MBBS SAQ · Paediatrics / Neurology
Febrile seizures — simple vs complex, acute termination and counselling
NEET-PG SAQ on febrile seizures: age 6–60 months definition, simple vs complex criteria, benzodiazepine doses, LP indications, no routine AED prophylaxis.
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Question
An 18-month-old previously well boy has a first episode of bilateral tonic–clonic movements lasting 3 minutes associated with fever 38.9 °C (otitis media). He is now post-ictal but recovering, with no focal neurology, no neck stiffness, and is interactive after 20 minutes. No prior afebrile seizures. Outline diagnosis/classification, acute seizure termination rules, investigations, ongoing management, and parental counselling on recurrence and epilepsy risk.
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Diagnosis: simple febrile seizure.
Definition: seizure with fever >38 °C in a child 6 months to 5 years (60 months), without CNS infection, metabolic cause, or prior afebrile seizure.[1]
Simple vs complex:
- Simple (~70%): generalised, <15 minutes, does not recur within 24 h — this case.
- Complex (~30%): focal features, ≥15 minutes, or recurs within 24 h.
- Febrile status epilepticus: continuous/recurrent without recovery >30 minutes.
Acute termination (if still seizing or ≥5 minutes):
- IV lorazepam 0.1 mg/kg (max 4 mg), or
- Buccal midazolam 0.5 mg/kg, or
- Rectal diazepam 0.5 mg/kg
- Support airway/oxygen; check glucose; escalate status pathway if ongoing.
Investigations:
- Identify fever source (otoscopy, urine if indicated, etc.).
- LP: strongly consider in any infant <12 months with fever + seizure; also if meningism, complex features, incomplete immunisation (Hib/pneumococcus), pretreatment with antibiotics, or ill appearance. Not routinely mandatory after a first simple febrile seizure in a well-appearing fully immunised child >12 months.[1]
- No routine EEG or neuroimaging after simple febrile seizure.
- Labs only if indicated (glucose if prolonged/not recovering; electrolytes if GI losses).
Management after recovery:
- Treat the cause of fever (e.g. antibiotics for bacterial AOM if indicated); antipyretics for comfort (do not reliably prevent recurrence).
- No continuous anticonvulsant prophylaxis for simple febrile seizures (risks outweigh benefits).[2]
- Rescue benzodiazepine education for prolonged recurrence in selected families.
- Admit/observe if complex, young infant, uncertain meningitis, or parental concern/social factors.
Counselling (high-yield):
- Common (2–5% of children); peak 12–18 months; does not cause brain damage in typical simple events.
- Recurrence ~30% after first (higher if first seizure <12 months, family history, low-grade fever at onset).
- Later epilepsy risk ~2–5% after simple, higher after complex (approx 4–15%).
- Safety: recovery position, do not force objects into mouth, time the seizure, call emergency services if >5 minutes or first event/parent unsure.
- Vaccination should continue; febrile seizures can rarely follow vaccines but vaccines are still recommended.
Common errors
- Starting long-term phenobarbital/valproate after a single simple febrile seizure.
- Routine CT/EEG for every simple event.
- Missing meningitis in young infants.
- Telling parents the child has epilepsy.
- Claiming antipyretics prevent all future febrile seizures.
Examiner notes
- Definition age band 6–60 months and simple/complex triad.
- Benzodiazepine doses for seizures ≥5 minutes.
- LP threshold language for <12 months.
- Recurrence ~30%; epilepsy risk low after simple seizures.
References2ShowHide
- [1]AAP Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics, 2011.PMID 21285335
- [2]AAP Steering Committee. Febrile seizures: long-term management guideline. Pediatrics, 2008.PMID 18519501