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

Management of Febrile Seizures in Children

Immediate Seizure Management

For active febrile seizures, position the child on their side, protect the head from injury, remove harmful objects from the environment, and never restrain the patient or place anything in the mouth. 1

During Active Seizure (First 5 Minutes)

• Allow the seizure to run its course while maintaining airway protection and safety positioning 1
• Most febrile seizures terminate spontaneously without intervention 2
• Assess airway, breathing, and circulation continuously 1
• Gentle passive cooling may assist in seizure termination, but avoid rapid cooling measures like alcohol rubdowns or ice baths as these can induce shivering and paradoxically elevate fever 3

For Prolonged Seizures (>5 Minutes)

• Administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min as first-line treatment 1, 4
• Activate emergency medical services immediately 4
• Early benzodiazepine administration may prevent progression to status epilepticus 4

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Classification: Simple vs. Complex Febrile Seizures

Simple febrile seizures are defined as generalized seizures lasting <15 minutes, occurring once in 24 hours, in febrile children (temperature ≥100.4°F/38°C) aged 6-60 months without intracranial infection. 1, 5

Complex Febrile Seizure Features:

• Duration ≥15 minutes 1, 5
• Focal neurologic findings 1, 5
• Multiple seizures within 24 hours 1, 5

This distinction is critical because it determines the diagnostic workup and need for neuroimaging 1, 4

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Diagnostic Evaluation

For Simple Febrile Seizures:

Routine laboratory tests, neuroimaging (CT/MRI), and EEG are NOT indicated for simple febrile seizures. 1, 5 The British Medical Association and American Academy of Pediatrics explicitly list EEG as an inappropriate investigation that should not be performed 1

Lumbar Puncture Indications:

• Required: Any child with meningeal signs, septic appearance, or behavioral disturbance 6
• Consider: Focal or repetitive febrile seizures without clear meningitis signs, based on clinical progression 6
• Not necessary: Simple febrile seizures without meningitis signs, including infants 6-12 months old 6
• Special consideration: Children <12 months with fever and seizure warrant careful evaluation, as meningeal signs may be absent in up to one-third of meningitis cases; early clinical re-evaluation at least 4 hours after initial assessment is helpful 1, 6

For Complex Febrile Seizures or Febrile Status Epilepticus (≥30 minutes):

• MRI brain imaging is recommended due to increased association with structural findings 4
• Exclude serious underlying pathology including meningitis, encephalitis, CNS infections, metabolic disorders, and structural abnormalities 4
• Consultation with pediatric neurology is essential 4

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Acute Fever Management

Antipyretics (acetaminophen or ibuprofen) should be used for the child's comfort and to prevent dehydration, but NOT for seizure prevention, as they do not prevent febrile seizures or reduce recurrence risk. 1, 5

• Rectal forms are preferred in the early treatment phase 3
• One exception: rectal acetaminophen may reduce short-term recurrence risk immediately following a febrile seizure 7
• Identify and treat the source of fever 1

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Long-Term Prophylaxis: What NOT to Do

Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 1, 5

Specific Medications to Avoid:

• Valproic acid: Risk of rare fatal hepatotoxicity, thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis, especially in children <2 years 1
• Phenobarbital: Causes hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions 1
• Intermittent diazepam: May reduce recurrence but does not improve long-term outcomes; causes lethargy, drowsiness, and ataxia 1

The harm-benefit analysis clearly favors no prophylactic treatment 1

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Rescue Medication Prescription

Consider prescribing rescue medications (rectal diazepam or buccal midazolam) when the risk of prolonged febrile seizure is >20%, specifically for children with: 6

• 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

For children without these high-risk features, rescue medications are not routinely indicated 1

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Prognosis and Recurrence Risk

Excellent Long-Term Prognosis:

Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, behavioral abnormalities, or structural brain damage. 1, 5

Epilepsy Risk:

• Risk of developing epilepsy is approximately 1%, identical to the general population 1, 5
• Even children with multiple simple febrile seizures, first seizure before 12 months, and family history of epilepsy have only 2.4% risk of developing epilepsy by age 25 years 1

Febrile Seizure Recurrence:

• Children <12 months at first seizure: approximately 50% probability of recurrence 1, 5
• Children >12 months at first seizure: approximately 30% probability of recurrence 1, 5
• Of those who have a second febrile seizure, 50% will have at least one additional recurrence 1
• Family history of febrile seizures increases recurrence risk 5

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Neurology Referral Indications

Request neurological consultation for: 6

• Prolonged febrile seizures (≥15 minutes) before age 1 year
• Prolonged AND focal febrile seizures, or repetitive focal febrile seizures within 24 hours
• Multiple complex febrile seizures (focal, prolonged, or repetitive)
• Abnormal neurological examination or development in a child with febrile seizures
• Febrile status epilepticus (≥30 minutes) to determine if underlying seizure disorder exists 4

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Parent Education and Counseling

Educate caregivers about the benign nature of simple febrile seizures, emphasizing that these events do not cause brain damage or affect future intelligence. 1, 5

Key Counseling Points:

• Reassure parents that witnessing a febrile seizure is terrifying but the condition is benign 7
• Provide practical home management guidance: positioning on side, protecting from injury, timing the seizure 1
• When to seek emergency care: Seizure lasting >5 minutes, difficulty breathing, or signs of meningitis 1
• Arrange follow-up with primary care physician, including verbal counseling and written materials 1, 6
• Explain recurrence risks based on age at first seizure 1

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Critical Pitfalls to Avoid

• Never delay benzodiazepine administration for seizures lasting >5 minutes 4
• Never assume a 30-minute seizure is benign—this requires thorough evaluation for serious underlying pathology 4
• Never perform routine EEG for simple febrile seizures—this is explicitly listed as inappropriate 1
• Never prescribe prophylactic anticonvulsants for simple febrile seizures due to unacceptable risk-benefit ratio 1, 5
• Never use rapid cooling measures (ice baths, alcohol rubdowns) as these may worsen fever through shivering 3