Febrile Seizures

A febrile seizure starts with a fever in a child aged about 6 months to 5 years. Nothing else explains it: no intracranial infection, no metabolic disturbance, no earlier afebrile seizure. It is the most common seizure disorder of childhood, and it affects 2% to 5% of children aged 6 to 60 months. Most come with a viral infection. Most are brief and generalized. Most stop before the child reaches the hospital.

On scene, you protect the airway. You stop a seizure that will not stop. You check glucose. Then you decide: simple febrile seizure, or one that needs a full evaluation. Meningitis is the one you cannot miss.

Why Kids Are Different

• Developmental window: febrile seizures cluster between about 6 months and 5 years. After age 6 years they are very rare. Before 6 months, a seizure with fever raises suspicion of a genetic epilepsy.
• Fever is required, but the threshold is unclear: studies use 38 °C or 38.4 °C as the cut-off. How fast the temperature climbs has not been shown to matter more than how high it gets.
• Family history matters: a sibling of a child with a febrile seizure has a 10% to 45% chance of one.
• Usually benign: short simple ones are not linked to neurological or cognitive impairment.

Classify the seizure after it stops. What separates simple from complex drives the evaluation. The amount of fever does not.

Age-Specific Presentation

• Under 6 months: fever with a seizure does not fit a simple febrile seizure. Treat it as possible meningitis or encephalitis until evaluated.
• 6 to 12 months: complex features turn up more often. Lumbar puncture is an option in some cases (see Special Populations).
• 1 to 5 years: this is the classic febrile seizure. A brief generalized convulsion with fever, often from a viral illness.
• 5 to 6 years: febrile seizures are uncommon at this age. Treat a seizure with fever as atypical and evaluate per protocol.
• Over 6 years: fever with a seizure is very rare. It does not fit a simple febrile seizure.

Still drowsy after the seizure? Or GCS still below 15 more than an hour after it ends? Then the child is not back to baseline. Evaluate further (see Monitoring, Reassessment & Disposition).

Look past the fever when a seizure is new, unusual or does not match the pattern above.

0 to 5 Minutes

1. Protect the airway (EMT, AEMT, Paramedic, RN): position the child on the side and clear the airway. Place an oropharyngeal or nasopharyngeal airway if obstruction persists after chin-lift, jaw thrust or suction.
2. Oxygen and monitoring: apply pulse oximetry, and capnography where stocked. Give oxygen with a target SpO₂ of 94–98%. Use bag-valve-mask ventilation if oxygenation or ventilation is compromised.
3. Do not delay for IV access: intranasal or intramuscular routes are preferred over IV or IO when no line is established. You do not need IV access to treat the seizure, though it may be placed for other reasons.
4. Check glucose: if the child is still seizing, check blood glucose. If it is below 60 mg/dL, treat per the hypoglycemia guideline.

At 5 Minutes or Longer

1. Give a benzodiazepine (Paramedic/RN, per local protocol): midazolam 0.2 mg/kg IM or IN (max 10 mg) if no IV or IO. Some protocols swap in fixed IM doses, as the RAMPART trial did: 10 mg above 40 kg and 5 mg at 13 to 40 kg. With IV or IO access, use lorazepam 0.1 mg/kg (max 4 mg) or diazepam 0.2 mg/kg (max 8 mg); IV midazolam 0.1 mg/kg (max 4 mg) is an alternative IV agent per protocol. Rectal diazepam is an alternative where stocked. Dose it by age and weight, per the product label or protocol.
2. Repeat once if still seizing: the second dose can be given at 5 minutes after the first, per protocol. Count any dose given at home or by a bystander. Guidelines differ on when to repeat versus when to reach for a second-line drug. Follow local protocol.
3. Stop at two doses without medical direction: more than two benzodiazepine doses carries a high risk of airway compromise. Weigh that risk, and contact medical direction before a third dose. Still seizing? A second-line drug follows the status epilepticus protocol, such as levetiracetam or fosphenytoin (see the status epilepticus condition page).

After the seizure stops, the work shifts. Find the cause of the fever. Confirm the child is returning to baseline.

1. Assess: airway, breathing, circulation and GCS. Look for focal deficits, neck stiffness and other meningeal signs, and note the time the seizure started and stopped.
2. Treat the fever for comfort: acetaminophen or ibuprofen per the Medications & Dosing table. Remove excess layers of clothing. Fever medicine does not stop or prevent a seizure.
3. Consider a 12-lead ECG after the seizure stops in a child with no seizure history, to look for a cardiac cause.
4. Reassess: repeat the neurologic check and glucose at intervals set by protocol until the child is back to baseline.

High-alert reminder: midazolam, lorazepam and diazepam are high-alert medications. Respect that. Doses vary by protocol; follow local protocols and medical direction.

• Airway: have bag-valve-mask ventilation ready for every benzodiazepine dose. Flumazenil is not used routinely. Its label carries a boxed warning: it can cause seizures, most often in patients on long-term benzodiazepines or in overdose.
• Testing: a well-appearing simple febrile seizure does not need routine blood tests, EEG or neuroimaging, per the AAP 2011 guideline. Complex features call for a fuller evaluation.
• Admission considerations: age under 18 months, complex features, drowsiness before the seizure, GCS below 15 more than an hour after it, meningeal signs, antibiotics given before the seizure, and incomplete immunization. Several seizures within 24 hours may also warrant admission. Protocol sets where the line falls.
• Transport: per local protocol, with a caregiver present when possible.

Caregiver Counseling

• Common and usually brief: about 30% of children have a second febrile seizure, per a Cochrane review.
• Recurrence risk: it climbs with a young age at onset, a first-degree relative with febrile seizures, a lower fever at the time of the seizure, and a short time between fever onset and the seizure.
• Epilepsy risk: about 1% after a simple febrile seizure and 4% to 15% after a complex one, depending on the number of complex features.
• No lasting harm in most: short simple febrile seizures are not linked to neurological or cognitive impairment. They are not linked to increased long-term mortality either.
• Fever medicine: makes the child more comfortable. It does not prevent seizures.
• Prevention drugs: continuous anticonvulsants are not routine. Intermittent diazepam reduced recurrence in trials. Adverse effects were recorded in up to 30% of children given phenobarbital and 36% given benzodiazepines, per a Cochrane review. That call belongs to the clinician.
• Vaccines: a febrile seizure is no reason to avoid vaccination.
• Home rescue medicine: many families keep a rescue dose at home. It is commonly rectal diazepam gel (labeled from age 2, dosed by age and weight) or intranasal midazolam or diazepam. Ask what was given. Count every home dose before giving another. The total matters, not only the last dose.
• When to call 911 again: a seizure that lasts 5 minutes or longer, a second seizure, or a child who does not wake up normally.

Under 6 Months

• Fever with a seizure does not fit a simple febrile seizure. Evaluate for meningitis or encephalitis.
• Before 6 months, a seizure with fever raises suspicion of a genetic epilepsy.
• Under 6 months, NSAIDs are contraindicated.

6 to 12 Months

• Complex features turn up more often in this group. Up to 45% of febrile seizures under 12 months are complex.
• Lumbar puncture is an option when the child is under-immunized against Haemophilus influenzae type b or Streptococcus pneumoniae. It is also an option when immunization status cannot be determined, per the AAP 2011 guideline.
• A child pretreated with antibiotics is another case where lumbar puncture is an option, per the AAP 2011 guideline.

Over 6 Years

• Fever with a seizure is very rare. It does not fit a simple febrile seizure. Evaluate for other causes.

Pre-Existing Neurological Disorder

• The AAP definition of a simple febrile seizure leaves out children with a neurological disorder that predisposes to seizures, and children with a prior afebrile seizure. Treat them as having a complex or unexplained seizure.

Scope depends on state and agency. The items above are commonly within scope. Your local protocol has the final word.

• Equipment: pulse oximetry, suction, bag-valve-mask with pediatric masks, capnography where stocked, and a weight-based dose chart (Broselow or length-based per the E3 Broselow page).
• Dose math: calculate in kg. Read the concentration aloud before every benzodiazepine dose.
• Destination: a pediatric-ready emergency department per protocol. Admission considerations are listed under Monitoring, Reassessment & Disposition.
• Restraint and positioning: a size-appropriate restraint on the stretcher. Never hold the child on a caregiver's lap.
• Heat loss and fever: remove extra layers and keep the child warm once the fever is controlled.
• Handoff: a structured report (IMIST-AMBO or MIST), including the seizure start and stop times, every benzodiazepine dose and its time, and the glucose.