Obtain a history of possible precipitating factors, such as trauma or toxin or drug ingestion. Inquire into recent condition(s) and medical history, as well as any family history of seizure disorders.

Have witnesses describe the event in detail, including the type of motor and eye movements, changes in breathing and skin color, and whether or not there was complete loss of consciousness or incontinence. Determine the duration of the seizure and the length of the postictal period.

Perform a physical examination that includes evaluation of pupil size and reactivity, along with funduscopy to look for retinal hemorrhage, which would suggest intentional injury. After the patient has experienced full recovery from the postictal state, the physical examination should be entirely normal.

In children older than 6 months of age, in the absence of a history of illness, vomiting or diarrhea, or suspected ingestion, routine laboratory testing is not needed.

A computed tomography (CT) scan should be obtained if there are findings of head trauma, focal (partial) seizure, seizure longer than 5 minutes, focal postictal deficits not rapidly resolving (Todd paralysis), persistently altered level of consciousness, sickle cell disease, bleeding disorders, malignancy, or human immunodeficiency virus (HIV) infection. For most children, immediate neuroimaging is not indicated.

Children who have just one unprovoked seizure—for whom there is no suspicion of trauma, infection, or intoxication—and who have returned to their baseline state, may be discharged with appropriate medical follow-up. Antiepileptic drugs are usually not prescribed.

Parents should be appropriately reassured and informed that 60% of such children never have a recurrence. Discharge instructions should describe what to do if the seizure recurs.

If seizure activity persists for more than 5 minutes, consider bag-valve-mask ventilation or intubation if there is significant respiratory compromise. An IV line should be placed, and a bedside glucose test should be performed. If the patient is hypoglycemic, 0.5 to 1 g/kg of glucose should be given as a bolus (2 mL/kg of 25% dextrose in water or, in neonates, 5 mL/kg of 10% dextrose in water).

With IV or IO (intraosseous) access:

— give lorazepam (Ativan), 0.1 mg/kg IV over 2 to 5 minutes; may repeat in 5 to 10 minutes up to a 4-mg dose (recommended treatment)

— or give diazepam (Valium), 0.2 to 0.5 mg/kg IV every 15 to 30 minutes to a maximum 5-mg dose.

Without IV or IO access:

— give lorazepam, 0.1 mg/kg rectally up to a 4-mg dose

— or give diazepam gel (Diastat), 0.5 mg/kg rectally up to a 10-mg dose

— or give midazolam (Versed), 0.1 to 0.2 mg/kg IM × 1 up to a 10-mg dose.

All children who present in status epilepticus should be considered for treatment with a long-acting antiepileptic drug, such as:

— phenytoin (Dilantin), 20 mg/kg IV at less than 1 mg/kg/min up to 1000 mg

— or fosphenytoin (Cerebyx), 20 mg/kg PE (phenytoin sodium equivalents) up to 1000 mg at less than 3 mg/kg/min (safety and efficacy not established for pediatric patients)

— or phenobarbital, 10 to 20 mg/kg IV up to 1000 mg at less than 1 to 2 mg/kg/min.

A careful history and physical examination should be done to identify a possible source of the fever and to rule out any evidence of trauma.

Children with fever without an identifiable source should be evaluated for urinary tract infection.

In patients whose level of consciousness has not returned to baseline; who have a bulging fontanel, a positive Kernig or Brodzinski sign, photophobia, severe headache, or pretreatment with antibiotics; or who are lethargic or irritable, lumbar puncture should be performed to exclude meningitis. Children who are younger than 6 months of age must be evaluated for metabolic abnormalities, underlying neurologic disorders, meningitis, and encephalitis.

Antibiotics are only indicated for focal infections.

Antipyretics have not been found to be effective in preventing the recurrence of febrile seizures. Benzodiazepines are also probably of no practical benefit when used for prophylaxis.

There is no evidence that children with simple febrile seizures have any difference in cognitive outcomes than children without such seizures, and although these seizures appear frightening, they are generally harmless. Parents should be reassured and given written, detailed information about febrile seizures and then referred back to their primary care physician for follow-up.

Febrile seizures that are focal, last more than 10 minutes, or recur within 24 hours are complex febrile seizures that require a more intensive investigation and are associated with a greater risk for later epilepsy.

What Not To Do:

Do not perform a lumbar puncture on an afebrile child who has returned to normal mental status and has no meningeal signs.

Do not do routine neuroimaging on children with first-time afebrile seizures or febrile seizure patients who have a normal neurologic examination with full postseizure recovery.

Do not do routine laboratory testing on children who are older than 6 months of age who have not been ill without vomiting or diarrhea and where there is no suspicion of a toxic ingestion.

Do not start antiepileptic drugs on patients with simple febrile seizures or first-time, unprovoked, uncomplicated seizures.

Do not try using “around-the-clock” acetaminophen or ibuprofen to prevent the recurrence of febrile seizures. It may only contribute to the parents’ fever phobia.