What is the recommended treatment protocol for febrile seizures in a child aged 6 months to 5 years, including acute seizure control, fever management, and the approach to simple versus complex febrile seizures?

Febrile Seizures Treatment Protocol

For simple febrile seizures, no anticonvulsant prophylaxis should be prescribed—neither continuous nor intermittent—because the potential toxicities clearly outweigh the minimal risks in this benign, self-limited condition. 1

Acute Seizure Management

Immediate Intervention for Active Seizures

• Position the child on their side, remove harmful objects, and protect the head from injury—never restrain the patient or place anything in the mouth during active seizure activity. 1
• Assess airway, breathing, and circulation immediately, and provide high-flow oxygen if available. 1

Pharmacologic Treatment for Prolonged Seizures (>5 minutes)

• First-line: Lorazepam 0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min; repeat once after at least 1 minute if seizures continue, with a maximum of two doses. 1
• When IV access is unavailable, administer rectal diazepam rather than intramuscular diazepam, which has erratic absorption. 2
• For febrile status epilepticus (seizures lasting ≥15 minutes), transfer promptly to a pediatric intensive care unit and follow escalation protocols with levetiracetam 40 mg/kg IV (maximum 2,500 mg) as second-line, then phenobarbital 10–20 mg/kg IV (maximum 1,000 mg) as third-line. 1

Fever Management

• Antipyretics (acetaminophen or ibuprofen) should be used for the child's comfort and to prevent dehydration, but NOT for seizure prevention—they do not prevent febrile seizures or reduce recurrence risk. 1, 2, 3
• Round-the-clock prophylactic antipyretics have no demonstrated effect on febrile seizure recurrence. 4

Approach to Simple vs. Complex Febrile Seizures

Simple Febrile Seizures (Generalized, <15 minutes, single episode in 24 hours)

Diagnostic Evaluation:

• No routine laboratory tests, neuroimaging (CT or MRI), or EEG are indicated for simple febrile seizures. 1, 2
• Evaluation should focus only on identifying the source of fever. 1, 3
• Exception: In children <12 months of age, strongly consider lumbar puncture because meningeal signs may be absent in up to one-third of meningitis cases. 1

Long-Term Management:

• The American Academy of Pediatrics explicitly recommends AGAINST both continuous and intermittent anticonvulsant prophylaxis based on high-quality randomized controlled trial evidence. 1, 2
• The harm-benefit analysis clearly favors no treatment: valproic acid carries risk of rare fatal hepatotoxicity (especially in children <2 years), phenobarbital causes behavioral adverse effects in 20–40% of patients and reduces mean IQ by 7 points during treatment, and intermittent diazepam causes lethargy and may mask evolving CNS infection. 1, 5
• Carbamazepine and phenytoin are ineffective for febrile seizure prevention. 1

Prognosis and Parent Education:

• Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or behavioral abnormalities, and cause no structural brain damage. 1, 2
• Risk of developing epilepsy by age 7 is approximately 1%, identical to the general population. 1, 2
• More than 90% of children who experience a febrile seizure will not develop epilepsy later in life. 2
• Recurrence risk is approximately 30% overall, with children <12 months at first seizure having ~50% probability of recurrence, and those >12 months having ~30% probability. 1, 3

Complex Febrile Seizures (≥15 minutes, focal features, or >1 episode in 24 hours)

Diagnostic Evaluation:

• Neuroimaging is generally NOT indicated for complex febrile seizures unless specific concerning features are present: postictal focal neurological deficits, febrile status epilepticus, or suspicion of underlying pathology. 1, 2
• Analysis of 161 children with complex febrile seizures showed head CT revealed no findings requiring intervention. 1, 2
• EEG is NOT routinely indicated for complex febrile seizures—it is explicitly listed as an inappropriate investigation by the American Academy of Pediatrics and British Medical Association. 1, 6

Acute Management:

• Patients with prolonged seizures (≥30 minutes) or refractory seizures requiring ≥2 IV anticonvulsants are at increased risk for acute encephalitis (up to 25–67%) and require hospital admission. 7
• For early recurrent seizures within 24 hours, 82% occur within 8 hours of the first seizure. 7

Long-Term Management:

• Routine anticonvulsant prophylaxis is NOT recommended even for complex febrile seizures, as many children have benign long-term outcomes without treatment. 8
• For highly selected cases with multiple complex febrile seizures or severe parental anxiety, intermittent diazepam prophylaxis during febrile illness may be considered, though it does not improve long-term outcomes. 2, 8
• An alternative strategy is parent-administered rectal diazepam at seizure onset to prevent febrile status epilepticus. 8

Referral Indications:

• Request neurological consultation for prolonged febrile seizures, repetitive focal febrile seizures, or abnormal neurological exam or development. 1

Critical Pitfalls to Avoid

• Never prescribe prophylactic anticonvulsants (phenobarbital, valproic acid, clobazam, diazepam, carbamazepine, phenytoin) for simple febrile seizures—the risks outweigh any potential benefit in this benign condition. 1, 5
• Do not rely on antipyretics to prevent seizure recurrence—they provide comfort only. 1, 3
• Do not order routine neuroimaging or EEG for simple febrile seizures—these are inappropriate investigations. 1, 2
• Recognize that staring episodes during fever suggest absence seizures or other afebrile seizure types occurring coincidentally with fever, not true febrile seizures, and warrant EEG evaluation. 1

Home Management Education for Parents

• Educate caregivers about the benign nature of simple febrile seizures and excellent prognosis. 1, 3
• Provide practical guidance: help child to ground, place in recovery position, clear area, time the seizure. 2
• Activate emergency services for: first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, seizures with traumatic injuries, breathing difficulties, or choking. 2
• Provide verbal counseling and supplementary written materials about febrile seizure management. 1