Febrile Seizures: Risks, Evaluation, and Prognosis

 

Am Fam Physician. 2019 Apr 1;99(7):445-450.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/febrile-seizures/.

Author disclosure: No relevant financial affiliations.

A febrile seizure is a seizure occurring in a child six months to five years of age that is accompanied by a fever (100.4°F or greater) without central nervous system infection. Febrile seizures are classified as simple or complex. A complex seizure lasts 15 minutes or more, is associated with focal neurologic findings, or recurs within 24 hours. The cause of febrile seizures is likely multifactorial. Viral illnesses, certain vaccinations, and genetic predisposition are common risk factors that may affect a vulnerable, developing nervous system under the stress of a fever. Children who have a simple febrile seizure and are well-appearing do not require routine diagnostic testing (laboratory tests, neuroimaging, or electroencephalography), except as indicated to discern the cause of the fever. For children with complex seizures, the neurologic examination should guide further evaluation. For seizures lasting more than five minutes, a benzodiazepine should be administered. Febrile seizures are not associated with increased long-term mortality or negative effects on future academic progress, intellect, or behavior. Children with febrile seizures are more likely to have recurrent febrile seizures. However, given the benign nature of febrile seizures, the routine use of antiepileptics is not indicated because of adverse effects of these medications. The use of antipyretics does not decrease the risk of febrile seizures, although rectal acetaminophen reduced the risk of short-term recurrence following a febrile seizure. Parents should be educated on the excellent prognosis of children with febrile seizures and provided with practical guidance on home management of seizures.

A febrile seizure is a seizure occurring in a child six months to five years of age that is accompanied by a fever (100.4°F [38°C] or greater) without central nervous system infection.1  Febrile seizures are classified as simple or complex (Table 1).1 Complex seizures last 15 minutes or more, are associated with focal neurologic findings, or recur within 24 hours. Febrile seizures are the most common convulsive event in childhood, occurring in 2% to 5% of children.1

WHAT IS NEW ON THIS TOPIC

A 2018 randomized trial of 423 children with febrile seizures found that rectal acetaminophen given every six hours for 24 hours significantly reduced the likelihood of short-term recurrence compared with no use of antipyretics.

The measles-mumps-rubella vaccine is associated with an excess risk of 10 febrile seizures per 10,000 children 16 to 23 months of age, but only four seizures per 10,000 children 12 to 15 months. This highlights the importance of providing timely measles-mumps-rubella immunizations.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Children with a simple febrile seizure who are well-appearing do not require routine diagnostic testing, such as laboratory tests, neuroimaging, or electroencephalography.

C

1, 31, 32

Continuous or intermittent antiepileptic medications are not recommended after a first febrile seizure because of potential adverse effects.

B

42

Antipyretic agents do not reduce recurrence of simple febrile seizures.

A

42

Risk factors for recurrence of febrile seizure are age younger than 18 months, fever duration of less than one hour before seizure onset, first-degree relative with a history of febrile seizures, and a temperature of less than 104°F (40°C).

B

38


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Children with a simple febrile seizure who are well-appearing do not require routine diagnostic testing, such as laboratory tests, neuroimaging, or electroencephalography.

C

1, 31, 32

Continuous or intermittent antiepileptic medications are not recommended after a first febrile seizure because of potential adverse effects.

B

42

Antipyretic agents do not reduce recurrence of simple febrile seizures.

A

42

Risk factors for recurrence of febrile seizure are age younger than 18 months, fever duration of less than one hour before seizure onset, first-degree relative with a history of febrile seizures, and a temperature of less than 104°F (40°C).

B

38


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

BEST PRACTICES IN NEUROLOGY

Recommendations

The Authors

show all author info

DUSTIN K. SMITH, DO, is senior medical officer at Naval Hospital Yokosuka, Branch Health Clinic Diego Garcia, British Indian Ocean Territory. At the time this article was written, he was the assistant program director of the Jacksonville Family Medicine Residency Program at Naval Hospital Jacksonville and an assistant professor of family medicine for the Uniformed Services University of the Health Sciences, Jacksonville, Fla....

KERRY P. SADLER, MD, is a chief resident in the Family Medicine Residency Program at Naval Hospital Jacksonville.

MOLLY BENEDUM, MD, is an associate program director of the Family Medicine Residency at Greenville (S.C.) Health System, and a clinical assistant professor in the Department of Family Medicine at the University of South Carolina Greenville School of Medicine.

Address correspondence to Dustin K. Smith, DO, Naval Branch Health Clinic Diego Garcia, PSC 466 Box 302, FPO-AP 96595. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Subcommittee on Febrile Seizures; American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389–394....

2. Thébault-Dagher F, Herba CM, Séguin JR, et al. Age at first febrile seizure correlates with perinatal maternal emotional symptoms. Epilepsy Res. 2017;135:95–101.

3. Berg AT, Shinnar S, Shapiro ED, Salomon ME, Crain EF, Hauser WA. Risk factors for a first febrile seizure: a matched case-control study. Epilepsia. 1995;36(4):334–341.

4. Bethune P, Gordon K, Dooley J, Camfield C, Camfield P. Which child will have a febrile seizure? Am J Dis Child. 1993;147(1):35–39.

5. Hardies K, Weckhuysen S, Peeters E, et al. Duplications of 17q12 can cause familial fever-related epilepsy syndromes. Neurology. 2013;81(16):1434–1440.

6. Haerian BS, Baum L, Kwan P, et al. Contribution of GABRG2 polymorphisms to risk of epilepsy and febrile seizure: a multicenter cohort study and meta-analysis. Mol Neurobiol. 2016;53(8):5457–5467.

7. Hall CB, Long CE, Schnabel KC, et al. Human herpesvirus-6 infection in children. A prospective study of complications and reactivation. N Engl J Med. 1994;331(7):432–438.

8. Chung B, Wong V. Relationship between five common viruses and febrile seizure in children. Arch Dis Child. 2007;92(7):589–593.

9. Francis JR, Richmond P, Robins C, et al. An observational study of febrile seizures: the importance of viral infection and immunization. BMC Pediatr. 2016;16(1):202.

10. Maglione MA, Das L, Raaen L, et al. Safety of vaccines used for routine immunization of U.S. children: a systematic review. Pediatrics. 2014;134(2):325–337.

11. Rowhani-Rahbar A, Fireman B, Lewis E, et al. Effect of age on the risk of fever and seizures following immunization with measles-containing vaccines in children. JAMA Pediatr. 2013;167(12):1111–1117.

12. Centers for Disease Control and Prevention. Vaccine safety. Childhood vaccines and febrile seizures. https://www.cdc.gov/vaccinesafety/concerns/febrile-seizures.html. Accessed September 30, 2018.

13. MacDonald SE, Dover DC, Simmonds KA, Svenson LW. Risk of febrile seizures after first dose of measles-mumps-rubella-varicella vaccine: a population-based cohort study. CMAJ. 2014;186(11):824–829.

14. Filer W. AAFP Maintains strong stance in support of immunizations across the lifespan. June 2, 2016. https://www.aafp.org/media-center/releases-statements/all/2016/aafp-maintains-strong-stance-in-support-of-immunizations-across-lifespan.html. Accessed August 31, 2018.

15. Kroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices. http://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accessed August 21, 2018.

16. Prymula R, Siegrist CA, Chlibek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet. 2009;374(9698):1339–1350.

17. Graves RC, Oehler K, Tingle LE. Febrile seizures: risks, evaluation, and prognosis. Am Fam Physician. 2012;85(2):149–153.

18. Kimia AA, Bachur RG, Torres A, Harper MB. Febrile seizures: emergency medicine perspective. Curr Opin Pediatr. 2015;27(3):292–297.

19. Agarwal M, Fox SM. Pediatric seizures. Emerg Med Clin North Am. 2013;31(3):733–754.

20. Chamberlain JM, Gorman RL. Occult bacteremia in children with simple febrile seizures. Am J Dis Child. 1988;142(10):1073–1076.

21. Shah SS, Alpern ER, Zwerling L, Reid JR, McGowan KL, Bell LM. Low risk of bacteremia in children with febrile seizures. Arch Pediatr Adolesc Med. 2002;156(5):469–472.

22. Trainor JL, Hampers LC, Krug SE, Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med. 2001;8(8):781–787.

23. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6–12.

24. Rutter N, Smales OR. Role of routine investigations in children presenting with their first febrile convulsion. Arch Dis Child. 1977;52(3):188–191.

25. Maksikharin A, Prommalikit O. Serum sodium levels do not predict recurrence of febrile seizures within 24 hours. Paediatr Int Child Health. 2015;35(1):44–46.

26. Green SM, Rothrock SG, Clem KJ, Zurcher RF, Mellick L. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics. 1993;92(4):527–534.

27. Guedj R, Chappuy H, Titomanlio L, et al. Risk of bacterial meningitis in children 6 to 11 months of age with a first simple febrile seizure: a retrospective, cross-sectional, observational study. Acad Emerg Med. 2015;22(11):1290–1297.

28. Joffe A, McCormick M, DeAngelis C. Which children with febrile seizures need lumbar puncture? A decision analysis approach. Am J Dis Child. 1983;137(12):1153–1156.

29. Hofert SM, Burke MG. Nothing is simple about a complex febrile seizure: looking beyond fever as a cause for seizures in children. Hosp Pediatr. 2014;4(3):181–187.

30. Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005;90(1):66–69.

31. Kimia AA, Ben-Joseph E, Prabhu S, et al. Yield of emergent neuroimaging among children presenting with a first complex febrile seizure. Pediatr Emerg Care. 2012;28(4):316–321.

32. Kuturec M, Emoto SE, Sofijanov N, et al. Febrile seizures: is the EEG a useful predictor of recurrences? Clin Pediatr (Phila). 1997;36(1):31–36.

33. McTague A, Martland T, Appleton R. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev. 2018;(1):CD001905.

34. Mastrangelo M, Midulla F, Moretti C. Actual insights into the clinical management of febrile seizures. Eur J Pediatr. 2014;173(8):977–982.

35. Okubo Y, Handa A. National trend survey of hospitalized patients with febrile seizure in the United States. Seizure. 2017;50:160–165.

36. Vestergaard M, Pedersen MG, Ostergaard JR, Pedersen CB, Olsen J, Christensen J. Death in children with febrile seizures: a population-based cohort study. Lancet. 2008;372(9637):457–463.

37. Verity CM, Greenwood R, Golding J. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med. 1998;338(24):1723–1728.

38. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures. A prospective cohort study. Arch Pediatr Adolesc Med. 1997;151(4):371–378.

39. Annegers JF, Hauser WA, Shirts SB, Kurland LT. Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med. 1987;316(9):493–498.

40. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013;54(12):2101–2107.

41. Shinnar S, Glauser TA. Febrile seizures. J Child Neurol. 2002;17(suppl 1):S44–S52.

42. Offringa M, Newton R, Cozijnsen MA, Nevitt SJ. Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev. 2017;(2):CD003031.

43. Murata S, Okasora K, Tanabe T, et al. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018;142(5):e20181009.

44. National Institute of Neurological Disorders and Stroke. Febrile seizures fact sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Febrile-Seizures-Fact-Sheet. Accessed September 13, 2018.

45. Millar JS. Evaluation and treatment of the child with febrile seizure. Am Fam Physician. 2006;73(10):1761–1764.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Aug 15, 2019

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article