Management of Pediatric Febrile

Seizures
Lilly Ma, DNP, CPNP-PC, and Sabrina Opiola McCauley, DNP, CPNP, NNP-BC

ABSTRACT
Febrile seizures are the most common seizure disorder. Febrile seizures are frightening
to witness, and therefore caregiver education is paramount to help relieve anxiety
levels. Acknowledgment of this concern by pediatric health care providers is needed to
understand the importance of education, reassurance, and anticipatory guidance for
caregivers. This article aims to discuss the assessment, diagnosis, and management of
febrile seizures for the nurse practitioner based on the most current literature. Through
appropriate clinical interventions, anticipatory guidance, and caregiver education, the
nurse practitioner can substantially increase the comfort of the patients and their
caregivers.

Keywords: anticipatory guidance, febrile seizure, fever, pediatric/child, primary care

Ó 2017 Elsevier Inc. All rights reserved.

F
ebrile seizures are the most common seizure
disorder in childhood, and children with this
condition may present to the primary care
provider’s office or the emergency department.
Febrile seizures have a peak incidence in the second
year of life,1 occurring in 2% to 5% of the pediatric
population.2 According to the most recent guidelines
from the American Academy of Pediatrics (AAP),3
a febrile seizure is a seizure accompanied by fever
(temperature 100.4 F or 38 C by any method)
and without central nervous system infection that
occurs in infants and children aged 6 through
60 months.
Most febrile seizures are benign but are none-
theless frightening for caregivers to witness; therefore
caregiver education is important to help relieve
anxiety levels. Febrile seizures are emotionally trau-
matic for caregivers. Many caregivers may think that
their child is dying during the seizure event and have
a persistent fear of recurrence.4 Acknowledgment of
this concern by nurse practitioners (NPs) is needed to
understand the importance of education, reassurance,
and anticipatory guidance for pediatric caregivers.
This article will discuss the assessment, diagnosis, and
management of febrile seizures, review current
literature, and address strategies to implement key
education points into current practice.
PATHOPHYSIOLOGY
The mechanism through which a fever can cause a
febrile seizure is still unclear. However, the cause of
febrile seizures is known to be multifactorial, with
genetic and environmental factors.5 An increase in
brain temperature alters neuronal functions and ion
channels, which influences neuronal firing and
excitability, resulting in seizures.6 Genetics comes
into play with neurodevelopmental vulnerability,
alterations in sodium channel expression,
hypothalamic dysregulation, and cortical and
hippocampal excitability.7 Environmental triggers are
believed to be involved through metabolic
dysregulatory pathways.7 The secretion of cytokine,
an inflammatory mediator, is also known to be part of
the mechanism of febrile seizures.6
RISK FACTORS
A febrile seizure is generally a benign condition,
related to various causative and risk factors (Table 1).
Febrile seizures are an age-dependent phenomenon,
occurring between 6 months and 5 years of age,
attributed to the vulnerability of the child’s devel-
oping nervous system. Family history of febrile
seizures, specifically in a first-degree relative, also
plays a role. The degree of the fever (103 F or
39 C), rather than the rate of the temperature rise, is

74 The Journal for Nurse Practitioners - JNP Volume 14, Issue 2, February 2018
Table 1. Causative and Risk Factors of Febrile Seizures defined as primary generalized seizures that last for
Factors Associated With Febrile Seizures
less than 15 minutes and do not recur within 24
Individual Age
hours.2 This is the most common type of febrile
Degree of fever seizure, occurring in 70%e75% of children with
History of febrile seizure febrile seizures.9 Complex febrile seizure is defined as
Familial First-degree relative with history focal, prolonged (duration longer than 15 minutes
of febrile seizures but less than 30 minutes), and/or recurrent within 24
Environmental Positive illness contact at home, hours. Approximately 20%e25% of febrile seizures
day care, or school are complex.9 Febrile status epilepticus is defined as
Virus Respiratory: influenza virus, generalized or focal seizures lasting more than 30
parainfluenza, respiratory syncytial minutes.2 The seizure can be continuous or
virus, adenovirus intermittent, without return to neurologic baseline
Enteric: enterovirus, Coxsackie virus,
during the period.
rotavirus
Herpesviruses: human herpesvirus,
cytomegalovirus, herpes simplex virus EVALUATION
Bacteria Respiratory: Streptococcus pneumoniae History
Enteric: Shigella dysenteriae, A thorough history should be taken on all children
Salmonella enteritidis after an episode of febrile seizure, including past
Urinary: Escherichia coli
medical history, medications, allergies, vaccination
Vaccination Measles, mumps, and rubella (MMR) history, a full review of systems, onset and charac-
Pertussis
teristic of the fever, events leading up to the febrile
Others Channelopathies, pH, water and seizure, characteristics of the seizure episode (dura-
electrolyte imbalance, cytokines
tion, body movements, and recurrence), and poten-
Adapted from Mohebbi, Holden, and Butler IJ.19 Copyright 2008 by Sage
tial sick contacts or exposures. A developmental
Publications.
history and family medical history is also important to
assess for risk factors. The NP must be able to use the
another risk factor in children.6 Although viral and history to distinguish whether the child had a simple,
bacterial infections are identified risk factors in febrile complex, or status epilepticus episode and develop a
seizures, there is a higher association with viral list of differential diagnoses. It is important for the NP
infections because they tend to cause high fevers. to understand that a febrile seizure is a diagnosis of
Finding the causative factor of the febrile seizure exclusion, and therefore a detailed history to deter-
event may help aid in diagnosis, management, and mine the need for further evaluation with diagnostic
prevention of recurrent episodes, as well as provide testing is necessary. Meningitis, encephalitis, or a
comfort to the child’s parents and caregivers. space-occupying brain lesion should be considered in
any child presenting with a fever and seizure.
CLINICAL PRESENTATION
Signs and symptoms of febrile seizures include loss of Physical Examination
consciousness, generalized or focal twitching or After a complete history has been conducted, a
jerking of arms and legs, eye deviation or rolling comprehensive examination should be performed to
back, pallor or cyanosis, and difficulty breathing. identify the cause of the fever. The NP must deter-
After the seizure, the child appears drowsy, lethargic, mine whether the child is clinically stable and his or
disoriented, and confused. This postictal state may last her hydration status. It is important to assess the pa-
up to 30 minutes, after which the child should return tient’s airway patency, ventilation and oxygen ade-
to baseline.8 quacy, and circulatory status.10
Febrile seizures are classified as simple, complex, A comprehensive neurologic examination should
or status epilepticus depending on characteristics, be conducted to ensure that the child is neurologi-
duration, and recurrence. Simple febrile seizure is cally healthy. The neurologic assessment should

www.npjournal.org The Journal for Nurse Practitioners - JNP 75

include any changes in mental status, drowsiness,
arousability, hallucinations, headache, irritability, and
neck stiffness or pain. These signs and symptoms may
indicate sepsis or meningitis and warrant further
evaluation. It is important to note that children with
febrile seizures are generally well appearing and re-
turn to baseline within 30 minutes.8 Therefore, any
abnormality noted on examination after this time
period should prompt suspicion for possible
systemic infection.
Diagnostic Tests
NPs assessing children after a febrile seizure should
focus their evaluation on identifying the cause of the
child’s fever. According to the AAP,3 simple febrile
seizures do not usually require further evaluation,
specifically neuroimaging, electroencephalogram
(EEG), or blood tests. Most children with complex
febrile seizures do not need routine work-up or
neuroimaging.11 In fact, an epileptiform EEG is not a
sensitive measure and has a poor positive predictive
value for the development of epilepsy among
neurologically healthy or mildly delayed children
with a first complex febrile seizure.12 A head
computed tomography scan is not routinely
recommended in the evaluation or management of
children with complex febrile seizures unless there is
indication of an intracranial hemorrhage or structural
lesion based on history and physical examination.9
In some patients with complex febrile seizures or
with a high index of suspicion of a more serious cause
of fever and seizure (Table 2), diagnostic tests may be
considered. In a child with a fever and seizure, a
lumbar puncture may be considered if there is a
suspicion for intracranial infection or meningitis
based on history and physical examination,

Table 2. Diagnostic Tests for Febrile Seizures

Diagnostic Tests Indications Differential Diagnoses
Neuroimaging CT or MRI should not be performed in the routine evaluation of
the child with a simple febrile seizure
If focal or prolonged seizure, obtain outpatient brain MRI without Space-occupying lesion
contrast Herniation
Mesial temporal sclerosis
EEG Should not be performed in the evaluation of a neurologically
healthy child with a simple febrile seizure

If abnormal neurodevelopmental state or more than one Febrile status epilepticus

complex feature of family history of epilepsy, may obtain
outpatient EEG
Lumbar puncture Any child who presents with a seizure and a fever and has Meningitis
meningeal signs and symptoms (neck stiffness, Kernig and/or Intracranial infection
Brudzinski signs); or in any child whose history or examination
suggests the presence of meningitis or intracranial infection
In any infant between 6 and 12 months of age who presents with Bacterial meningitis
a seizure and fever, and is considered deficient (immunizations
not complete or status cannot be determined) in Haemophilus
influenza type b (Hib) or Streptococcus pneumoniae
immunizations
Any child who presents with seizure and fever and is pretreated Meningitis
with antibiotics, because antibiotics can mask the signs and
symptoms of meningitis

Blood tests The following tests should not be performed routinely for the Blood abnormalities
sole purpose of identifying the cause of a simple febrile seizure:
measurement of serum electrolytes, calcium, phosphorus,
magnesium, or blood glucose, or complete blood cell count

76 The Journal for Nurse Practitioners - JNP Volume 14, Issue 2, February 2018
immunization status, or the recent or current use of
antibiotics, which may mask meningitis. However,
the risk of bacterial meningitis is extremely low, with
an estimated risk of 0% among children aged between
6 and 11 months with a first simple febrile seizure.13
A nonurgent, outpatient magnetic resonance imaging
scan of the brain may be considered for children with
focal complex seizures and postictal neurologic deficit
to evaluate for an underlying structural brain
abnormality.9 Refer to Table 2 for indications of
diagnostic tests and a list of differential diagnoses to be
considered.
TREATMENT
The AAP3 reports febrile seizures to be common and
benign in children, with excellent prognosis and no
long-term complications. There is no specific treat-
ment for febrile seizures; rather, the aim is to treat
the underlying cause. Depending on the NP’s
assessment and the child’s clinical status, care may
include oxygen supplementation, pulse oximetry,
cardiac monitoring, and intravenous fluids. It is
important to assess and maintain the child’s oxygen-
ation and hydration status, transferring to an appro-
priate facility as needed.
Antipyretics
Although antipyretics may improve the child’s
comfort, it will not prevent a febrile seizure or reduce
the recurrence of febrile seizures. A systematic re-
view14 of randomized controlled trials and a meta-
analysis aimed at determining the effectiveness of
antipyretic use in prevention of subsequent febrile
seizures assessed a sample of 540 children. Among the
sample, 348 children received antipyretics, including
acetaminophen, ibuprofen, and diclofenac, and 192
received a placebo. No statistically significant differ-
ence was found between the antipyretics and the
placebo groups in the recurrence rate of
febrile seizures.
Many caregivers administer antipyretics even
when there is a mild elevation in temperature because
they are concerned that the child must maintain a
“normal” temperature.15 Generally, acetaminophen
and ibuprofen are considered safe and effective
antipyretics for children, but education to prevent
overdose is important to avoid adverse events such as
www.npjournal.org
hepatotoxicity, gastrointestinal upset, respiratory
failure, metabolic acidosis, renal failure, and coma.8
Combination therapy of alternating acetaminophen
and ibuprofen may place children at increased risk of
toxicity because of administration errors and should
be carefully considered by the NP.
Antiepileptic Drugs
Febrile seizures are a benign condition and do not
cause long-term complications; therefore, the use of
antiepileptic drugs are not typically recommended.
Immediate management includes the use of a rescue
seizure medication such as rectal diazepam or intra-
nasal midazolam to stop an ongoing seizure when the
febrile seizure lasts longer than 5 minutes and respi-
ration becomes a concern.6 Continuous antiepileptic
therapy with phenobarbital, primidone, or valproic
acid and intermittent therapy with oral diazepam
have shown to be effective in reducing the risk of
recurrence.8 However, NPs must consider the
potential toxicities associated with these antiepileptic
drugs. The adverse effects likely outweigh the
relatively minor risks associated with febrile seizures.
If antiepileptic therapy is considered, a pediatric
neurology referral should be initiated. Ultimately, the
most effective treatment of febrile seizures is aimed
toward treating the febrile illness rather than
the seizure.
Neurology Referral
A nonurgent neurologic consult can be obtained if
there is clinical suspicion for an underlying neuro-
logic or developmental disorder.6 It should be
considered in children with persistent neurologic
deficits after a complex febrile seizure, recurrent
complex febrile seizure, febrile status epilepticus,
abnormalities on evaluation, or seizures not clearly
related to fever.9
Dravet syndrome, previously known as severe
myoclonic epilepsy of infancy, is characterized by
intractable epilepsy and poor neurodevelopmental
outcomes. This rare, catastrophic, lifelong form of
epilepsy manifests as frequent or prolonged seizures in
the first year of life, and therefore neurologic evalu-
ation and genetic testing should be considered in
children with  2 prolonged febrile seizures by 1 year
of age.16
The Journal for Nurse Practitioners - JNP 77
POTENTIAL RISKS
Children with simple febrile seizures have a high
rate of recurrence. A prospective cohort study17
aimed at identifying the risks and predictors of single
and multiple recurrent febrile seizures included a
total sample of 428 children with their first febrile
seizures. The study suggested that the risk of the
recurrence of febrile seizures decreased with older
age at onset of first episode. Children younger than
12 months at the time of their first simple febrile
seizure have an approximately 50% probability of
having recurrent febrile seizures, children older than
12 months at the time of their first event have an
approximately 30% probability of a second febrile
seizure. Additionally, 50% of those who do have a
second febrile seizure can have at least 1 additional
recurrence.17
The risk of epilepsy depends on several factors
(Table 3), including age at onset of first febrile
seizure, number of recurrent episodes of febrile
seizures, and family history of epilepsy. The risk of
developing epilepsy by age 7 in children who have
experienced a simple febrile seizure is 1%, which is
the same as the general population.18 Children who
have had multiple simple febrile seizures, are
younger than 12 months at the time of their first
febrile seizure, and have a family history of epilepsy
are at higher risk for epilepsy, with generalized
afebrile seizures developing by 25 years of age
in 2.4%.18
Table 3. Risk Factors for Recurrent Febrile Seizures and
Subsequent Epilepsy
Recurrent febrile seizures Family history of febrile seizures
Age < 18 months
Lower peak fever with previous
febrile seizure(s)
Shorter duration of fever with
previous febrile seizure(s)
Subsequent epilepsy Neurodevelopmental
abnormality
Complex febrile seizure
Family history of epilepsy
Shorter duration of fever with
prior febrile seizure(s)
Adapted from Shinnar and Glauser.18 Copyright 2002 by Sage Publications.
78 The Journal for Nurse Practitioners - JNP
ROLE OF THE NP
Clinical Practice
NPs will encounter febrile seizures at some point in
their careers and will most likely manage them in the
outpatient setting. The assessment and evaluation of
children who present with febrile seizures should be
directed toward determining the specific cause for the
fever using history and physical examination findings
along with appropriate diagnostic tests to reduce the
period of morbidity and hospitalization, decrease the
need for neurologic studies, relieve the anxiety of the
child’s caregivers, and reduce the administration of
anticonvulsants.19 The NP caring for the child should
focus on making sure the child is clinically stable,
monitoring for signs and symptoms of serious illness,
improving the child’s comfort by maintaining
hydration, and educating caregivers on the
appropriate use of antipyretics.
Education
In addition to the evaluation and management of the
child’s health, a major role of the NP is educating the
child’s family. The NP is often the main source of
information for the child’s caregivers on febrile sei-
zures. Anticipatory guidance, as outlined in Table 4,
should be provided at each visit because fevers are
common and can result in febrile seizures in any child.
The NP should counsel caregivers on what they
should do if a febrile seizure occurs. First, lay the
child on the floor in the side-lying position to prevent
aspiration; remove objects in the surrounding area
that may injure the child. With the caregiver at the
child’s back, caregiver should put her fingers under
the chin. Straighten the airway by pushing chin
upward. DO NOT place anything in the child’s
mouth. The caregiver should also be educated to time
the duration of the seizure and to note what is
occurring during the seizure episode. Recommending
that caregivers take a cardiopulmonary resuscitation
class can also be beneficial in reducing their anxiety.
Fever is a frequent cause of concern; it is important
to help the caregivers understand that fever itself is not
a danger to a generally healthy individual. The NP
should educate and reassure caregivers that fever is not
the primary illness, but is the immune system’s phys-
iologic mechanism to fight infection.15 Caregivers
Volume 14, Issue 2, February 2018
Table 4. Anticipatory Guidance and Education on Febrile Seizures for Caregivers
 Febrile seizures occur in 2%e5% of all children between the ages of 6 months and 5 years.
 Febrile seizures tend to run in families.
 Febrile seizures often occur in the first 24 hours of the febrile illness.
 A febrile seizure might present with body stiffening; twitching of the face, arms and legs, or both; eye rolling; jerking of the
arms and legs; staring; or loss of consciousness.
 These seizures might appear frightening to observers but are generally harmless.
 Your child might appear not to be breathing and the skin color might become darker. Call 911 or emergency personnel.
Caregivers should consider taking a CPR class.
 First, lay the child on the floor in the side-lying position to prevent aspiration; remove objects in the surrounding area that
may injure the child. With the caregiver at the child’s back, caregiver should put her fingers under the chin. Straighten the
airway by pushing chin upward. DO NOT place anything in the child’s mouth.
 You should time the duration of the seizure and note what is occurring during the seizure episode.
 Febrile seizures do not cause brain damage or paralysis.
 A child who has febrile seizures has only a slightly increased risk of having a seizure disorder compared with that of a child
who has never had a febrile seizure.
 Febrile seizures can recur with subsequent febrile illnesses. Your child should be seen by a health care provider for an
evaluation after every episode.
 Medicines are generally not given to prevent simple febrile seizures.
 Use of medicines such as acetaminophen or ibuprofen for fevers has not been shown to prevent febrile seizures.
 Although immunizations are associated with febrile seizures, this is not a reason not to immunize your child.
Adapted from Warden, Zibulewsky, Mace, Gold, and Gausche-Hill.10

should be reassured that the fever does not worsen the
course of the illness, nor will it cause neurologic
complications. They should also be educated to
monitor the child for any changes in activity level and
observe for signs or symptoms of illness. The NP
should inform caregivers that although febrile seizures
are dramatic events, they do not indicate future
neurologic dysfunction or disease.
It is also important to address concerns of the
correlation between vaccinations and febrile seizures.
Vaccines associated with febrile seizures include
measles, mumps, rubella, and varicella (MMRV) and
diphtheria, tetanus toxoid, and pertussis (DTP).2
Postvaccination febrile seizures are rare and often
occur within the first 3 days after administration of a
live attenuated vaccine, with increased risk when
multiple vaccines are given.2 However, febrile
seizures due to vaccination are no different from
those of other causes and should not discourage
caregivers from vaccinating their children.
When counseling caregivers on the management
of fever, it is important to emphasize that the goal of
antipyretic therapy is not to “normalize” body tem-
perature; rather, it is part of supportive care to
improve the child’s comfort in addition to hydration
and rest. Approximately half of caregivers consider a
temperature of < 100.4 F or 38 C to be a fever, and
25% of caregivers would give antipyretics when their
temperature does not indicate fever.20 Additionally,
caregivers have reported awakening their child from
sleep to give them antipyretics.20
It is critically important that all caregivers be given
clear instructions on the appropriate administration of
antipyretics because of the risk of overdose and its
fatal complications. The accurate formulation, dose,
dosing interval, and daily maximum dosage of each
type of antipyretic must be discussed. All medications
should be labeled clearly with dosing instructions and
include an appropriate dosing device. Child safety,
including proper handling and storage of antipyretics,
should also be encouraged.
Parents should be reassured that febrile seizures do
not cause brain damage or paralysis, nor do they place
the child at risk for developmental or behavioral
consequences.21 It is also important to educate
parents that a child with history of febrile seizure has a
low risk of developing epilepsy.18
Although febrile seizures are benign, the child
should still be evaluated, whether in the primary
care setting or in the emergency department, after
every episode. The need for a follow-up should be
determined on the basis of the underlying cause
of the fever and the clinical presentation of the
child. The caregiver should note the onset of fever,

www.npjournal.org The Journal for Nurse Practitioners - JNP 79

characteristics and duration of the seizures, and pos-
tictal state.
Future Research
There are still gaps in knowledge revolving around
febrile seizures, indicating the need for further
research. Future studies should determine the
appropriate use of neuroimaging studies, the timing
of administration of antiviral and antibacterial drugs,
and the acute and chronic administration of anti-
convulsants in simple and complex febrile seizures.
CONCLUSION
Although most febrile seizures are benign, their careful
assessment and management is important. NPs evalu-
ating children after a febrile seizure should focus on
identifying the cause of the child’s fever and treating
the febrile illness rather than the seizure. Febrile sei-
zures are frightening for caregivers to witness, and
therefore education is necessary to help relieve their
anxiety levels. Acknowledgment of this concern by
NPs is needed to understand the importance of edu-
cation, reassurance, and anticipatory guidance for their
pediatric patients and their caregivers.
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Lilly Ma, DNP, CPNP-PC, is a pediatric nurse practitioner in
the Department of Pediatric Neurology, NYU Langone Medical
Center, New York, NY. She can be reached at LillyMa89@
gmail.com. Sabrina Opiola McCauley, DNP, CPNP,
NNP-BC, is an assistant professor of nursing at the Columbia
University School of Nursing, New York, NY. In compliance
with national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.
1555-4155/17/$ see front matter
© 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.nurpra.2017.09.021
Volume 14, Issue 2, February 2018