What is the recommended acute treatment and follow‑up for a simple febrile seizure in a child aged 6 months to 5 years presenting with fever ≥38 °C?

Management of Simple Febrile Seizures in Children

Acute Management

For a simple febrile seizure in a child aged 6 months to 5 years, the acute treatment is supportive only—position the child on their side, protect the head, remove dangerous objects, and allow the seizure to resolve spontaneously without medication, as most terminate within 1-2 minutes. 1

During the Seizure

• Place the child in the recovery position (lateral decubitus) to maintain airway patency and prevent aspiration 1, 2
• Clear the surrounding area of harmful objects and cushion the head from injury 2
• Never restrain the child or place anything in the mouth during active seizure activity 1, 2
• Do not administer anticonvulsants for a simple febrile seizure that resolves spontaneously 1

When to Administer Emergency Medication

• Administer benzodiazepines only if the seizure continues beyond 5 minutes, as this indicates progression to status epilepticus rather than a simple febrile seizure 2, 3
• First-line: Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 2
• Alternative if IV access unavailable: Rectal diazepam 0.2-0.5 mg/kg (maximum 5 mg for children under 5 years) 1, 4

When to Activate Emergency Services

• Call emergency services for first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, or seizures with traumatic injuries, breathing difficulties, or choking 1

Diagnostic Evaluation

Routine diagnostic testing—including laboratory tests, neuroimaging (CT/MRI), and EEG—is NOT indicated for simple febrile seizures in well-appearing, fully immunized children. 1, 2, 3, 5

Evaluation to Identify Fever Source

• Perform only the diagnostic tests necessary to identify the source of fever (e.g., urinalysis for suspected UTI, rapid strep test for pharyngitis) 1, 2
• No routine blood work, lumbar puncture, or neuroimaging is required for simple febrile seizures 1, 2, 5

Critical Exception: Infants Under 12 Months

• Strongly consider lumbar puncture in children under 12 months of age with fever and seizure, as meningeal signs may be absent in up to one-third of bacterial meningitis cases 1, 4
• This recommendation reflects the higher risk of occult meningitis in this age group despite immunization 4

When Further Evaluation IS Indicated

• Lumbar puncture: if clinical signs suggest meningitis or encephalitis at any age 1, 4
• Neuroimaging: only if focal neurological deficits persist post-ictally, concern for intracranial pathology exists, or febrile status epilepticus occurred 1, 2
• Neurology referral: if the seizure was complex (>15 minutes, focal features, or multiple within 24 hours), abnormal neurological exam, or developmental concerns 1

Long-Term Management and Prophylaxis

Neither continuous nor intermittent anticonvulsant prophylaxis should be prescribed for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 1, 2, 6, 7

Why No Prophylaxis

• Simple febrile seizures cause no structural brain damage, no decline in IQ, academic performance, neurocognitive function, or behavior 1, 2
• The risk of developing epilepsy by age 7 is approximately 1%, identical to the general population 1, 2
• Even high-risk children (multiple seizures, age <12 months at first seizure, family history of epilepsy) have only 2.4% risk of epilepsy by age 25 1, 2
• No medication prevents the development of epilepsy; increased epilepsy risk is due to genetic predisposition, not the febrile seizures themselves 1, 2

Specific Medications to Avoid

• Phenobarbital: causes hyperactivity, irritability, lethargy, and sleep disturbances in 20-40% of patients; reduces IQ by mean of 7 points during treatment (persisting 5.2 points lower 6 months after discontinuation) 1, 2
• Valproic acid: rare fatal hepatotoxicity (especially in children <2 years), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis 1, 2
• Intermittent diazepam: causes lethargy, drowsiness, ataxia; may mask evolving CNS infection 1, 2
• Carbamazepine and phenytoin: ineffective for febrile seizure prevention 2

Role of Antipyretics

• Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizures or reduce recurrence risk 1, 2, 3, 7
• Use antipyretics only for the child's comfort and to prevent dehydration, not for seizure prevention 1, 2

Parent Education and Follow-Up

The cornerstone of management is comprehensive parent education emphasizing the benign nature, excellent prognosis, and practical home management of simple febrile seizures. 1, 2, 3

Key Counseling Points

• Simple febrile seizures are common (2-5% of children) and self-limited, typically resolving within 1-2 minutes 1, 6
• More than 90% of children with febrile seizures will NOT develop epilepsy 1
• Recurrence risk is approximately 30% overall; higher (50%) in children <12 months at first seizure, lower (30%) in those >12 months 1, 2
• Of those who have a second febrile seizure, 50% will have at least one additional recurrence 2
• No long-term adverse effects on intelligence, academic performance, or behavior occur 1, 2, 3

Home Management Instructions

• During a seizure: place child on side, protect head, remove dangerous objects, time the seizure 1, 2
• Never restrain or place anything in the mouth 1, 2
• Call emergency services if seizure lasts >5 minutes, multiple seizures occur, or breathing difficulties develop 1
• Provide supplementary written materials to reinforce verbal counseling 1

Routine Follow-Up

• Schedule follow-up with the primary care physician for ongoing reassurance and to address parental concerns 1
• No routine neurology referral is needed for simple febrile seizures 1, 2

Common Pitfalls to Avoid

• Do not order routine EEG, CT, or MRI for simple febrile seizures—these are explicitly listed as inappropriate investigations 1, 2, 5
• Do not prescribe prophylactic anticonvulsants—the American Academy of Pediatrics is unequivocal that risks outweigh benefits 1, 2, 7
• Do not recommend aggressive antipyretic use to prevent seizures—this is ineffective and creates false expectations 1, 2, 3
• Do not dismiss parental anxiety—provide thorough education and written materials to address concerns 1, 3
• Do not confuse simple with complex febrile seizures—complex features (>15 minutes, focal, or recurrent within 24 hours) warrant different evaluation 1, 2