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Febrile Seizures
Febrile 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 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 sei-
zures 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. (Am Fam Physician. 2019;99(7):445-450. Copyright
© 2019 American Academy of Family Physicians.)
A febrile seizure is a seizure occurring in a that may affect a vulnerable, developing nervous
child six months to five years of age that is accom- system under the stress of a fever. Other risk fac-
panied by a fever (100.4°F [38°C] or greater) with- tors include exposures in utero, such as maternal
out central nervous system infection.1 Febrile smoking and maternal stress;being in the neo-
seizures are classified as simple or complex natal intensive care unit for more than 28 days
(Table 1).1 Complex seizures last 15 minutes or (odds ratio [OR] = 5.6);developmental delay
more, are associated with focal neurologic find- (OR = 4.9);having a first-degree relative with
ings, or recur within 24 hours. Febrile seizures
are the most common convulsive event in child-
hood, occurring in 2% to 5% of children.1 TABLE 1
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FEBRILE SEIZURES
SORT:KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Children with a simple febrile seizure who are C 1, 31, 32 herpesvirus 6, influenza, adenovirus,
well-appearing do not require routine diagnostic and parainfluenza.7,8
testing, such as laboratory tests, neuroimaging, or Certain vaccine preparations
electroencephalography.
and associated age at administra-
Continuous or intermittent antiepileptic medi- B 42 tion have been shown to increase
cations are not recommended after a first febrile the risk of febrile seizures.9 The
seizure because of potential adverse effects. measles-mumps-rubella vaccine is
Antipyretic agents do not reduce recurrence of A 42 associated with an increased risk of
simple febrile seizures. febrile seizures (10 additional cases
per 10,000 children 16 to 23 months
Risk factors for recurrence of febrile seizure are B 38
age younger than 18 months, fever duration of less
of age, but only four additional cases
than one hour before seizure onset, first-degree per 10,000 children 12 to 15 months
relative with a history of febrile seizures, and a of age).10,11 Because the increased risk
temperature of less than 104°F (40°C). of seizures with measles-containing
A = consistent, good-quality patient-oriented evidence;B = inconsistent or limited-quality vaccines is lower when administered
patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert at 12 to 15 months, the age recom-
opinion, or case series. For information about the SORT evidence rating system, go to https:// mended by the Centers for Disease
www.aafp.org/afpsort.
Control and Prevention, it is import-
ant to provide timely immunizations
to mitigate potential risks.11,12 There is
BEST PRACTICES IN NEUROLOGY also a slight increase in risk in the 24
hours following the administration of
the measles-mumps-rubella-varicella
Recommendations from the Choosing Wisely Campaign
vaccine compared with separate
Recommendation Sponsoring organization measles-mumps-rubella and vari-
Do not routinely order an electroencephalography American Academy
cella vaccines (3.5 additional cases per
for neurologically healthy children who have a simple of Nursing 10,000 children).13
febrile seizure. The risk of seizure is not significantly
increased following the influenza vac-
Neuroimaging (computed tomography, magnetic American Academy
resonance imaging) is not necessary in a child with a of Pediatrics
cine or the modern acellular pertus-
simple febrile seizure. sis vaccine.12 Because the sequelae of
preventable infections and the impor-
Source: For more information on the Choosing Wisely Campaign, see http://www.choosing
wisely.org. For supporting citations and to search Choosing Wisely recommendations relevant
tance of maintaining herd immunity
to primary care, see https://www.aafp.org/afp/recommendations/search.htm. are more important than the rare
potential complications from vaccina-
tions, the American Academy of Fam-
a history of febrile seizures (OR = 4.5);having a second- ily Physicians and Advisory Committee on Immunization
degree relative with a history of febrile seizures (OR = 3.6); Practices recommend children receive all routine vaccina-
and day care attendance (OR = 3.1).2-4 tions.14,15 The Centers for Disease Control and Prevention
Certain genes that have been identified as risk factors does not recommend administering antipyretics following
for familial epilepsy syndromes may also increase the risk immunizations, because this does not prevent febrile sei-
of febrile seizures.5,6 Underlying genetic disorders may zures and has the potential to decrease antibody response.16
increase susceptibility to environmental risk factors. The
risk of febrile seizures is related to the height of the tempera- Evaluation
ture elevation, not the rate of temperature rise, and seizure The evaluation of children with febrile seizures should
threshold varies by age and individual susceptibilities.3 begin with a focused history and physical examination to
Viral infections, particularly those associated with high determine the cause of the fever.1,17-19 Key features of the
fevers, increase the risk of febrile seizures because high history include description and duration of the convulsive
fevers have been shown to increase neuronal excitabil- episode, personal or family history of seizures or epilepsy,
ity and lower the seizure threshold.2 Viruses most com- recent illness or antibiotic use, recent vaccinations, and
monly correlated with febrile seizures include human immunization status for Haemophilus influenzae type b
446 American Family Physician www.aafp.org/afp Volume 99, Number 7 ◆ April 1, 2019
FEBRILE SEIZURES
448 American Family Physician www.aafp.org/afp Volume 99, Number 7 ◆ April 1, 2019
FEBRILE SEIZURES
initial management of febrile seizures. First, parents should 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.
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5. Hardies K, Weckhuysen S, Peeters E, et al. Duplications of 17q12 can
should not be restrained, and nothing should be put in the cause familial fever-related epilepsy syndromes. Neurology. 2013;
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than five minutes.44 Physicians may also provide parents children. A prospective study of complications and reactivation. N Engl
with an estimated risk of febrile seizure recurrence using J Med. 1994;331(7):432-438.
the tool in Table 2.38 8. Chung B, Wong V. Relationship between five common viruses and
febrile seizure in children. Arch Dis Child. 2007;92(7):589-593.
This article updates previous articles on this topic by Graves, et al.,17 9. Francis JR, Richmond P, Robins C, et al. An observational study of
and Millar.45 febrile seizures:the importance of viral infection and immunization.
BMC Pediatr. 2016;16(1):202.
Data Sources: A PubMed search was completed using the
key terms febrile seizures and febrile convulsions. The search 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;
included meta-analyses, randomized controlled trials, clinical
134(2):325-337.
trials, and reviews. We also searched the Cochrane database,
1 1. Rowhani-Rahbar A, Fireman B, Lewis E, et al. Effect of age on the risk
Essential Evidence Plus, and the National Guideline Clear-
of fever and seizures following immunization with measles-containing
inghouse. References in these resources were also searched.
vaccines in children. JAMA Pediatr. 2013;167(12):1 111-1117.
Search dates:February 20, 2018; May 1, 2018; August 15, 2018;
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and December 8, 2018.
vaccines and febrile seizures. https://w ww.cdc.gov/vaccinesafety/
The views expressed in this article are those of the authors and concerns/febrile-seizures.html. Accessed September 30, 2018.
do not necessarily reflect the official policy or position of the 1 3. MacDonald SE, Dover DC, Simmonds KA, Svenson LW. Risk of febrile
Department of the Navy, Department of Defense, or the U.S. seizures after first dose of measles-mumps-rubella-varicella vaccine:a
government. 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://w ww.aafp.org/media-center/
The Authors releases-statements/all/2016/aafp -maintains-strong-stance -in -
support-of-immunizations-across-lifespan.html. Accessed August 31,
DUSTIN K. SMITH, DO, is senior medical officer at Naval Hospi- 2018.
tal Yokosuka, Branch Health Clinic Diego Garcia, British Indian
15. Kroger AT, Duchin J, Vázquez M. General best practice guidelines for
Ocean Territory. At the time this article was written, he was the immunization. Best practices guidance of the Advisory Committee on
assistant program director of the Jacksonville Family Medicine Immunization Practices. http://w ww.cdc.gov/vaccines/hcp/acip-recs/
Residency Program at Naval Hospital Jacksonville and an assis- general-recs/downloads/general-recs.pdf. Accessed August 21, 2018.
tant professor of family medicine for the Uniformed Services 16. Prymula R, Siegrist CA, Chlibek R, et al. Effect of prophylactic parac-
University of the Health Sciences, Jacksonville, Fla. etamol administration at time of vaccination on febrile reactions and
antibody responses in children:two open-label, randomised controlled
KERRY P. SADLER, MD, is a chief resident in the Family Medi- trials. Lancet. 2009;374(9698):1 339-1350.
cine Residency Program at Naval Hospital Jacksonville. 17. Graves RC, Oehler K, Tingle LE. Febrile seizures:risks, evaluation, and
prognosis. Am Fam Physician. 2012;85(2):149-153.
MOLLY BENEDUM, MD, is an associate program director of
the Family Medicine Residency at Greenville (S.C.) Health 18. Kimia AA, Bachur RG, Torres A, Harper MB. Febrile seizures:emergency
medicine perspective. Curr Opin Pediatr. 2015;27(3):292-297.
System, and a clinical assistant professor in the Department
of Family Medicine at the University of South Carolina Green- 19. Agarwal M, Fox SM. Pediatric seizures. Emerg Med Clin North Am. 2013;
31(3):733-754.
ville School of Medicine.
20. Chamberlain JM, Gorman RL. Occult bacteremia in children with sim-
Address correspondence to Dustin K. Smith, DO, Naval ple febrile seizures. Am J Dis Child. 1988;142(10):1073-1076.
Branch Health Clinic Diego Garcia, PSC 466 Box 302, 21. Shah SS, Alpern ER, Zwerling L, Reid JR, McGowan KL, Bell LM. Low
FPO-AP 96595. Reprints are not available from the authors. 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
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450 American Family Physician www.aafp.org/afp Volume 99, Number 7 ◆ April 1, 2019