Clinical Case: 2.5-Year-Old with Fever + Uprolling of Eyes + No Cry for 2 Minutes

Diagnosis: Simple Febrile Seizure (most likely)

Why this fits:

• Age 6 months to 6 years - 2.5 years is squarely within range
• Fever present (the trigger)
• Generalized semiology: uprolling of eyes = tonic phase; no cry = ictal period (cry suppressed during seizure)
• Duration ~2 minutes = well under the 15-minute threshold
• Single episode (as described)

Simple vs. Complex Febrile Seizure - Key Distinction

Immediate Management

1. Airway, Breathing, Circulation

• Place child in recovery position (left lateral)
• Ensure airway is clear; seizure likely self-terminated

2. Treat the Fever

• Paracetamol (15 mg/kg oral/PR) or Ibuprofen (10 mg/kg oral) - this is the primary treatment goal
• Find and treat the source of fever (viral URTI, AOM, UTI are common causes)

3. If Seizure is Still Active (it has stopped here, but for reference)

• Rectal/IV diazepam 0.5 mg/kg PR, or midazolam 0.2 mg/kg buccal/IN
• For status (>5 min): IV lorazepam 0.1 mg/kg is first-line

Workup - What is and is NOT Needed

NOT needed for simple febrile seizure in a well-appearing, fully immunized child:

• Routine blood work (CBC, electrolytes, glucose unless clinically indicated)
• Neuroimaging (CT/MRI)
• EEG
• Routine lumbar puncture

LP should be considered if:

• Clinical signs of meningitis (neck stiffness, bulging fontanelle, petechiae, Kernig's/Brudzinski's sign, photophobia)
• Age 6-12 months + unimmunized/unknown immunization status for H. influenzae type b or S. pneumoniae
• Child was pre-treated with antibiotics (can mask meningitis signs)
• Complex febrile seizure features

In this child (2.5 years), LP is not routine - assess clinically for meningismus.

Counseling Parents

Risk Factors for Recurrence (up to ~30-40%)

• Age <1 year at first febrile seizure
• Family history of febrile seizures
• Low fever at time of seizure
• Short duration of fever before the seizure
• Daycare attendance (more infectious illness exposure)

Risk Factors for Later Epilepsy (elevated from 1% baseline)

• Complex features (each adds risk: 1 feature = 6-8%, 2 = 17-22%, all 3 = ~49%)
• Pre-existing neurodevelopmental abnormality
• Family history of afebrile epilepsy
• Recurrent febrile seizures

Red Flags Requiring Urgent Reassessment

• Prolonged post-ictal state (>30-60 min)
• Focal neurologic deficit after seizure (Todd's paralysis)
• Fever + petechial rash (meningococcemia)
• Neck stiffness, refusal to flex neck
• Seizure duration >15 min or repeated seizures same day

Disposition

• Child can be discharged once back to baseline, with:
  • Source of fever identified and managed
  • Normal neurologic exam
  • Parents educated on recurrence and when to return
  • Follow-up with pediatrician