Febrile Seizures in Kids: A Parent's Guide

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Types of Febrile Seizures

• Simple Febrile Seizure: Generalized (usually tonic-clonic), lasting under 15 minutes, and no recurrence within 24 hours.
• Complex Febrile Seizure: Focal features, longer than 15 minutes, or recurs within 24 hours.
• Febrile Status Epilepticus: Seizure lasting over 30 minutes.
• Some use the term "simple febrile seizure plus" for multiple febrile seizures within 24 hours.

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What are Febrile Seizures?

• Febrile seizures occur in children aged 6 months to 5 years, triggered by fever (temperature ≥38°C or 100.4°F), without central nervous system infection or metabolic imbalance, and no prior afebrile seizures.
• They are the most common type of seizures in this age group, affecting 2%-5% of neurologically healthy children.
• They typically occur with rapid fever onset.

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Causes and Risk Factors

• Triggered mostly by infections causing fever, e.g., otitis media, roseola, human herpesvirus 6 and 7, shigella.
• Genetic predisposition: positive family history of febrile seizures is common; some inherited as autosomal dominant.
• Risk factors for recurrence include: age under 1 year, duration of fever under 24 hours, moderate fever (38-39°C), family history of febrile seizures or epilepsy, complex febrile seizure, daycare attendance, male gender, and low serum sodium at presentation.
• Iron deficiency is associated with increased risk, so screening/treatment is advised.

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Symptoms and Presentation

• Fever followed by a seizure episode: loss of consciousness, tonic-clonic movements, possible focal manifestations.
• Postictal state of short duration after simple febrile seizures.
• Complex seizures may have longer or focal symptoms with recurrence.
• Observe closely for signs of meningitis, encephalopathy, and other serious conditions.

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Evaluation and Assessment

• History & Exam: Detailed history about seizure type, duration, family history; neurological exam; look for underlying infection or neurological abnormalities.
• Lumbar puncture: Recommended for infants under 6 months with fever and seizure or if ill-appearing at any age.
• Neuroimaging (CT/MRI): Not routinely indicated after a first simple febrile seizure; may be considered if neurological abnormalities present or complex febrile seizures.
• EEG: Not routinely needed after a simple febrile seizure; may be used if complex features or abnormal neurological exam.
• Tests to rule out serious infection, serum sodium for risk stratification.

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Treatment

• Acute seizure management: Support airway, breathing, and circulation. If seizure lasts longer than 5 minutes, administer benzodiazepines such as rectal diazepam, buccal or intranasal midazolam.
• Antiepileptic drugs: Not recommended as continuous or intermittent therapy for simple febrile seizures due to side effects and lack of long-term benefits.
• Intermittent oral or rectal diazepam during febrile illness can be considered in select cases with recurrent seizures or high anxiety.
• Antipyretics (acetaminophen or ibuprofen): Used to reduce fever discomfort but do not prevent seizure recurrence as seizures often occur as temperature rises or falls.
• Discourage routine continuous antiepileptic or prophylactic therapy except in very high-risk children with other neurological abnormalities.
• Treat iron deficiency if present to decrease seizure risk.

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Risks and Prognosis

• Simple febrile seizures have no increased mortality or long-term adverse effects.
• Complex febrile seizures have a roughly 2-fold increased mortality risk over next two years, likely due to underlying pathology.
• Recurrence rates: about 30% after first episode, up to 50% after multiple episodes.
• Risk of developing epilepsy later is 2-7% after febrile seizures versus 1% in general population.
• High-risk factors for later epilepsy: complex febrile seizures, family history of epilepsy, neurodevelopmental abnormalities, seizures occurring shortly after fever onset.

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Prevention

• There's no definitive way to prevent febrile seizures.
• Antipyretics relieve fever discomfort but do not prevent seizures.
• Intermittent diazepam during fever can be offered in some high-risk recurrent cases but does not eliminate risk.
• Good hydration and prompt treatment of infections are helpful.
• Early diagnosis and treatment of iron deficiency might lower risk.

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Parental Guidance and Home Management

• Educate parents on the benign nature of most febrile seizures.
• Teach seizure first aid:
  • Keep the child safe; place on side to maintain airway.
  • Do NOT put anything in the child's mouth.
  • Do NOT try to restrain movements.
  • Note seizure duration; seek medical help if seizure lasts longer than 5 minutes.
• Manage fever with antipyretics for comfort.
• Keep child hydrated.
• Develop an action plan for future seizures; rectal diazepam or midazolam may be prescribed for home use in prolonged seizures.
• Address parental anxiety with reassurance; provide emotional support and clear information.
• When to seek immediate care:
  • First seizure in the child.
  • Seizure lasting over 5 minutes.
  • Child does not return to normal consciousness soon after seizure.
  • Signs of serious illness (stiff neck, difficulty breathing, persistent vomiting, rash, lethargy).
  • Recurrent seizures without full recovery between.

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In summary, febrile seizures are common and mostly benign childhood events associated with fever. Proper assessment can distinguish simple from complex types, guide investigations, and help stratify risk. Acute treatment focuses on seizure safety and timely abortive medication if seizures are prolonged. Continuous antiepileptic therapy is generally not warranted. Parental education on first aid, seizure handling, and emotional support is critical to effective home management and reducing anxiety.

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