Febrile seizure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Control of the seizure is the first goal in treatment. During a witnessed seizure, the patient should be protected from physical injury. Additionally, airway, breathing, and circulatory assessment and support are vital. Most seizures will stop spontaneously within a few minutes, and anticonvulsant therapy is not needed. Body temperature should be reduced to relieve discomfort.

Although many children presenting to the hospital with simple febrile seizures are managed appropriately, a large number are over-investigated and overtreated, based on the clinical experience of the treating doctor.[42][82] Clinical acumen remains the most important tool for identifying children with seizures who are candidates for a more elaborate diagnostic evaluation.[83] Recognizing the pattern of a simple febrile seizure in young children is important to limit interventions and to reassure parents.[84]

First simple febrile seizure

Most causative infections are viral and do not require antibiotics.[11][41]
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.[46][85][86][87] Antipyretics facilitate heat loss, but are not absorbed sufficiently rapidly to affect the height of the temperature above the individual’s temperature threshold that leads to seizure.[86]
Recommendations differ; ibuprofen is long-acting and is often the preferred antipyretic agent.[88]

Febrile illness and one prior seizure

There is no evidence of the effectiveness of antipyretics in preventing future febrile seizure.[42][81]

Early administration of an antipyretic and oral diazepam at first sign of fever or seizure activity is not recommended in the American Academy of Pediatrics (AAP) guidelines for simple febrile seizures, largely due to the fact that although antipyretics facilitate heat loss they are not absorbed sufficiently rapidly to reduce the peak temperature, and the potential toxicities associated with anticonvulsant agents outweigh the minor risks associated with simple febrile seizures.[2] However, a systematic review with meta-analysis concluded that treatment remains controversial and depends on appropriate judgment and the experience of the physician.[89] Another systematic review concluded that, although statistically significant benefits have been shown for some anticonvulsants in preventing seizure recurrence, there was a high prevalence of adverse events and the quality of the evidence was low.[87] [ ] The number needed to treat to prevent one seizure over 1 to 2 years was 16, which was considered to be clinically unimportant in the context of associated adverse events. Antipyretic intervention does not affect the recurrence rate of subsequent febrile seizures, and there is no indication for initiation of chronic anticonvulsant drugs for simple febrile seizures.[81][90]

Complex febrile seizure

Patients with complex febrile seizures have episodes of either focal, prolonged (lasting >15 minutes), or multiple seizures in 24 hours. Treatment may include administration of ibuprofen until the fever abates. Additionally, diazepam can be given rectally and repeated if the seizure activity continues. Furthermore, the use of rectal diazepam will reduce the risk of febrile seizure recurrence during an illness, but benefits and potential toxicity should be carefully considered.[87][91] Complex febrile seizures have a relatively guarded prognosis compared with simple febrile seizures, and the 2008 AAP guidelines for treatment of simple febrile seizures do not apply.

Initial management of infants and young children with complex febrile seizures is often at the primary or secondary level, but there should be a low threshold for referral to a pediatrician (secondary/tertiary level) for evaluation of the underlying cause and further management.[81][92]

Febrile status epilepticus

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.[93][94]
The FEBSTAT study, a prospective multicenter study of febrile status epilepticus, found that prolonged seizures occurred in very young children and were most often focal, partial, and long, lasting a median of 68 minutes.[9] Febrile status epilepticus was frequently the first febrile seizure, and status was unrecognized in the emergency department. Further analysis of the results from the study found that human herpesvirus (HHV-6 and HHV-7) accounted for around one third of febrile status epilepticus, and that febrile status epilepticus rarely causes cerebrospinal fluid (CSF) pleocytosis; thus, CSF pleocytosis should not be attributed to febrile status epilepticus but should be considered evidence of probable meningitis.[18][95]
Ambulance treatment of febrile seizures. In one prospective study of children presenting to the emergency department with prolonged febrile seizures (>15 minutes), of those receiving rectal diazepam in the ambulance only 11% responded, compared with 58% of patients treated with intravenous diazepam.[96]
Status epilepticus should be managed according to local/national guidelines.

Anticonvulsant treatment

Upon assessment of a patient with a seizure continuing >5 minutes, a dose of rectal diazepam is given. Then, if the seizure does not abate in 10 minutes, another dose is given.
If these 2 doses of rectal diazepam fail, one dose of intravenous fosphenytoin is given.
If the seizure still persists, intravenous diazepam is given with a repeat dose at 5 minutes if necessary. Lorazepam is an alternative treatment.
If the above measures fail, a specialist (pediatric neurologist or pediatric intensivist) should be consulted for the treatment of status epilepticus.
If emergency hospital services are not readily accessible, diazepam should be provided to be administered in rectal form as soon as possible after the first 5 minutes of seizure activity. Rectal diazepam is the regimen of choice for acute treatment of a prolonged febrile seizure or a cluster of febrile seizures.[97][98][99]
In the US, rectal diazepam is not approved by the Food and Drug Administration for febrile seizures or prolonged seizures in children below the age of 2 years. Children <2 years old should be admitted to the hospital emergency department for intravenous anticonvulsant therapy.

Prevention of recurrent febrile seizures

The strongest predictor of recurrence is age <12 to 16 months at the time of the first febrile seizure.[100]
Other risk factors include family history of febrile seizures in first-degree relative, lower temperature, and shorter duration of fever before initial seizure.[101] The higher the temperature, the higher the risk of recurrence.[23]
90% of seizure recurrence occurs within 2 years.
Febrile seizures recur in approximately 30% of children during subsequent febrile illnesses.[102]
Prediction of recurrence for individual children is difficult; the mainstay of management is around education of families.[100]
Patients with 2 or more complex febrile seizures in whom diazepam is ineffective may be considered for long-term anticonvulsant treatment in consultation with a neurologist.
Prophylactic efficacy with intermittent oral diazepam shows variable results in controlled studies, and is not generally recommended in the current AAP guidelines for simple febrile seizures.[2][87] [ ] However, it may be indicated in certain cases, such as frequent febrile seizure recurrence, low temperature threshold for febrile seizure, and/or parental anxiety.[66]
A systematic review found no clinically important benefit of antiepileptic and antipyretic treatments for the prevention of recurrent febrile seizures in children.[87] Although significant seizure prevention was shown for some intermittent anticonvulsant treatments, such as oral diazepam, oral clobazam, or rectal diazepam (versus placebo or no treatment), the benefits were not consistent over time and there was a high prevalence of adverse events.
Long-term management requires thorough assessment and risk stratification to devise a customized plan for each child, paying attention to the caregiver situation at home and day care.[103]

Use of this content is subject to our disclaimer