What is the immediate management for a pediatric patient presenting with a febrile seizure?

Immediate Management of Pediatric Febrile Seizures

Acute Seizure Management

For an actively seizing child, immediately position them on their side, protect the head, clear the surrounding area of harmful objects, and never restrain the child or place anything in their mouth. 1, 2

During Active Seizure (First 5 Minutes)

• Place the child in the recovery position (on their side) to maintain airway patency 1
• Remove any objects that could cause injury from the immediate environment 2
• Protect the head from trauma without restraining the child 3
• Never attempt to restrain the patient or insert anything into the mouth during seizure activity 1, 3
• Allow the seizure to terminate spontaneously, as most febrile seizures resolve within 1-2 minutes 1

For Seizures Lasting >5 Minutes

Administer benzodiazepines immediately for any seizure exceeding 5 minutes, as early treatment may prevent progression to status epilepticus. 2

• First-line treatment: Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 2, 3
• When IV access is unavailable, administer rectal diazepam 1
• IM diazepam should be avoided due to erratic absorption 1
• Activate emergency medical services immediately for seizures lasting >5 minutes 2

When to Activate Emergency Services

Emergency medical services should be called for: 1

• First-time seizures
• Seizures lasting >5 minutes 2
• Multiple seizures without return to baseline consciousness 1
• Seizures associated with traumatic injuries, breathing difficulties, or choking 1

Post-Seizure Assessment

Immediate Evaluation

• Assess airway, breathing, and circulation 3
• Perform focused neurological examination looking for focal deficits or altered mental status 2
• Measure temperature to confirm fever ≥100.4°F (38°C) 3
• Evaluate for signs of meningitis or serious bacterial infection 2, 4

Lumbar Puncture Indications

A lumbar puncture is required in any child with meningitis symptoms, septic signs, or behavioral disturbance. 4

• Mandatory for children <12 months with fever and seizure if meningeal signs, sepsis, or altered behavior are present 4
• Should be discussed for focal or repetitive febrile seizures without clear meningitis signs, based on clinical progression 4
• Not necessary for simple febrile seizures without meningitis signs, even in infants 6-12 months old 4
• Early clinical re-evaluation (at least 4 hours after initial assessment) is helpful, particularly in infants <12 months 4

Diagnostic Testing for Simple Febrile Seizures

Children with simple febrile seizures who are well-appearing do not require routine laboratory tests, neuroimaging, or EEG. 3, 5

• Diagnostic workup should focus on identifying the source of fever 3
• Neuroimaging is NOT indicated for simple febrile seizures 3
• MRI brain imaging should be reserved for febrile status epilepticus (seizures >30 minutes) 2

Temperature Management

Antipyretics (acetaminophen or ibuprofen) should be given for comfort but do not prevent febrile seizures or reduce recurrence risk. 1, 3

• Use antipyretics to improve comfort and prevent dehydration, not for seizure prevention 3
• Rectal forms are preferred immediately post-seizure if the child cannot take oral medications 6
• Gradual passive cooling in a cooler (not cold) environment is appropriate 6
• Avoid rapid cooling measures like alcohol rubdowns, as they may induce shivering and paradoxically elevate fever 6

Critical Pitfalls to Avoid

• Never delay benzodiazepine administration for seizures lasting >5 minutes 2
• Do not assume a 30-minute seizure is benign—this requires thorough evaluation for serious underlying pathology including CNS infections 2
• Never prescribe prophylactic anticonvulsants for simple febrile seizures, as risks clearly outweigh benefits 1, 3
• Do not use antipyretics with the expectation of preventing seizure recurrence 1, 5

Prophylactic Management Considerations

Rescue Medication Prescription

A rescue benzodiazepine (rectal diazepam) might be prescribed for home use when the risk of prolonged febrile seizure recurrence exceeds 20%. 4

High-risk criteria include: 4

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

Long-Term Anticonvulsant Prophylaxis

Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for simple febrile seizures, as potential toxicities clearly outweigh the minimal risks. 1, 3

• Valproic acid carries risk of rare fatal hepatotoxicity, particularly in children <2 years 3
• Phenobarbital causes hyperactivity, irritability, and sleep disturbances 3
• Intermittent diazepam causes lethargy and may mask evolving CNS infections 1

When to Request Neurological Consultation

Refer to pediatric neurology for: 4

• Prolonged febrile seizures (>15 minutes) before age 1 year
• Prolonged AND focal febrile seizures
• Repetitive focal febrile seizures within 24 hours
• Multiple complex febrile seizures (focal, prolonged, or repetitive)
• Abnormal neurological examination or developmental delay in a child with febrile seizures
• Febrile status epilepticus to determine if underlying seizure disorder exists 2

Parent Education and Reassurance

Simple febrile seizures have an excellent prognosis with no long-term effects on IQ, academic performance, neurocognitive function, or behavior. 2, 3

Key counseling points: 1, 2, 5

• Simple febrile seizures cause no structural brain damage
• Risk of developing epilepsy is approximately 1% (same as general population)
• Recurrence risk is approximately 30% overall, higher (50%) in children <12 months at first seizure
• Provide practical guidance on home seizure management and when to activate emergency services
• Schedule follow-up with primary care physician for ongoing support 4