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Evidence Based Strategies: Febrile Seizures by the Numbers: Providing Anticipatory Guidance to Families

Column Author:  Jonah Lund, MD | Child Neurology Resident, PGY-2

Column Author:  Kathleen Berg, MD, FAAP | Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Febrile seizures are common in the pediatric population, with approximately 2%-5% of children experiencing a febrile seizure. Although there is low risk of significant adverse events with supportive care alone,1 caregivers of patients often experience significant distress.2-4 Part of providing supportive care for patients and their families who experience a febrile seizure includes acknowledging their stress and providing anticipatory guidance including reviewing the risk of recurrence of seizures. The purpose of this article is to provide a quick primer on the definition of febrile seizures, diagnostic considerations, the risk of recurrence after their first episode, and tips for clearly communicating with families.

Febrile seizures typically occur in children aged 6-60 months of age. Although they occur during times of illness related to fevers, patients do not necessarily need to be febrile at the time of the seizure. There are two categories of febrile seizures: simple and complex. Simple febrile seizures consist of generalized movements without focal features that last less than 15 minutes and occur only once within a 24-hour period. Complex febrile seizures have one or more of the following criteria: They last longer than 30 minutes, contain focal movements, or occur more than once within a 24-hour period.5

In addition to categorizing the event as simple or complex, evaluations for febrile seizures always include consideration of the cause of fever itself. Common causes include upper respiratory tract infection, viral gastroenteritis, acute otitis media, or urinary tract infections. Laboratory evaluation, if any, should be directed based on symptoms and exam findings. Concern for meningitis or other intracranial infections should be evaluated with a lumbar puncture and possibly neuroimaging. If a patient does not need further evaluation or treatment for the source of their fever, they are safe to discharge home without additional work-up in the acute setting.

Complex febrile seizures with focality or a focal neurological examination warrant caution and consideration of alternative diagnoses. Additional work-up the acute setting may be needed. Patients with complex febrile seizures without focality can follow-up in the Neurology clinic where they will undergo EEG and, potentially, neuroimaging.   

Witnessing their child have a seizure can be incredibly stressful for caregivers. In a cross-sectional study using standardized tools to assess maternal anxiety and uncertainty (n = 190), having a child who had a febrile seizure was correlated with higher anxiety and greater uncertainty in mothers.2 In a qualitative study of parents whose child had experienced a febrile seizure (n=119), 89% of those in the febrile seizure group described fear with a median intensity of 10/10.3 Not only is parental stress high, but a randomized controlled trial reported that longer duration of time to follow-up correlated with higher anxiety.4 It is challenging for caregivers to be left wondering if it will happen again. Fear of seizures and misperceptions about seizure precautions can lead to excessive limitations on a child’s activity or social interactions.

Common questions at the time of discharge from families include risk of recurrence, ability to prevent recurrence, and long-term consequences. Here are some facts and figures that can help with providing accurate reassurance and anticipatory guidance for patients and families whose child has experienced a febrile seizure:

 

  1. Will my child have another febrile seizure?

Approximately 33% of children who experience a febrile seizure will have another febrile seizure.5,6,7

  1. Children younger than 1 year have a higher risk, closer to 50%, while children over the age of 3 years have a lower risk, closer to 20%.
  2. Other factors associated with increased risk of recurrence include: lower-grade fever, first degree family member with history of febrile seizure, febrile seizure occurring within one hour of fever onset.
  1. Will my child have epilepsy?

Different factors are associated with a higher risk of developing epilepsy for those who experience a febrile seizure, such as complex febrile seizure, occurrence of seizure within one hour of fever onset, age >3 years old, presence of neurodevelopmental abnormality, or family history of epilepsy.6 Adverse effect rates of antiepileptic medications are approximately 30%, which limits their utility when epilepsy has not yet been diagnosed.5

  1. Risk of epilepsy without febrile seizure: 0.5%
  2. Risk of epilepsy with simple febrile seizure: 1%-2%
  3. Risk of epilepsy with complex febrile seizures: 6%-8%
  1. Did the seizure cause damage to my child’s brain?

Short seizures (< 30 minutes) do not cause brain damage. Many studies have shown no correlation with development of cognitive, academic or behavioral issues after experiencing a febrile seizure.6

  1. Should I give my child medication to reduce fever?

Fevers are common in children and cannot be entirely prevented. Further, treatment with antipyretics has not been shown to prevent febrile seizures but may be used for symptomatic treatment of fevers.6

  1. What precautions should I take?

Most precautions are the same as you would recommend for any caregiver of a child in this age group. Caregivers should always watch their child around water and practice helmet use for biking, skateboarding, etc. They should know it is OK for their child to play sports.

Febrile seizures are frightening to children’s caregivers. By using clear and empathic communication with caregivers, providers can acknowledge their emotional stress, address their concerns, and help allay their fears. Children’s Mercy’s Febrile Seizure Clinical Pathway, available at Seizure: Febrile | Children's Mercy Kansas City offers providers additional evidence-based guidance, including frequently asked questions and family education handouts for both simple and complex febrile seizures.

 

References:

  1. Raghavan VR, Porter JJ, Neuman MI, Lyons TW. Trends in management of simple febrile seizures at US children’s hospitals. Pediatrics. 2021;148(5):e2021051517. doi:10.1542/peds.2021-051517
  2. Al-Hammouri MM, Rababah JA, Jamahneh OM, Kasem A, Suliman MM. Uncertainty, knowledge, and anxiety of mothers concerning febrile seizure: a comparison between affected and unaffected mothers. J Pediatr Nurs. 2024;78:e411-e416. doi:10.1016/j.pedn.2024.08.002
  3. Rice SA, Müller RM, Jeschke S, et al. Febrile seizures: perceptions and knowledge of parents of affected and unaffected children. Eur J Pediatr. 2022;181(4):1487-1495. doi:10.1007/s00431-021-04335-1
  4. Klotz KA, Özcan J, Sag Y, Schönberger J, Kaier K, Jacobs J. Anxiety of families after first unprovoked or first febrile seizure - a prospective, randomized pilot study. Epilepsy Behav. 2021;122:108120. doi:10.1016/j.yebeh.2021.108120
  5. Rosengard JL Vidaurre J, Ochoa JG, Dergalust S, Moshé SL. Pediatric epilepsy. In: Roach ES, ed. Pediatric Neurology: Clinical Assessment and Management. Springer Publishing Company; 2021:83-84.
  6. Tiwari A, Meshram RJ, Kumar Singh R. Febrile seizures in children: a review. Cureus. 2022;14(11):e31509. Published online November 14, 2022. doi:10.7759/cureus.31509
  7. Kim JS, Woo H, Kim WS, Sung WY. Clinical profile and predictors of recurrent simple febrile seizure. Pediatr Neurol. 2024;156:4-9. doi:10.1016/j.pediatrneurol.2024.04.001
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