyretics do not prevent febrile seizures or reduce recurrence risk (though rectal acetaminophen may reduce short-term recurrence). 1, 3
• Do not over-investigate simple febrile seizures—the harm-benefit analysis clearly favors minimal intervention. 1

Parent Education and Counseling

Reassure parents that simple febrile seizures are benign with excellent prognosis: 2, 3

• No decline in IQ, academic performance, or neurocognitive function. 7, 1
• No structural brain damage. 7, 1
• Risk of developing epilepsy is approximately 1%, identical to the general population. 7, 1

Recurrence Risk Counseling

• Children <12 months at first seizure: approximately 50% recurrence risk. 7, 2
• Children >12 months at first seizure: approximately 30% recurrence risk. 7, 2
• Of those with a second seizure, 50% will have at least one additional recurrence. 1

When to Consider Rescue Medication for Home Use

Prescribe rectal diazepam for home use when risk of prolonged febrile seizure exceeds 20%: 5

• Age at first febrile seizure <12 months
• History of previous febrile status epilepticus
• First febrile seizure was focal
• Abnormal development, neurological exam, or MRI
• Family history of nonfebrile seizures

When to Refer to Pediatric Neurology

Neurological consultation is indicated for: 5

• Prolonged febrile seizure before age 1 year
• Prolonged AND focal febrile seizures
• Repetitive (within 24 hours) focal febrile seizures
• Multiple complex febrile seizures (focal, prolonged, or repetitive)
• Abnormal neurological examination or development in a child with febrile seizures