Febrile Seizures

Description

Diagnostic criteria

General and supportive measures 

Medicine treatment 

Referral

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DESCRIPTION

Febrile seizures occur between the ages of 6 months and 6 years of age in association with a significant fever (>38.5°C) in the absence of an intracranial infection and typically associated with viral upper respiratory tract infections. These are the most common type of seizures in children of this age.

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However, the diagnosis requires the exclusion of other causes of seizures. Febrile convulsions can be simple or complex.

Simple febrile seizures (SFS):

• are generalised,
• occur once per illness,
• are less than 15 minutes (typically 1–2 minutes),
• are not associated with any neurological deficit,
• are self-limiting,
• consist of only one seizure during the febrile illness which needs no specific treatment, and
• may be associated with a family history of simple febrile seizures.

Complex febrile seizures have one or more of the following characteristics:

• Seizure duration of 15 minutes or more;

OR

• are recurrent within the same febrile illness;

AND/OR

• have a focal onset.

AND/OR

• are associated with post-ictal, focal neurological abnormalities.

Children with febrile seizures have a good prognosis, and very rarely develop epilepsy. The overall risk for recurrence of simple febrile seizures is 30–40%. Factors which increase the risk for recurrent febrile seizures include:

• seizure disorder in a first-degree relative,
• onset before 12 months of age,
• initial complex seizures.

DIAGNOSTIC CRITERIA

Clinical

• Investigate for intracranial, extracranial, and biochemical causes of fever or seizure.
• Signs of meningism are unreliable in children under 18 months of age.
• If raised intracranial pressure or meningitis cannot be excluded, the diagnosis of febrile seizures cannot be made. Treat children empirically for meningitis if suspected.

Investigations

Lumbar puncture

• Lumbar puncture is indicated in:
  − All children with clinical features of meningitis.
• Lumbar puncture may be indicated in:
  − Children where meningitis cannot be excluded, e.g. under 18 months of age or those who have received antibiotics prior to the event.
• In children ≥ 18 months of age, where a focus of extracranial infection is present and intracranial infection such as meningitis has been excluded clinically, no further investigation is required.

Neuroimaging

• Children with complex febrile seizures and/or persistent lethargy may require neuroimaging, followed by a lumbar puncture if raised intracranial pressure can reliably be excluded based on clinical assessment. (see Paediatric Hospital Level STGs and EML, Lumbar puncture).
• Based on clinical findings, investigate complex febrile seizures for possible underlying conditions such as meningitis, focal brain lesions and epilepsy.

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Note:

An EEG is of no value in simple febrile seizures but may be considered in recurrent complex febrile seizures.

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GENERAL AND SUPPORTIVE MEASURES

• Reassure parents and caregivers.
• Educate parents and caregivers regarding the first aid management of seizures.
• Counsel against tepid sponging and fans as this increases the core temperature.
• Counsel that recurrent febrile seizures occur in 30-40% of patients.
• Look for a cause of the fever.
• Always exclude meningitis (See Meningitis).

MEDICINE TREATMENT

For fever related symptoms (temperature > 38.5°C):

• Paracetamol, oral, 15 mg/kg/dose 6 hourly.

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Note:

Paracetamol has no effect on seizure prevention.

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If convulsing for > 5 minutes: See Status epilepticus (convulsive).

Continuous antiseizure medication prophylactic therapy

• Routine daily antiseizure medication prophylaxis is not recommended for patients with simple febrile seizures.
• For children with recurrent complex febrile seizures, discuss the treatment options with a specialist.

REFERRAL

All febrile seizures, except if:

• Previous episode of simple febrile seizures has been investigated,

AND

 - the child regains full consciousness and function immediately after the seizure,

AND

- meningitis has been excluded (See Meningitis).

• Complex convulsions:
  - All patients with recurrent complex febrile seizures without an obvious cause of the seizure and/or not responding to initial management should be discussed with a specialist.
  - Developmental delay/regression.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.0_26 May 2025

Chapter 15: Central Nervous System Conditions_15.6 Febrile Seizures