As in adults, most children suffering a first unprovoked seizure do not have another one, especially if their EEG is normal. The risk is higher in children with autistic spectrum disorders and if the seizure happens during sleep.⁷ If it occurs, recurrent seizure is most common in the first six months after the first one.⁷ While sudden unexpected death in epilepsy (SUDEP) is a known and feared entity that is currently impossible to predict in any given patient, most excess mortality in children with epilepsy is not caused by a seizure itself.⁹ Great care should be taken when evaluating infants. Sepsis, meningitis, or disseminated herpes infection can manifest initially with a seizure with or without an abnormal temperature. Appropriate discharge instructions related to trauma and burn prevention, avoiding driving and taking care of babies, and not swimming or lying in a bath without close supervision are of paramount importance.

Febrile Seizures

Febrile seizures are most commonly defined as those occurring in children of defined age (6 to 60 months, per the American Academy of Pediatrics 2008 guideline) without prior afebrile seizures or neurological abnormalities and occurring in association with acute febrile illness when no other precipitating condition is identified.10 Complex febrile seizures have focal onset, have lateralizing signs, last longer than 15 minutes, are associated with prolonged postictal deficits, or occur more than once in a given acute febrile illness. These represent approximately 40 percent of all febrile seizure presentations.¹⁰ Febrile seizures that are not complex are defined as simple. Children typically are highly febrile if presenting soon after the seizure; low-grade fever is unusual with febrile seizures unless antipyretics were already given. Seizures lasting more than five minutes currently meet criteria for status epilepticus (SE).¹¹

Management of patients with simple febrile seizures in the emergency department is similar to the management of children presenting with fever without a seizure and focuses on exclusion of serious illness such as meningitis or sepsis. The 2011 guidelines from the American Academy of Pediatrics do not recommend routine imaging, EEG, lumbar puncture, blood work, or urinalysis solely because of a simple or complex febrile seizure. Unimmunized young children (less than one year old), those on antibiotics, or those with sick appearance warrant a more extensive workup. Children seizing in the emergency department can be given benzodiazepines with intramuscular (IM), IV, intranasal, and rectal routes described.^3,10,12 The decision to prescribe rectal diazepam for use in subsequent febrile seizure episodes is controversial and must be balanced with potential of apnea after its administration.¹⁰ As the seizure typically occurs when fever spikes, antipyretics do not help to prevent first or subsequent febrile seizures.