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

Management of Febrile Seizures in Children

For a child presenting with a febrile seizure, the immediate priority is supportive care with positioning on their side and protecting from injury, followed by identifying the fever source, with no routine neuroimaging, EEG, or prophylactic anticonvulsants indicated for simple febrile seizures. 1

Immediate Management During Active Seizure

• Position the child on their side to prevent aspiration, clear the surrounding area of harmful objects, and protect the head from injury 1, 2
• Never restrain the patient or place anything in the mouth during active seizure activity 1, 2
• Most febrile seizures are self-limiting and resolve spontaneously within minutes 2
• For seizures lasting >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

When to Activate Emergency Services

• Call emergency services for: first-time seizure, seizure in a child under 6 months, seizure lasting >5 minutes, repeated seizures without return to baseline, or seizure with traumatic injury or respiratory difficulty 2

Classification: Simple vs Complex Febrile Seizures

Simple febrile seizures are defined by ALL of the following criteria 1:

• Generalized (not focal) seizure
• Duration <15 minutes
• Single episode within 24 hours
• Temperature ≥100.4°F (38°C)
• No intracranial infection present

Complex febrile seizures have ANY of the following features 1:

• Duration ≥15 minutes
• Focal neurologic findings
• Recurrence within 24 hours

Diagnostic Evaluation

For Simple Febrile Seizures:

• Routine neuroimaging, EEG, and laboratory tests are NOT indicated 1
• The American Academy of Pediatrics and American College of Radiology explicitly list EEG as an inappropriate investigation that should not be performed 1
• Focus diagnostic efforts on identifying the source of fever (e.g., urinary tract infection, otitis media, viral illness) 1

Age-Specific Lumbar Puncture Indications:

• Children <12 months with fever and seizure should undergo lumbar puncture to rule out meningitis, as meningeal signs may be absent in up to one-third of cases 1
• For children ≥12 months: lumbar puncture is required if there are signs of meningitis (meningismus, altered mental status, excessive somnolence, irritability, systemic illness) 1
• Lumbar puncture should be discussed for focal or repetitive febrile seizures even without overt meningeal signs 3
• Lumbar puncture is NOT necessary for simple febrile seizures in children ≥12 months without signs of meningitis 1

For Complex Febrile Seizures:

• The neurological examination should guide further evaluation 4
• Consider neuroimaging (MRI with diffusion-weighted imaging is most sensitive) if there are persistent focal findings or concern for structural abnormality 1

Long-Term Management and Prophylaxis

The American Academy of Pediatrics recommends that neither continuous nor intermittent anticonvulsant prophylaxis is used for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks 1

Why No Prophylaxis:

• Valproic acid carries risks of rare fatal hepatotoxicity, thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis, especially in children <2 years 1
• Phenobarbital causes hyperactivity, irritability, lethargy, sleep disturbances, hypersensitivity reactions, and cognitive impairment (mean IQ reduction of 7 points during treatment) 1
• Intermittent diazepam may reduce recurrence but does not improve long-term outcomes and causes lethargy, drowsiness, and ataxia 1

Antipyretic Use:

• Use antipyretics (acetaminophen or ibuprofen) for the child's comfort and to prevent dehydration, NOT for seizure prevention 1
• Antipyretics do not prevent febrile seizures or reduce recurrence risk 1
• One study showed rectal acetaminophen reduced short-term recurrence risk, but this is not standard practice 4

Rescue Medications:

• Patients with known epilepsy or high-risk features may have rescue medications prescribed (rectal diazepam or buccal midazolam) for seizures lasting >5 minutes 1

Indications for Neurology Referral

Request neurological consultation if ANY of the following are present 1, 3:

• Prolonged febrile seizures (≥15 minutes), especially before age 1 year
• Repetitive focal febrile seizures
• Multiple complex febrile seizures
• Abnormal neurological exam or developmental delay
• High risk of prolonged febrile status epilepticus (>20% risk): 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 3

Prognosis and Parent Education

Excellent Long-Term Outcomes:

• Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or behavioral abnormalities 1
• No evidence exists that simple febrile seizures cause structural brain damage 1
• The risk of developing epilepsy by age 7 is approximately 1%, identical to the general population 1
• 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

Recurrence Risk:

• Overall recurrence risk is approximately 30% 1, 2
• Children <12 months at first seizure have approximately 50% probability of recurrent febrile seizures 1, 2
• Children >12 months at first seizure have approximately 30% probability of a second febrile seizure 1
• Of those who have a second febrile seizure, 50% have at least one additional recurrence 1

Practical Home Management Instructions:

• Position the child on their side during a seizure 2
• Do not place anything in the mouth 2
• Seek emergency care if the seizure lasts >5 minutes or the child does not return to baseline 1
• Reassure parents that febrile seizures, while frightening, are benign and do not cause brain damage or affect intelligence 2, 4

Common Pitfalls to Avoid

• Do not order routine EEG for simple febrile seizures - this is explicitly listed as inappropriate by the American Academy of Pediatrics 1
• Do not prescribe prophylactic anticonvulsants for simple febrile seizures - the harm clearly outweighs any benefit 1
• Do not skip lumbar puncture in infants <12 months - meningeal signs are often absent in this age group 1
• Do not tell parents that antipyretics will prevent seizure recurrence - they will not 1
• If a child is already on phenobarbital for simple febrile seizures, taper and discontinue it - it was inappropriately initiated and provides no benefit 1