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Febrileseixure

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A febrile seizure is a convulsion triggered by fever (usually >38°C) in children aged 6 months to 5 years, without an underlying CNS infection or other cause. Most are benign, self-limiting, and do not require long-term treatment.
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I also want the complex febrile seizure management details from Harriet Lane and the risk factors section from Tintinalli's.
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Febrile Seizure

Definition

A febrile seizure is a seizure accompanied by fever (temperature ≥38°C / 100.4°F) without evidence of CNS infection, occurring in children aged 6 months to 5-6 years. It is thought that the rapid rise or defervescence of fever (rather than the absolute peak temperature) is the trigger. About 2-5% of children will experience at least one febrile seizure in their lifetime.
  • Rosen's Emergency Medicine, p. 3159
  • Tintinalli's Emergency Medicine, p. 936

Classification

Simple Febrile Seizure

  • Generalized (tonic-clonic), nonfocal
  • Duration < 15 minutes
  • Does not recur within the same 24-hour period
  • Occurs in a child 6-60 months of age

Complex (Complicated) Febrile Seizure

  • Focal onset, OR
  • Duration > 15 minutes, OR
  • Recurs within 24 hours, OR
  • Occurs outside the typical age range (< 6 months or > 6 years)
  • Harriet Lane Handbook, 23rd ed., p. 739-741
  • Tintinalli's Emergency Medicine

Epidemiology & Natural History

FeatureData
Prevalence2-5% of all children
Peak age14-18 months
Recurrence risk (< 12 months at first seizure)~50%
Recurrence risk (> 12 months at first seizure)~30%
Risk of epilepsy (general population)0.5-1%
Risk of epilepsy after simple febrile seizure~1-2% (similar to general population)
Risk of epilepsy with multiple risk factorsUp to 7-10%
  • Tintinalli's, Rosen's, Goodman & Gilman's

Risk Factors for Epilepsy Later in Life

The following raise the risk of subsequent epilepsy to up to 7-10%:
  • Pre-existing neurological disorder or developmental delay
  • Family history of epilepsy
  • Complex febrile seizure (focal, prolonged, or repeated in same day)
  • First febrile seizure before 12 months of age
  • Todd's paralysis, focal neurologic findings, or abnormal EEG/imaging
  • Goodman & Gilman's, p. (block6)
  • Tintinalli's, p. 936

Common Causes of Fever Triggering Febrile Seizures

  • Viral infections (most common) - especially roseola (HHV-6)
  • Ear infections (acute otitis media)
  • Upper respiratory tract infections
  • Post-vaccination fever (MMR, MMRV - small increased risk; the risk is outweighed by vaccine benefits)
  • Goodman & Gilman's

Evaluation

Simple Febrile Seizure - Well-Appearing Child

  • No routine blood work, neuroimaging, or EEG required
  • Focus evaluation on identifying the source of fever (e.g., urinalysis and culture)
  • Routine lumbar puncture (LP) is NOT indicated

When to Perform LP

Lumbar puncture should be strongly considered when:
  • Signs/symptoms of meningitis or intracranial infection (meningeal irritation, altered sensorium)
  • Child aged 6-12 months who is incompletely immunized against H. influenzae type b or S. pneumoniae
  • Child was pretreated with antibiotics (can mask signs of meningitis)
Note: Children > 12 months can usually be assessed clinically for meningitis. The incidence of bacterial meningitis after simple febrile seizure is very low (0.4-1.2%).

Complex Febrile Seizure

  • Obtain EEG
  • Consider non-emergent MRI (to evaluate for focal lesion)
  • LP if concern for CNS infection
  • Routine blood tests and imaging are still not mandatory in the absence of signs/symptoms
  • Harriet Lane Handbook, Rosen's, Tintinalli's

Treatment

Acute Management

  • Most simple febrile seizures self-terminate before medical attention is needed (typically last < 2 minutes)
  • If prolonged or active: manage as per status epilepticus protocol
  • Antipyretics (acetaminophen, ibuprofen) for comfort - however, there is no evidence that antipyretics prevent recurrent febrile seizures

Preventive / Prophylactic Therapy

  • Chronic anticonvulsant prophylaxis is NOT recommended - side effects (e.g., phenobarbital causes cognitive effects) outweigh the modest risk-reduction benefit
  • Prophylactic anticonvulsants would only treat the febrile seizure, not prevent later epilepsy
  • For high-risk children with recurrent febrile seizures: rectal or oral diazepam at the time of fever may prevent recurrence and avoids chronic therapy side effects
  • For complex febrile seizures: consider prescribing rectal diazepam for home emergency use
  • Goodman & Gilman's, Swanson's Family Medicine Review, Harriet Lane Handbook

Parental Counseling

Key points to convey to parents:
  1. Simple febrile seizures are benign and self-limiting
  2. The child is not at significantly increased risk for epilepsy after a single simple febrile seizure (~1%)
  3. About 1/3 of children will have a recurrence, most within 1-2 years
  4. Febrile seizures do not cause brain damage
  5. Antipyretics should be used for comfort but will not reliably prevent another seizure

Summary Table

FeatureSimpleComplex
Duration< 15 min> 15 min
FocalityGeneralizedFocal possible
Recurrence in 24hNoYes (possible)
Age range6-60 monthsOutside range possible
EEG needed?NoYes
LP needed?Only if meningitis signsConsider if meningitis concern
Neuroimaging?NoConsider non-emergent MRI
Antiseizure Rx?Not indicatedNot routinely; diazepam for home use
Epilepsy risk~1% (general population)Up to 7-10% with risk factors
Sources:
  • Tintinalli's Emergency Medicine: A Comprehensive Study Guide
  • Rosen's Emergency Medicine: Concepts and Clinical Practice
  • Harriet Lane Handbook, 23rd Edition (Johns Hopkins Hospital)
  • Goodman & Gilman's The Pharmacological Basis of Therapeutics
  • Swanson's Family Medicine Review
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