When can a child with a complex febrile seizure be considered for discharge?

Discharge Criteria for Complex Febrile Seizures in Children

A child with a complex febrile seizure can be discharged once meningitis/encephalitis has been clinically excluded, the child has returned to baseline neurological status, the fever source has been identified and appropriately treated, and parents have been educated on seizure management—typically within 24 hours of presentation if these criteria are met. 1, 2, 3

Immediate Post-Seizure Assessment Required Before Discharge Consideration

• The child must have returned to their baseline neurological status with a normal neurological examination, as any persistent focal deficits or altered mental status requires extended observation and neuroimaging 4, 1
• Vital signs must be stable, including resolution of active seizure activity and adequate oxygenation 1
• The child should be alert, interactive, and able to tolerate oral intake 1, 5

Critical Exclusions Before Discharge

Meningitis/Encephalitis Evaluation

• Lumbar puncture is mandatory if there are any meningeal signs, septic appearance, or behavioral disturbances, as meningitis can present with seizures and delayed diagnosis carries risk of permanent neurological morbidity and death 5, 3, 6
• For complex febrile seizures (focal features, duration >15 minutes, or recurrence within 24 hours) without clear meningeal signs, lumbar puncture should be discussed based on clinical symptoms and their evolution over time, particularly in children under 12 months where meningeal signs may be absent in up to one-third of cases 5, 3
• An early clinical re-evaluation at least 4 hours after initial assessment is helpful, especially in infants younger than 12 months, to monitor for evolving signs of central nervous system infection 3
• Simple observation without lumbar puncture is acceptable only when the child has a clear fever source, normal neurological exam, normal behavior, and no septic appearance 3, 6

Neuroimaging Indications

• Routine neuroimaging (CT or MRI) is not indicated for complex febrile seizures unless there are persistent post-ictal focal deficits, signs of increased intracranial pressure, or concern for trauma/abuse 4, 2
• CT head revealed no findings requiring intervention in 161 children with complex febrile seizures across six studies 4
• Neuroimaging may be indicated for febrile status epilepticus (seizure lasting >30 minutes) due to increased association with imaging findings 4

Fever Source Identification and Treatment

• The underlying cause of fever must be identified and appropriately treated before discharge 1, 7
• Blood cultures, urinalysis, and urine culture should be obtained as clinically indicated, since urinary tract infections can cause fever and lower seizure threshold 5
• If bacterial infection is suspected (meningitis, sepsis), empirical antimicrobial therapy must be initiated and hospital admission is required 5

Mandatory Parent Education Before Discharge

• Parents must receive verbal counseling and written materials about the benign nature of complex febrile seizures and their excellent prognosis 1, 2, 8
• Specific instructions on when to activate emergency services: first-time seizure, seizure in child under 6 months, seizure lasting >5 minutes, repeated seizures without return to baseline, or seizure with traumatic injury or respiratory difficulty 2
• Practical guidance on home seizure management: position child on side, protect head, remove harmful objects, never restrain or place anything in mouth 1, 2
• Antipyretics (acetaminophen, ibuprofen) should be used for comfort and preventing dehydration, but parents must understand these do not prevent seizure recurrence 1, 2, 6

Rescue Medication Prescription Criteria

• Rescue medication (rectal diazepam or buccal midazolam) should be prescribed when risk of prolonged febrile seizure exceeds 20%: age at first seizure <12 months, history of previous febrile status epilepticus, first seizure was focal, abnormal development/neurological exam/MRI, or family history of nonfebrile seizures 1, 3
• Parents must be trained on proper administration technique before discharge 1

Neurology Referral Indications (Outpatient Follow-up)

• Neurological consultation should be arranged for: prolonged febrile seizure before age 1 year, prolonged AND focal seizures, repetitive focal seizures within 24 hours, multiple complex febrile seizures, or abnormal neurological exam/development 1, 3
• EEG and neurology evaluation are recommended for children with complex febrile seizures, but these can be arranged as outpatient follow-up and do not preclude discharge 4, 2

Conditions Requiring Hospital Admission Rather Than Discharge

• Persistent altered mental status or focal neurological deficits 4, 1
• Suspected or confirmed meningitis/encephalitis requiring antimicrobial therapy and close monitoring 5, 3
• Febrile status epilepticus (seizure >30 minutes) 4
• Age under 6 months (febrile seizures are not typical in this age group and require complete evaluation) 2, 5
• Inability to identify fever source or concern for serious bacterial infection 5
• Social concerns about parental ability to monitor child or access emergency care 8

Common Pitfalls to Avoid

• Do not routinely order EEG, CT, or laboratory tests for well-appearing children with complex febrile seizures who have returned to baseline, as these do not alter management and lead to over-investigation 4, 1, 6
• Do not prescribe continuous anticonvulsant prophylaxis (phenobarbital, valproic acid) as potential toxicities clearly outweigh minimal risks, with no improvement in long-term outcomes 1
• Do not falsely reassure parents that antipyretics prevent seizure recurrence, as there is no evidence supporting this practice (though rectal acetaminophen may reduce short-term recurrence risk) 7, 6
• Ensure follow-up with primary care physician is scheduled, as post-seizure visits are important for ongoing parental support and education 3, 8