What is the management for a child presenting with a febrile seizure?

Management of Febrile Seizures in Children

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

Acute Seizure Management

For actively seizing children, administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min as first-line treatment for seizures lasting >5 minutes. 2, 3

• If IV access is unavailable, use rectal diazepam; avoid IM diazepam due to erratic absorption 2
• Position the child on their side, protect the head from injury, and remove harmful objects from the environment 2, 3
• Never restrain the patient or place anything in the mouth during active seizure activity 2, 3
• Assess and secure airway, breathing, and circulation immediately 2

Critical Initial Assessment

Measure blood glucose concentration immediately with a glucose oxidase strip in any child who is still convulsing or unrousable. 1, 2, 4

Indications for Lumbar Puncture

Perform lumbar puncture if ANY of the following are present: 1, 2, 4, 5

• Clinical signs of meningism or sepsis
• Child is unduly drowsy, irritable, or systemically ill
• After a complex convulsion (focal, prolonged >15 minutes, or recurrent within 24 hours)
• Age <12 months (strongly consider; almost always indicated) 1, 4
• Age 12-18 months (discuss based on clinical presentation and ability to reassess within 4 hours) 5
• Child has not completely recovered within one hour 1

A lumbar puncture is NOT necessary for simple febrile seizures in children >12 months without meningeal signs, even though this represents a change from older conservative approaches. 5 The key caveat: the clinician must be prepared to review this decision within a few hours and perform early clinical re-evaluation. 1, 5

Fever Management

Treat fever with paracetamol (acetaminophen) to promote comfort and prevent dehydration, but understand that antipyretics do NOT prevent febrile seizures or reduce recurrence risk. 2, 3

• Avoid physical methods such as fanning, cold bathing, and tepid sponging as they cause discomfort without benefit 2
• Ensure adequate fluid intake 1

Disposition Decisions

Admit children who: 2, 3

• Have not returned to neurologic baseline
• Have concerning neurologic findings on examination
• Require ongoing seizure management
• Are systemically ill or require investigation for serious bacterial infection
• Had a complex convulsion lasting >20 minutes (neuroimaging with CT or MRI usually performed first) 2, 3

Children with simple febrile seizures who have returned to baseline and have no concerning features can be discharged home with appropriate parent education. 6, 7

Long-Term Prophylaxis: The Evidence Against Treatment

The harm-benefit analysis clearly favors no prophylactic treatment for simple febrile seizures. 1, 3

Why Prophylaxis Is Not Recommended:

• Phenobarbital and valproic acid are effective at preventing recurrence but carry unacceptable risks: 1

  • Valproic acid: rare fatal hepatotoxicity (especially in children <2 years who are at greatest risk of febrile seizures), thrombocytopenia, weight changes, gastrointestinal disturbances, pancreatitis 1, 3
  • Phenobarbital: hyperactivity, irritability, lethargy, sleep disturbances, hypersensitivity reactions 1, 3

• Intermittent diazepam causes lethargy, drowsiness, and ataxia, and risks masking an evolving CNS infection 1

• Carbamazepine and phenytoin are NOT effective for preventing febrile seizure recurrence 1

Exception: Rescue Medications for High-Risk Recurrence

Consider prescribing rescue rectal diazepam when the risk of prolonged febrile seizure recurrence is >20%, specifically when: 5

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

This is for acute rescue during a recurrent seizure, NOT for continuous prophylaxis. 5

Diagnostic Testing: What NOT to Do

Routine EEG is NOT indicated and should not be performed for simple febrile seizures. 1, 3, 4

Routine neuroimaging is NOT indicated for simple febrile seizures. 3

Routine laboratory tests (blood urea, serum electrolytes, serum calcium) are NOT necessary in most cases. 4

The only routine investigation needed is identifying the source of fever. 3

Indications for Neurology Referral

Request neurological consultation if: 3, 5

• Prolonged febrile seizure (>15 minutes) before age 1 year
• Prolonged AND focal febrile seizures, or repetitive focal seizures within 24 hours
• Multiple complex febrile seizures (focal, prolonged, or repetitive)
• Abnormal neurological examination or abnormal development

Parent Education and Prognosis

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

Key counseling points: 3, 6

• No structural brain damage occurs from simple febrile seizures 3
• Risk of developing epilepsy by age 7 is approximately 1%, identical to the general population 3
• Even children with multiple risk factors (multiple simple febrile seizures, first seizure before 12 months, family history of epilepsy) have only 2.4% risk of developing epilepsy by age 25 years 3

Recurrence risk: 3, 6

• Overall recurrence risk is approximately 30% 1, 6
• Children <12 months at first seizure: approximately 50% probability of recurrence 3
• Children >12 months at first seizure: approximately 30% probability of recurrence 3
• Of those who have a second febrile seizure, 50% have at least one additional recurrence 3

Provide verbal counseling and supplementary written materials about home management and when to seek emergency care, as witnessing a febrile seizure is a terrifying experience for parents who often believe their child is dying. 5, 6, 8

Common Pitfalls to Avoid

• Do not over-investigate simple febrile seizures with EEG, neuroimaging, or extensive metabolic panels 3, 4
• Do not prescribe continuous anticonvulsant prophylaxis—the toxicities outweigh benefits 1
• Do not dismiss the need for lumbar puncture in infants <12 months, as meningeal signs may be absent 1, 4, 5
• Do not tell parents that antipyretics prevent seizures—they do not, though they improve comfort 2, 3
• Do not delay lumbar puncture in any child with concerning features (meningism, altered mental status, systemic illness, incomplete recovery) 1, 2, 4