1. Blood studies. According to a policy statement from the American Academy of Pediatrics (AAP), routine blood studies are not indicated in the workup of a first simple febrile seizure and should only be performed as part of the evaluation for a source of the fever.
2. Lumbar puncture (LP). In a policy statement from the AAP, recommendations regarding LP with a first simple febrile seizure are as follows:
a. LP should be strongly considered in infants younger than 12 months of age.
b. LP should be considered in children between 12 and 18 months of age.
c. In children older than 18 months, LP is not routinely warranted and is only recommended in presence of meningeal signs.
d. LP is usually indicated in children who present with complex febrile seizure after mass-occupying lesion and increased intracranial pressure have been ruled out.
C. Radiographic and Other Studies. Routine neuroimaging studies (eg, CT or MRI scan) are not recommended in evaluation of simple febrile seizure. Similarly, there is no evidence to support obtaining routine EEG. EEG does not help predict recurrence or later development of epilepsy in children with febrile seizures.
V. Plan. Febrile seizures are self-limited and, typically, very short events. Because of this, most seizures will have terminated before coming to medical attention and patients will not require stabilization. Patients with persistent seizures require airway management and more aggressive treatment of seizure activity with medications, as discussed in Chapter 84 (see p. 391). Long-term care of children with febrile seizures is directed primarily at parental reassurance, as discussed below.
A. Antipyretics. Antipyretics such as acetaminophen and ibuprofen do not prevent recurrences of febrile seizures when given with future episodes of fever.
B. Anticonvulsants. The ability of several anticonvulsants to prevent recurrent febrile seizures has been studied. However, given the benign nature of febrile seizures, side effects of most of these medications generally outweigh benefits. Oral diazepam given at the onset of future febrile illnesses may be indicated when parental anxiety about seizures is severe.
C. Parental Reassurance. This is perhaps the most important aspect of care for children with febrile seizures. Parents need to be informed that simple febrile seizures do not cause brain damage and that risk of child having nonfebrile seizures in future is only slightly greater than that of the general population. It is also important to prepare parents for the fact that approximately one third of children with febrile seizures will experience a future febrile seizure (50% recurrence risk if first episode occurs before the age of 12 months).
D. Hospitalization. Admission to the hospital is only necessary if clinician has a suspicion of underlying disease, there is a recurrent or prolonged seizure episode, or parents seem unable to cope with the seizure.
VI. Problem Case Diagnosis. On evaluation in the emergency department, the 2-year-old boy was alert and playful. Physical exam was normal, except for rectal temperature of 102°F (38.8°C). The seizure was described as generalized, lasting 5 minutes. Developmentally the child is normal, with no previous history of seizures. Diagnosis is febrile seizure.
VII. Teaching Pearl: Question. What are the risk factors for recurrence of febrile seizures?
VIII. Teaching Pearl: Answer. Risk factors for febrile seizures include young age of first febrile seizure (before 6-12 months), family history of febrile seizures, short duration of fever before initial seizure, and relatively lower fever at time of initial seizure. Children with febrile seizures are not at increased risk for mental retardation or epilepsy.
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