UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Treatment and prognosis of febrile seizures

Authors
John J Millichap, MD, FAAP
J. Gordon Millichap, MD, FRCP
Section Editor
Douglas R Nordli, Jr, MD
Deputy Editor
April F Eichler, MD, MPH

INTRODUCTION

Febrile seizures are the most common neurologic disorder of infants and young children, occurring in 2 to 4 percent of children younger than five years of age. They are an age-dependent phenomenon with a strong genetic predisposition. While often frightening to parents and witnesses, febrile seizures are a mostly benign occurrence and are associated with a low risk for future epilepsy. Approximately one-third of children will have recurrent febrile seizures during early childhood, and the risk is increased in association with certain clinical features, including young age, low fever, family history of febrile seizures, and abnormal development at the time of first seizure.

Febrile seizures are described as being simple or complex. Simple febrile seizures are the most common type and are characterized by a single generalized seizure lasting less than 10 to 15 minutes. Complex febrile seizures include those that are focal, prolonged, or recurrent within a 24-hour period. (See "Clinical features and evaluation of febrile seizures".)

While simple febrile seizures have typically spontaneously resolved by the time the child is evaluated and do not need to be treated, prolonged seizures may require abortive treatment with benzodiazepines in the ambulance or in the emergency department. Prophylactic antiseizure drugs can decrease the risk of recurrent febrile seizures, but given the benign nature of most seizures, the risks of side effects generally outweigh the benefits.

This topic will review the treatment and prognosis of febrile seizures, including febrile status epilepticus. Management of afebrile seizures and epilepsy in infants and children are discussed separately. (See "Seizures and epilepsy in children: Initial treatment and monitoring".)

INITIAL ASSESSMENT

The initial evaluation of children with seizure in the setting of fever must distinguish febrile seizure from alternative and more serious etiologies such as central nervous system infection. This can be accomplished with a thorough history and physical examination in most cases, along with neuroimaging and lumbar puncture in selected circumstances. Children with focal or prolonged febrile seizures may require more extensive evaluation than those with simple febrile seizures, particularly at the time of the first seizure. Therapies discussed below assume that such etiologies have been ruled out and that the diagnosis of febrile seizure has been established. (See "Clinical features and evaluation of febrile seizures".)

                   

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Aug 26 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Appleton R, Macleod S, Martland T. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev 2008; :CD001905.
  2. Chamberlain JM, Okada P, Holsti M, et al. Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial. JAMA 2014; 311:1652.
  3. Neville BG, Chin RF, Scott RC. Childhood convulsive status epilepticus: epidemiology, management and outcome. Acta Neurol Scand Suppl 2007; 186:21.
  4. Scott RC, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet 1999; 353:623.
  5. McIntyre J, Robertson S, Norris E, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 2005; 366:205.
  6. McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med 2010; 17:575.
  7. Ahmad S, Ellis JC, Kamwendo H, Molyneux E. Efficacy and safety of intranasal lorazepam versus intramuscular paraldehyde for protracted convulsions in children: an open randomised trial. Lancet 2006; 367:1591.
  8. Arya R, Gulati S, Kabra M, et al. Intranasal versus intravenous lorazepam for control of acute seizures in children: a randomized open-label study. Epilepsia 2011; 52:788.
  9. Seinfeld S, Shinnar S, Sun S, et al. Emergency management of febrile status epilepticus: results of the FEBSTAT study. Epilepsia 2014; 55:388.
  10. Shinnar S, Hesdorffer DC, Nordli DR Jr, et al. Phenomenology of prolonged febrile seizures: results of the FEBSTAT study. Neurology 2008; 71:170.
  11. Bassan H, Barzilay M, Shinnar S, et al. Prolonged febrile seizures, clinical characteristics, and acute management. Epilepsia 2013; 54:1092.
  12. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366:591.
  13. Jeong JH, Lee JH, Kim K, et al. Rate of and risk factors for early recurrence in patients with febrile seizures. Pediatr Emerg Care 2014; 30:540.
  14. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures. A prospective cohort study. Arch Pediatr Adolesc Med 1997; 151:371.
  15. Offringa M, Bossuyt PM, Lubsen J, et al. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data from five studies. J Pediatr 1994; 124:574.
  16. Frantzen E, Lennox-Buchthal M, Nygaard A. Longitudinal EEG and clinical study of children with febrile convulsions. Electroencephalogr Clin Neurophysiol 1968; 24:197.
  17. Berg AT, Shinnar S, Hauser WA, et al. A prospective study of recurrent febrile seizures. N Engl J Med 1992; 327:1122.
  18. Pavlidou E, Tzitiridou M, Kontopoulos E, Panteliadis CP. Which factors determine febrile seizure recurrence? A prospective study. Brain Dev 2008; 30:7.
  19. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics 1978; 61:720.
  20. Wilmshurst JM, Gaillard WD, Vinayan KP, et al. Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics. Epilepsia 2015; 56:1185.
  21. Berg AT, Darefsky AS, Holford TR, Shinnar S. Seizures with fever after unprovoked seizures: an analysis in children followed from the time of a first febrile seizure. Epilepsia 1998; 39:77.
  22. Knudsen FU. Febrile seizures: treatment and prognosis. Epilepsia 2000; 41:2.
  23. de Haan GJ, van der Geest P, Doelman G, et al. A comparison of midazolam nasal spray and diazepam rectal solution for the residential treatment of seizure exacerbations. Epilepsia 2010; 51:478.
  24. Hesdorffer DC, Shinnar S, Lax DN, et al. Risk factors for subsequent febrile seizures in the FEBSTAT study. Epilepsia 2016; 57:1042.
  25. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures American Academy of Pediatrics. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics 2008; 121:1281.
  26. Offringa M, Newton R. Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev 2012; :CD003031.
  27. Rosman NP, Colton T, Labazzo J, et al. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med 1993; 329:79.
  28. Hirabayashi Y, Okumura A, Kondo T, et al. Efficacy of a diazepam suppository at preventing febrile seizure recurrence during a single febrile illness. Brain Dev 2009; 31:414.
  29. Verrotti A, Latini G, di Corcia G, et al. Intermittent oral diazepam prophylaxis in febrile convulsions: its effectiveness for febrile seizure recurrence. Eur J Paediatr Neurol 2004; 8:131.
  30. Lux AL. Treatment of febrile seizures: historical perspective, current opinions, and potential future directions. Brain Dev 2010; 32:42.
  31. Nordli DR Jr, Moshé SL, Shinnar S, et al. Acute EEG findings in children with febrile status epilepticus: results of the FEBSTAT study. Neurology 2012; 79:2180.
  32. Shinnar S, Bello JA, Chan S, et al. MRI abnormalities following febrile status epilepticus in children: the FEBSTAT study. Neurology 2012; 79:871.
  33. Meremikwu M, Oyo-Ita A. Paracetamol for treating fever in children. Cochrane Database Syst Rev 2002; :CD003676.
  34. Uhari M, Rantala H, Vainionpää L, Kurttila R. Effect of acetaminophen and of low intermittent doses of diazepam on prevention of recurrences of febrile seizures. J Pediatr 1995; 126:991.
  35. Strengell T, Uhari M, Tarkka R, et al. Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Arch Pediatr Adolesc Med 2009; 163:799.
  36. Rosenbloom E, Finkelstein Y, Adams-Webber T, Kozer E. Do antipyretics prevent the recurrence of febrile seizures in children? A systematic review of randomized controlled trials and meta-analysis. Eur J Paediatr Neurol 2013; 17:585.
  37. Millichap JG. Febrile Convulsions, Macmillan, New York 1968.
  38. Goodman LS, Gilman A. The Pharmacological Basis of Therapeutics, 2nd, The Macmillan Company, New York 1955. p.283.
  39. Vestergaard M, Pedersen MG, Ostergaard JR, et al. Death in children with febrile seizures: a population-based cohort study. Lancet 2008; 372:457.
  40. Holm IA, Poduri A, Crandall L, et al. Inheritance of febrile seizures in sudden unexplained death in toddlers. Pediatr Neurol 2012; 46:235.
  41. Leaffer EB, Hinton VJ, Hesdorffer DC. Longitudinal assessment of skill development in children with first febrile seizure. Epilepsy Behav 2013; 28:83.
  42. Martinos MM, Yoong M, Patil S, et al. Recognition memory is impaired in children after prolonged febrile seizures. Brain 2012; 135:3153.
  43. Verity CM, Greenwood R, Golding J. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med 1998; 338:1723.
  44. Nørgaard M, Ehrenstein V, Mahon BE, et al. Febrile seizures and cognitive function in young adult life: a prevalence study in Danish conscripts. J Pediatr 2009; 155:404.
  45. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976; 295:1029.
  46. Annegers JF, Hauser WA, Shirts SB, Kurland LT. Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med 1987; 316:493.
  47. Vestergaard M, Pedersen CB, Sidenius P, et al. The long-term risk of epilepsy after febrile seizures in susceptible subgroups. Am J Epidemiol 2007; 165:911.
  48. Neligan A, Bell GS, Giavasi C, et al. Long-term risk of developing epilepsy after febrile seizures: a prospective cohort study. Neurology 2012; 78:1166.
  49. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia 2013; 54:2101.
  50. Wo SB, Lee JH, Lee YJ, et al. Risk for developing epilepsy and epileptiform discharges on EEG in patients with febrile seizures. Brain Dev 2013; 35:307.
  51. Harini C, Nagarajan E, Kimia AA, et al. Utility of initial EEG in first complex febrile seizure. Epilepsy Behav 2015; 52:200.
  52. MILLICHAP JG, MADSEN JA, ALEDORT LM. Studies in febrile seizures. V. Clinical and electroencephalographic study in unselected patients. Neurology 1960; 10:643.
  53. Jeong KA, Han MH, Lee EH, Chung S. Early postictal electroencephalography and correlation with clinical findings in children with febrile seizures. Korean J Pediatr 2013; 56:534.
  54. Kanemura H, Mizorogi S, Aoyagi K, et al. EEG characteristics predict subsequent epilepsy in children with febrile seizure. Brain Dev 2012; 34:302.
  55. Berg AT, Shinnar S, Levy SR, Testa FM. Childhood-onset epilepsy with and without preceding febrile seizures. Neurology 1999; 53:1742.
  56. Barr WB, Ashtari M, Schaul N. Bilateral reductions in hippocampal volume in adults with epilepsy and a history of febrile seizures. J Neurol Neurosurg Psychiatry 1997; 63:461.
  57. Theodore WH, Bhatia S, Hatta J, et al. Hippocampal atrophy, epilepsy duration, and febrile seizures in patients with partial seizures. Neurology 1999; 52:132.
  58. Tanabe T, Hara K, Shimakawa S, et al. Hippocampal damage after prolonged febrile seizure: one case in a consecutive prospective series. Epilepsia 2011; 52:837.
  59. Fernández G, Effenberger O, Vinz B, et al. Hippocampal malformation as a cause of familial febrile convulsions and subsequent hippocampal sclerosis. Neurology 1998; 50:909.
  60. VanLandingham KE, Heinz ER, Cavazos JE, Lewis DV. Magnetic resonance imaging evidence of hippocampal injury after prolonged focal febrile convulsions. Ann Neurol 1998; 43:413.
  61. Scott RC, King MD, Gadian DG, et al. Hippocampal abnormalities after prolonged febrile convulsion: a longitudinal MRI study. Brain 2003; 126:2551.
  62. Provenzale JM, Barboriak DP, VanLandingham K, et al. Hippocampal MRI signal hyperintensity after febrile status epilepticus is predictive of subsequent mesial temporal sclerosis. AJR Am J Roentgenol 2008; 190:976.
  63. Auer T, Barsi P, Bone B, et al. History of simple febrile seizures is associated with hippocampal abnormalities in adults. Epilepsia 2008; 49:1562.
  64. Hamati-Haddad A, Abou-Khalil B. Epilepsy diagnosis and localization in patients with antecedent childhood febrile convulsions. Neurology 1998; 50:917.
  65. Lewis DV, Shinnar S, Hesdorffer DC, et al. Hippocampal sclerosis after febrile status epilepticus: the FEBSTAT study. Ann Neurol 2014; 75:178.
  66. Maytal J, Shinnar S. Febrile status epilepticus. Pediatrics 1990; 86:611.
  67. Nordli DR, Moshé SL, Shinnar S. The role of EEG in febrile status epilepticus (FSE). Brain Dev 2010; 32:37.