Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

febrile status epilepticus

1st line – consultation with paediatric neurologist or paediatric intensivist

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INITIAL
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febrile status epilepticus
1st line – 

consultation with paediatric neurologist or paediatric intensivist

Febrile status epilepticus may be defined as a prolonged seizure or recurrent brief seizures without complete recovery of consciousness. The duration criterion is controversial, but preparations for implementation of a full status epilepticus protocol should begin after failure of initial benzodiazepine treatment.[89][90]

Status epilepticus should be managed according to local/national guidelines.

ACUTE

first simple febrile seizure

1st line – antipyretic

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ACUTE
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first simple febrile seizure
1st line – 

antipyretic

Simple febrile seizure: generalised, lasts <15 minutes, not repeated in a 24-hour period.

Antipyretic agents are ineffective for preventing recurrences of febrile seizures and for lowering body temperature in patients with a febrile episode that leads to a recurrent febrile seizure.[81]

Antipyretics, on their own, have not been shown to prevent febrile seizures or their recurrence.[46][80][82] They facilitate heat loss, but are not absorbed sufficiently rapidly to reduce the peak temperature.[81][82]

Recommendations differ; ibuprofen acts for longer, and is often the preferred antipyretic agent.[83]

Primary options

ibuprofen: children 6 months-12 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

OR

paracetamol: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

Consider – anticonvulsant

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ACUTE
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first simple febrile seizure
Consider – 

anticonvulsant

Additional treatment recommended for SOME patients in selected patient group

If a patient has a seizure lasting more than 5 minutes, an initial dose of buccal midazolam may be given. If the seizure does not abate in 10 minutes, another dose is given. If buccal midazolam is not available, rectal diazepam may be given.

Rectal diazepam is not approved for children below the age of 1 year in the UK or 2 years in the US.

If these two doses of a benzodiazepine fail, one dose of intravenous phenytoin is given.

If the seizure persists after phenytoin has been started, the next step for terminating the seizure involves intensive care treatment and a specialist (paediatric intensivist) should be consulted.

Primary options

midazolam: children <3 months of age: consult specialist for guidance on dose; children 3-11 months of age: 2.5 mg buccally as a single dose, repeat after 10 minutes if required; children 1-4 years of age: 5 mg buccally as a single dose, repeat after 10 minutes if required; children 5-9 years of age: 7.5 mg buccally as a single dose, repeat after 10 minutes if required; children 10-17 years of age: 10 mg buccally as a single dose, repeat after 10 minutes if required

OR

diazepam: children <2 years of age: consult specialist for guidance on dose; children 2-5 years of age: 0.5 mg/kg rectally as a single dose, may repeat in 4-12 hours if required; children 6-11 years of age: 0.3 mg/kg rectally as a single dose, may repeat in 4-12 hours if required

Secondary options

phenytoin: infants and children: 15-20 mg/kg intravenously as a single dose; consult specialist for further guidance on dose

first complex seizure

1st line – antipyretic

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ACUTE
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first complex seizure
1st line – 

antipyretic

The seizure is prolonged (lasting over 15 minutes), focal, or multiple in 24 hours.

Between 9% and 35% of all first febrile seizures are complex.[6]

Treatment involves an antipyretic until the fever abates.

Primary options

ibuprofen: children 6 months-12 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

OR

paracetamol: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

Plus – anticonvulsant

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ACUTE
|
first complex seizure
Plus – 

anticonvulsant

Treatment recommended for ALL patients in selected patient group

If a patient has a seizure lasting more than 5 minutes, an initial dose of buccal midazolam may be given. If the seizure does not abate in 10 minutes, another dose is given. If buccal midazolam is not available, rectal diazepam may be given.

Rectal diazepam is not approved for children below the age of 1 year in the UK or 2 years in the US.

If these two doses of a benzodiazepine fail, one dose of intravenous phenytoin is given.

If the seizure persists after phenytoin has been started, the next step for terminating the seizure involves intensive care treatment and a specialist (paediatric intensivist) should be consulted.

Primary options

midazolam: children <3 months of age: consult specialist for guidance on dose; children 3-11 months of age: 2.5 mg buccally as a single dose, repeat after 10 minutes if required; children 1-4 years of age: 5 mg buccally as a single dose, repeat after 10 minutes if required; children 5-9 years of age: 7.5 mg buccally as a single dose, repeat after 10 minutes if required; children 10-17 years of age: 10 mg buccally as a single dose, repeat after 10 minutes if required

OR

diazepam: children <2 years of age: consult specialist for guidance on dose; children 2-5 years of age: 0.5 mg/kg rectally as a single dose, may repeat in 4-12 hours if required; children 6-11 years of age: 0.3 mg/kg rectally as a single dose, may repeat in 4-12 hours if required

Secondary options

phenytoin: infants and children: 15-20 mg/kg intravenously as a single dose; consult specialist for further guidance on dose

ONGOING

febrile illness with prior history of simple seizure or 1 complex seizure

1st line – antipyretic

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ONGOING
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febrile illness with prior history of simple seizure or 1 complex seizure
1st line – 

antipyretic

Antipyretics improve the child's comfort, but will not prevent seizure recurrence; they facilitate heat loss, but are not absorbed sufficiently rapidly to reduce the peak temperature.[81][82]

Using around-the-clock prophylactic administration of antipyretics has not been shown to affect the incidence of recurrence of febrile seizures, and is not recommended.[97]

Primary options

ibuprofen: children 6 months-12 years of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day

OR

paracetamol: 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day

Consider – prophylactic diazepam

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ONGOING
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febrile illness with prior history of simple seizure or 1 complex seizure
Consider – 

prophylactic diazepam

Additional treatment recommended for SOME patients in selected patient group

Oral diazepam is not generally recommended to prevent simple febrile seizure recurrence, due to its potential toxicities.[2][82] However, it may be indicated in certain cases, such as frequent febrile seizure recurrence, low temperature threshold for febrile seizure, and/or parental anxiety.[63]

Prophylactic diazepam may be continued until fever, and therefore risk of seizure, abates.

Primary options

diazepam: children >6 months: 0.3 mg/kg orally every 8 hours

history of 2 or more complex febrile seizures with ineffective diazepam treatment

1st line – prophylactic anticonvulsant

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ONGOING
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history of 2 or more complex febrile seizures with ineffective diazepam treatment
1st line – 

prophylactic anticonvulsant

Long-term anticonvulsant treatment may be considered in consultation with a neurologist.[98]

The patient may be slowly weaned off the anticonvulsant after 6 months without seizures.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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