Pediatric emergency medicine trisk 2617 2617
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and family factors. The consequences of further seizures must be balanced against
the potential side effects of the anticonvulsant agents. Treatment is seldom started
after a single, uncomplicated nonfebrile seizure because most such patients will
not experience a seizure recurrence. It is preferable to make long-term treatment
decisions in conjunction with the provider who will be responsible for ongoing
follow-up of the patient, either a neurologist or the child’s primary care physician.
Sometimes, it may be necessary to begin prophylactic treatment in the ED,
pending a more complete outpatient evaluation.
Disposition
Hospital admission is generally required for children who have had a prolonged
seizure requiring acute treatment with anticonvulsant medication. With the
exception of very young infants, other children, even those with a first-time
seizure, can generally be followed as outpatients if they appear well after the
seizure, follow-up can be ensured, and the parents are comfortable with home
management. Seizure first aid should be explained to the family before discharge.
Some practitioners may choose to prescribe rectal diazepam as a rescue
medication until a decision is made about instituting chronic anticonvulsant
therapy.
After a simple febrile seizure, hospitalization is seldom necessary, and children
may be followed by their primary physician. Some useful information can be
given to parents after a first febrile seizure. First, they should be informed of the
benign nature of the convulsions and the lack of evidence that they cause any type
of neurologic injury unless they are prolonged. Approximately one-third of
children with a first febrile seizure will have another one. Of recurrences, 75%
occur within 1 year, and they are uncommon beyond 2 years; fewer than 10% of
children with febrile seizures have more than three. The recurrence rate is lower if
the seizures begin after the first year of life, and the risk is also reduced in
children with higher temperature and longer duration of fever before the initial
febrile seizure. For example, the recurrence risk is about 35% when the first
seizure occurs at a temperature of 38.5°C (101.3°F), compared with a risk of 13%
with a temperature of 40°C (104°F). Having a complex first febrile seizure (even
febrile SE) does not increase the risk of recurrence, nor does it increase the
chance that a recurrent seizure, if it occurs, will be complex.
Many parents are concerned that febrile seizures will lead to future epilepsy. A
child who has had a febrile seizure but no other risk factors for epilepsy may have
a slightly increased risk of future nonfebrile seizures, but the magnitude of this
increase is still extremely small: 1% to 2% lifetime risk versus a 0.5% to 1%
