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Febrile Seizures - Primary Steps for Primary Care

Dr Malik with infant patient

Febrile seizures are the most common seizure type in childhood, affecting 2-5 percent of children. These seizures are associated with a febrile illness in the absence of central nervous system infection or electrolyte imbalance, and they typically occur between the ages of 6 months and 5 years (peak 18 months). Most febrile seizures can be managed in a primary care setting. Below are answers to common questions, as well as the signs and symptoms that may indicate the need for a neurology evaluation. For an in-depth, case-based review of febrile seizures and other epilepsy syndromes associated with febrile seizures follow this link:

Patel A, Perry MS. Febrile Seizures. Journal of Clinical Outcomes Management 2017, 24(7):325-334

What are the types of febrile seizures?


Generalized in appearance, <10 minutes in duration and/or occur once in a 24-hour time period.

What workup is needed?

Routine labs are not needed except as they pertain to diagnosis of fever source. Lumbar puncture is not often needed unless signs of meningitis are present. Routine EEG and imaging is not indicated.

What treatment is needed?

Treatment of the fever source is most important. Daily preventive antiepileptic therapy is not indicated. Benzodiazepine (i.e., clonazepam) use during febrile illness could be considered for children presenting with multiple febrile seizures to help prevent recurrence. Use of antipyretics to prevent febrile seizures has not been demonstrated effective, as typically the seizure is the first sign of the febrile illness.


Focal in onset, >10 minutes in duration and/or occur more than once during a 24-hour time period.

What workup is needed?

Routine labs as needed to determine fever source. Lumbar puncture should be strongly considered in children <12 months, as well as 12-18 months as signs of meningitis may be less obvious. Children pretreated with antibiotics or whose immunization status is unknown also may warrant lumbar puncture. Imaging is rarely needed. EEG is often not needed. If the child presents with recurrent complex febrile seizures, an abnormal EEG may guide treatment of underlying epilepsy.

What treatment is needed?

Rescue therapy for prolonged or recurrent febrile seizures may include rectal diazepam or buccal midazolam. Intermittent oral benzodiazepine use during a febrile illness may also help prevent seizure recurrence. Daily preventive anti-epileptic drugs as maintenance therapy are not needed.


Seizure in the setting of fever lasting > 30 minutes.

What is the risk of recurrence after a febrile seizure?

Thirty percent after one febrile seizure, 60 percent after two and 90 percent after three.

What are the risks of febrile seizures?

There is no significant increased risk of developing epilepsy or developmental delays after first simple febrile seizure. Patients with multiple febrile seizures can carry a four- to five- fold increased risk of developing epilepsy.

Not all febrile seizures are benign and some may be the first signs of other epilepsy syndromes, such as Dravet syndrome, PCDH19-associated epilepsy, hemiconvulsion-hemiplegia epilepsy and febrile infection-related epilepsy syndrome.

Referrals and consultations

Red flags suggesting neurology referral may be of value:

  1. Recurrent complex febrile seizures or febrile status epilepticus.
  2. Seizures that occur every time the child has a febrile illness.
  3. Seizures in the setting of modest hyperthermia (i.e., hot baths, overheating).
  4. Alternating hemiclonic seizures (i.e., presenting once with predominantly left-sided focal febrile seizure, then again with predominantly right-sided involvement).
  5. Developmental delays or decline.
  6. Strong family history of febrile seizures.
  7. Unprovoked (afebrile) seizures.

Contact the Jane and John Justin Neuroscience Center at Cook Children’s with your questions about any patient with seizures. For consultation questions, call us at 682-885-2500.

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