What is the treatment for a 17-month-old patient with a seizure and fever, potentially indicating febrile seizures?

Management of Seizure with Fever in a 17-Month-Old Child

For a 17-month-old child presenting with seizure and fever, lumbar puncture is almost always indicated to rule out meningitis, as this age falls within the high-risk group where meningeal signs may be absent. 1, 2

Immediate Assessment and Stabilization

During Active Seizure

• Place the child on their side on the ground to minimize injury risk and reduce aspiration if vomiting occurs 1, 3
• Clear the area around the child of objects that could cause injury 1, 3
• Stay with the child and time the seizure duration 1, 3
• Never restrain the child or place anything in their mouth 1, 3
• Activate emergency services immediately if the seizure lasts longer than 5 minutes, as seizures beyond this duration may require anticonvulsant medications and typically do not resolve spontaneously 1, 3

Post-Seizure Assessment

• Measure blood glucose immediately with a glucose oxidase strip if the child is still convulsing or unrousable 1, 2
• Activate emergency services if the child does not return to baseline mental status within 5-10 minutes after seizure cessation 1, 3

Critical Diagnostic Evaluation

Lumbar Puncture Indications

At 17 months of age, lumbar puncture should be strongly considered and is almost always indicated because: 1, 2

• Children under 18 months (and especially under 12 months) frequently lack classic meningeal signs even when meningitis is present 1, 2
• In up to one-sixth of children with meningitis, seizures are the presenting sign, and one-third of these patients lack meningeal signs 4
• Delay in diagnosing bacterial meningitis can result in serious neurologic morbidity and death 4

Additional absolute indications for lumbar puncture include: 1, 2

• Any signs of meningism present
• Child is excessively drowsy, irritable, or systemically ill
• Prolonged seizure or incomplete recovery within one hour
• Complex seizure features (focal, lasting >15 minutes, or multiple seizures in 24 hours)

What NOT to Do Routinely

• Do not routinely perform EEG, blood urea, serum electrolytes, or serum calcium in straightforward febrile seizure cases 1, 2
• EEG is not a guide to treatment or prognosis after a single febrile seizure 1
• Neuroimaging is not routinely indicated unless there are focal neurologic findings or concern for structural abnormality 1

Fever Management

Antipyretic Treatment

• Administer acetaminophen (paracetamol) to promote comfort and prevent dehydration, NOT to prevent seizure recurrence 1, 5, 6
• Antipyretics (acetaminophen, ibuprofen, paracetamol) are NOT effective for stopping a seizure or preventing subsequent febrile seizures 1, 5
• Ensure adequate fluid intake to prevent dehydration 1, 5
• Do not use physical cooling methods (fanning, cold bathing, tepid sponging) as these cause discomfort without benefit 1

Anticonvulsant Therapy Decisions

Acute Seizure Management

• For seizures lasting more than 5 minutes, benzodiazepine administration is indicated 7
• Rectal diazepam can be considered for home use by parents to prevent prolonged recurrent seizures 8

Chronic Prophylaxis

• Do not prescribe continuous or intermittent anticonvulsant therapy for simple febrile seizures 5, 3
• The adverse effects of chronic anticonvulsants outweigh benefits in this benign condition 3, 8
• Intermittent diazepam prophylaxis during febrile episodes may be reserved for highly selected cases with multiple prolonged recurrences or special circumstances 8

Prognosis and Parent Counseling

Excellent Long-Term Outcome

• Reassure parents that febrile seizures have an excellent prognosis with no long-term effects on brain development, intelligence, or academic performance 3, 7
• Febrile seizures do not cause brain damage, intellectual decline, learning disabilities, or behavioral problems 3, 7
• The risk of developing epilepsy after a simple febrile seizure is only approximately 2.5%, similar to the general population 1, 2, 3

Recurrence Risk

• Overall recurrence risk is approximately 30% 1, 5
• Risk increases to 50% in children under 1 year of age at first seizure 5
• First-degree family history of febrile seizures increases recurrence risk to nearly 50% 1

Common Pitfalls to Avoid

• Do not dismiss the need for lumbar puncture in a 17-month-old child - this age group requires particularly careful evaluation as meningeal signs are frequently absent even with serious CNS infection 1, 2
• Do not delay medical evaluation - the child should be assessed by a physician after the first febrile seizure to identify the fever source and ensure appropriate treatment 3
• Do not prescribe antipyretics with the expectation of preventing future seizures, as this creates false expectations for parents 1, 5
• Do not perform unnecessary investigations (EEG, extensive metabolic panels) in straightforward cases 1, 2