What is the recommended treatment for febrile seizures in pediatric patients?

Management of Febrile Seizures in Pediatric Patients

Acute Management of Active Seizures

For febrile seizures lasting more than 5 minutes, administer IV lorazepam 0.05-0.1 mg/kg (maximum 4 mg) slowly at 2 mg/min, or IV diazepam 0.2-0.5 mg/kg (maximum 5 mg for children <5 years) over 2 minutes as first-line treatment. 1, 2

Immediate Intervention Steps

• Position the child on their side, remove harmful objects from the environment, and protect the head from injury 2
• Never restrain the patient or place anything in the mouth during active seizure activity 2, 3
• Assess airway, breathing, and circulation immediately 2

Medication Administration Algorithm

• When IV access is available: Administer IV lorazepam (preferred) or IV diazepam as first-line benzodiazepines 1, 2
• When IV access is not available: Use rectal diazepam solution, which is effective in 80% of cases when given early (seizures ≤15 minutes) and 57% when given late (seizures >15 minutes) 3, 4
• Never use IM diazepam: This route causes tissue necrosis, is contraindicated, and has erratic absorption 1, 3

If Seizures Persist

• Repeat benzodiazepine dose every 5-10 minutes if seizures continue 1
• Immediately follow with a long-acting anticonvulsant such as fosphenytoin or phenobarbital after benzodiazepine administration 1
• Search for underlying causes including hypoglycemia, electrolyte abnormalities, infection, and hypoxia 1

Classification and Diagnostic Approach

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 2, 3

Complex febrile seizures have duration ≥15 minutes, focal neurologic findings, or recurrence within 24 hours 2, 3

Diagnostic Testing for Simple Febrile Seizures

Routine diagnostic testing is NOT indicated for simple febrile seizures in well-appearing children. 2, 5

• No routine laboratory tests, neuroimaging, or EEG should be performed 2, 5
• Evaluation should focus only on identifying the source of fever 2, 5
• EEG is explicitly listed as an inappropriate investigation that should not be performed on more than a small minority of patients with simple febrile seizures 2
• Neuroimaging is not indicated, as the American College of Radiology found that even when abnormalities are present (11.4% of cases), they do not alter clinical management 3

Special Consideration for Infants

• Children under 12 months of age 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 2

Diagnostic Testing for Complex Febrile Seizures

• The neurologic examination should guide further evaluation 5
• Neuroimaging may be considered only when postictal focal neurological deficits are present, underlying pathology is suspected, or febrile status epilepticus has occurred 3

Long-Term Management and Prophylaxis

Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 2, 3

Why Prophylaxis is Not Recommended

• The harm-benefit analysis clearly favors no treatment for simple febrile seizures 2
• Prophylaxis does not prevent the development of epilepsy or improve long-term outcomes 2, 6
• Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or behavioral abnormalities 2
• No evidence exists that simple febrile seizures cause structural brain damage 2

Specific Medications to Avoid

Valproic acid: Risk of rare fatal hepatotoxicity, thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis, especially in children younger than 2 years 2

Phenobarbital: Causes hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions in 20-40% of patients, with mean IQ reduction of 7 points during treatment 2

Intermittent diazepam prophylaxis: May reduce recurrence rates but does not improve long-term outcomes and causes lethargy, drowsiness, and ataxia 2

Home Rescue Medication Option

• For selected cases with multiple or prolonged recurrences, parents may be provided with rectal diazepam solution to administer at home at seizure onset to prevent prolonged recurrent seizures 6, 4
• This approach is effective, inexpensive, feasible for non-professionals, has few side effects, and is well accepted by parents 6

Role of Antipyretics

Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizures or reduce recurrence risk. 2, 3, 5

• Antipyretics should be used for the child's comfort and to prevent dehydration, but not for seizure prevention 2
• One study showed rectal acetaminophen reduced the risk of short-term recurrence following a febrile seizure, but this is not the standard recommendation 5

Prognosis and Parent Education

Excellent Long-Term Outcomes

• Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, or neurocognitive function 2
• No structural brain damage occurs from simple febrile seizures 2
• The risk of developing epilepsy by age 7 is approximately 1%, identical to the general population 2
• 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 2

Recurrence Risk

• Children younger than 12 months at first seizure have approximately 50% probability of recurrent febrile seizures 2
• Children older than 12 months at first seizure have approximately 30% probability of a second febrile seizure 2, 3
• Of those who have a second febrile seizure, 50% have at least one additional recurrence 2

Parent Counseling Points

• Educate caregivers about the benign nature of simple febrile seizures and excellent prognosis 2, 3
• Provide practical home management guidance and when to seek emergency care 2
• Provide both verbal counseling and supplementary written materials 2

When to Seek Emergency Care

• First-time seizures 3
• Seizures lasting >5 minutes 3
• Multiple seizures without return to baseline 3
• Seizures with traumatic injuries, breathing difficulties, or choking 3

Referral Indications

• Neurological consultation should be requested if there are prolonged febrile seizures, repetitive focal febrile seizures, or abnormal neurological exam or development 2
• Refer to pediatric neurology if the first antiepileptic medication fails in children with epilepsy 2

Critical Pitfalls to Avoid

• Never delay benzodiazepine administration to obtain additional history or imaging for active seizures, as time-to-treatment directly influences outcome and mortality 1
• Do not prescribe prophylactic anticonvulsants for simple febrile seizures, as the risks outweigh benefits 2, 3
• Do not perform routine neuroimaging or EEG for simple febrile seizures 2, 3
• Never use IM diazepam due to tissue necrosis and contraindication 1, 3