CLINICAL PRACTICE GUIDELINE

Febrile Seizures: Clinical Practice Guideline for the

Long-term Management of the Child With Simple
Febrile Seizures
Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures

ABSTRACT
Febrile seizures are the most common seizure disorder in childhood, affecting 2%
to 5% of children between the ages of 6 and 60 months. Simple febrile seizures are
defined as brief (!15-minute) generalized seizures that occur once during a
24-hour period in a febrile child who does not have an intracranial infection,
metabolic disturbance, or history of afebrile seizures. This guideline (a revision of
the 1999 American Academy of Pediatrics practice parameter [now termed clinical
practice guideline] The Long-term Treatment of the Child With Simple Febrile
Seizures) addresses the risks and benefits of both continuous and intermittent
anticonvulsant therapy as well as the use of antipyretics in children with simple
febrile seizures. It is designed to assist pediatricians by providing an analytic
framework for decisions regarding possible therapeutic interventions in this patient population. It is not intended to replace clinical judgment or to establish a
protocol for all patients with this disorder. Rarely will these guidelines be the only
approach to this problem. Pediatrics 2008;121:12811286
The expected outcomes of this practice guideline include:
1. optimizing practitioner understanding of the scientific basis for using or avoiding various proposed treatments for children with simple febrile seizures;

www.pediatrics.org/cgi/doi/10.1542/
peds.2008-0939
doi:10.1542/peds.2008-0939
All clinical reports from the American
Academy of Pediatrics automatically expire
5 years after publication unless reaffirmed,
revised, or retired at or before that time.
The guidance in this report does not
indicate an exclusive course of treatment
or serve as a standard of medical care.
Variations, taking into account individual
circumstances, may be appropriate.
Key Word
fever
Abbreviation
AAPAmerican Academy of Pediatrics
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2008 by the
American Academy of Pediatrics

2. improving the health of children with simple febrile seizures by avoiding

therapies with high potential for adverse effects and no demonstrated ability to
improve childrens long-term outcomes;
3. reducing costs by avoiding therapies that will not demonstrably improve childrens long-term outcomes; and
4. helping the practitioner educate caregivers about the low risks associated with simple febrile seizures.
The committee determined that with the exception of a high rate of recurrence, no long-term effects of simple
febrile seizures have been identified. The risk of developing epilepsy in these patients is extremely low, although
slightly higher than that in the general population. No data, however, suggest that prophylactic treatment of children
with simple febrile seizures would reduce the risk, because epilepsy likely is the result of genetic predisposition rather
than structural damage to the brain caused by recurrent simple febrile seizures. Although antipyretics have been
shown to be ineffective in preventing recurrent febrile seizures, there is evidence that continuous anticonvulsant
therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with diazepam are effective in
reducing febrile-seizure recurrence. The potential toxicities associated with these agents, however, outweigh the
relatively minor risks associated with simple febrile seizures. As such, the committee concluded that, on the basis of
the risks and benefits of the effective therapies, neither continuous nor intermittent anticonvulsant therapy is
recommended for children with 1 or more simple febrile seizures.
INTRODUCTION
Febrile seizures are seizures that occur in febrile children between the ages of 6 and 60 months who do not have an
intracranial infection, metabolic disturbance, or history of afebrile seizures. Febrile seizures are subdivided into 2
categories: simple and complex. Simple febrile seizures last for less than 15 minutes, are generalized (without a focal
component), and occur once in a 24-hour period, whereas complex febrile seizures are prolonged ("15 minutes), are
focal, or occur more than once in 24 hours.1 Despite the frequency of febrile seizures (2%5%), there is no unanimity
of opinion about management options. This clinical practice guideline addresses potential therapeutic interventions
in neurologically normal children with simple febrile seizures. It is not intended for patients with complex febrile
seizures and does not pertain to children with previous neurologic insults, known central nervous system abnorPEDIATRICS Volume 121, Number 6, June 2008

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malities, or a history of afebrile seizures. This clinical

practice guideline is a revision of a 1999 American Academy of Pediatrics (AAP) clinical practice parameter, The
Long-term Treatment of the Child With Simple Febrile
Seizures.2
For a child who has experienced a simple febrile
seizure, there are potentially 4 adverse outcomes that
theoretically may be altered by an effective therapeutic
agent: (1) decline in IQ; (2) increased risk of epilepsy; (3)
risk of recurrent febrile seizures; and (4) death. Neither
a decline in IQ, academic performance or neurocognitive
inattention nor behavioral abnormalities have been
shown to be a consequence of recurrent simple febrile
seizures.3 Ellenberg and Nelson4 studied 431 children
who experienced febrile seizures and observed no significant difference in their learning compared with sibling controls. In a similar study by Verity et al,5 303
children with febrile seizures were compared with control children. No difference in learning was identified,
except in those children who had neurologic abnormalities before their first seizure.
The second concern, increased risk of epilepsy, is
more complex. Children with simple febrile seizures
have approximately the same risk of developing epilepsy
by the age of 7 years as does the general population (ie,
1%).6 However, children who have had multiple simple
febrile seizures, are younger than 12 months at the time
of their first febrile seizure, and have a family history of
epilepsy are at higher risk, with generalized afebrile seizures developing by 25 years of age in 2.4%.7 Despite
this fact, no study has demonstrated that successful
treatment of simple febrile seizures can prevent this later
development of epilepsy, and there currently is no evidence that simple febrile seizures cause structural damage to the brain. Indeed, it is most likely that the increased risk of epilepsy in this population is the result of
genetic predisposition.
In contrast to the slightly increased risk of developing
epilepsy, children with simple febrile seizures have a
high rate of recurrence. The risk varies with age. Children younger than 12 months at the time of their first
simple febrile seizure have an approximately 50% probability of having recurrent febrile seizures. Children
older than 12 months at the time of their first event have
an approximately 30% probability of a second febrile
seizure; of those who do have a second febrile seizure,
50% have a chance of having at least 1 additional recurrence.8
Finally, there is a theoretical risk of a child dying
during a simple febrile seizure as a result of documented
injury, aspiration, or cardiac arrhythmia, but to the committees knowledge, it has never been reported.
In summary, with the exception of a high rate of
recurrence, no long-term adverse effects of simple febrile
seizures have been identified. Because the risks associated with simple febrile seizures, other than recurrence,
are so low and because the number of children who
have febrile seizures in the first few years of life is so
high, to be commensurate, a proposed therapy would
need to be exceedingly low in risks and adverse effects,
inexpensive, and highly effective.
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AMERICAN ACADEMY OF PEDIATRICS

METHODS
To update the clinical practice guideline on the treatment of children with simple febrile seizures, the AAP
reconvened the Subcommittee on Febrile Seizures. The
committee was chaired by a child neurologist and consisted of a neuroepidemiologist, 2 additional child neurologists, and a practicing pediatrician. All panel members reviewed and signed the AAP voluntary disclosure
and conflict-of-interest form. The guideline was reviewed by members of the AAP Steering Committee on
Quality Improvement and Management; members of the
AAP Sections on Neurology, Pediatric Emergency Medicine, Developmental and Behavioral Pediatrics, and
Epidemiology; members of the AAP Committees on Pediatric Emergency Medicine and Medical Liability and
Risk Management; members of the AAP Councils on
Children With Disabilities and Community Pediatrics;
and members of outside organizations including the
Child Neurology Society and the American Academy of
Neurology.
A comprehensive review of the evidence-based literature published since 1998 was conducted with the aim
of addressing possible therapeutic interventions in the
management of children with simple febrile seizures.
The review focused on both the efficacy and potential
adverse effects of the proposed treatments. Decisions
were made on the basis of a systematic grading of the
quality of evidence and strength of recommendations.
The AAP established a partnership with the University of Kentucky (Lexington, KY) to develop an evidence
report, which served as a major source of information for
these practice-guideline recommendations. The specific
issues addressed were (1) effectiveness of continuous
anticonvulsant therapy in preventing recurrent febrile
seizures, (2) effectiveness of intermittent anticonvulsant
therapy in preventing recurrent febrile seizures, (3) effectiveness of antipyretics in preventing recurrent febrile
seizures, and (4) adverse effects of either continuous or
intermittent anticonvulsant therapy.
In the original practice parameter, more than 300
medical journal articles reporting studies of the natural
history of simple febrile seizures or the therapy of these
seizures were reviewed and abstracted.2 An additional
65 articles were reviewed and abstracted for the update.
Emphasis was placed on articles that differentiated simple febrile seizures from other types of seizures, that
carefully matched treatment and control groups, and
that described adherence to the drug regimen. Tables
were constructed from the 65 articles that best fit these
criteria. A more comprehensive review of the literature
on which this report is based can be found in a forthcoming technical report (the initial technical report can
be accessed at http://aappolicy.aappublications.org/cgi/
content/full/pediatrics;103/6/e86). The technical report
also will contain dosing information.
The evidence-based approach to guideline development
requires that the evidence in support of a recommendation
be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. Evidence-based recommendations reflect the quality
of evidence and the balance of benefit and harm that is

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 Benefit: prevention of recurrent febrile seizures,

which are not harmful and do not significantly increase the risk for development of future epilepsy.
Harm: adverse effects including rare fatal hepatotox-

icity (especially in children younger than 2 years who

are also at greatest risk of febrile seizures), thrombocytopenia, weight loss and gain, gastrointestinal disturbances, and pancreatitis with valproic acid and hyperactivity, irritability, lethargy, sleep disturbances,
and hypersensitivity reactions with phenobarbital;
lethargy, drowsiness, and ataxia for intermittent diazepam as well as the risk of masking an evolving central
nervous system infection.
Benefits/harms assessment: preponderance of harm

over benefit.
Policy level: recommendation.
FIGURE 1
Integrating evidence-quality appraisal with an assessment of the anticipated balance
between benefits and harms if a policy is conducted leads to designation of a policy as a
strong recommendation, recommendation, option, or no recommendation. RCT indicates randomized, controlled trial.

anticipated when the recommendation is followed. The

AAP policy statement Classifying Recommendations for
Clinical Practice Guidelines9 was followed in designating
levels of recommendations (see Fig 1 and Table 1).
RECOMMENDATION
On the basis of the risks and benefits of the effective
therapies, neither continuous nor intermittent anticonvulsant therapy is recommended for children with 1 or
more simple febrile seizures.
Aggregate evidence quality: B (randomized, controlled

trials and diagnostic studies with minor limitations).

BENEFITS AND RISKS OF CONTINUOUS ANTICONVULSANT

THERAPY
Phenobarbital
Phenobarbital is effective in preventing the recurrence of
simple febrile seizures.10 In a controlled double-blind
study, daily therapy with phenobarbital reduced the rate
of subsequent febrile seizures from 25 per 100 subjects
per year to 5 per 100 subjects per year.11 For the agent to
be effective, however, it must be given daily and maintained in the therapeutic range. In a study by Farwell et
al,12 for example, children whose phenobarbital levels
were in the therapeutic range had a reduction in recurrent seizures, but because noncompliance was so high,
an overall benefit with phenobarbital therapy was not
identified.
The adverse effects of phenobarbital include hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions. The behavioral adverse effects

TABLE 1 Guideline Definitions for Evidence-Based Statements

Statement

Definition

Implication

Strong recommendation

A strong recommendation in favor of a particular action is made when

the anticipated benefits of the recommended intervention clearly
exceed the harms (as a strong recommendation against an action is
made when the anticipated harms clearly exceed the benefits) and
the quality of the supporting evidence is excellent. In some clearly
identified circumstances, strong recommendations may be made
when high-quality evidence is impossible to obtain and the
anticipated benefits strongly outweigh the harms.
A recommendation in favor of a particular action is made when the
anticipated benefits exceed the harms but the quality of evidence is
not as strong. Again, in some clearly identified circumstances,
recommendations may be made when high-quality evidence is
impossible to obtain but the anticipated benefits outweigh the
harms.
Options define courses that may be taken when either the quality of
evidence is suspect or carefully performed studies have shown little
clear advantage to 1 approach over another.
No recommendation indicates that there is a lack of pertinent
published evidence and that the anticipated balance of benefits
and harms is presently unclear.

Clinicians should follow a strong recommendation unless

a clear and compelling rationale for an alternative
approach is present.

Recommendation

Option

No recommendation

Clinicians would be prudent to follow a recommendation

but should remain alert to new information and
sensitive to patient preferences.

Clinicians should consider the option in their decisionmaking, and patient preference may have a substantial
role.
Clinicians should be alert to new published evidence that
clarifies the balance of benefit versus harm.

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may occur in up to 20% to 40% of patients and may be

severe enough to necessitate discontinuation of the
drug.1316
Primidone
Primidone, in doses of 15 to 20 mg/kg per day, has also
been shown to reduce the recurrence rate of febrile
seizures.17,18 It is of interest that the derived phenobarbital level in a Minigawa and Miura study17 was below
therapeutic (16 !g/mL) in 29 of the 32 children, suggesting that primidone itself may be active in preventing
seizure recurrence. As with phenobarbital, adverse effects include behavioral disturbances, irritability, and
sleep disturbances.18
Valproic Acid
In randomized, controlled studies, only 4% of children
taking valproic acid, as opposed to 35% of control subjects, had a subsequent febrile seizure. Therefore, valproic acid seems to be at least as effective in preventing
recurrent simple febrile seizures as phenobarbital and
significantly more effective than placebo.1921
Drawbacks to therapy with valproic acid include its
rare association with fatal hepatotoxicity (especially in
children younger than 2 years, who are also at greatest
risk of febrile seizures), thrombocytopenia, weight loss
and gain, gastrointestinal disturbances, and pancreatitis.
In studies in which children received valproic acid to
prevent recurrence of febrile seizures, no cases of fatal
hepatotoxicity were reported.15
Carbamazepine
Carbamazepine has not been shown to be effective in
preventing the recurrence of simple febrile seizures.
Antony and Hawke13 compared children who had been
treated with therapeutic levels of either phenobarbital or
carbamazepine, and 47% of the children in the carbamazepine-treated group had recurrent seizures compared
with only 10% of those in the phenobarbital group. In
another study, Camfield et al22 treated children (whose
conditions failed to improve with phenobarbital therapy) with carbamazepine. Despite good compliance, 13
of the 16 children treated with carbamazepine had a
recurrent febrile seizure within 18 months. It is theoretically possible that these excessively high rates of recurrences might have been attributable to adverse effects of
carbamazepine.
Phenytoin
Phenytoin has not been shown to be effective in preventing the recurrence of simple febrile seizures, even
when the agent is in the therapeutic range.23,24 Other
anticonvulsants have not been studied for the continuous treatment of simple febrile seizures.
BENEFITS AND RISKS OF INTERMITTENT ANTICONVULSANT
THERAPY
Diazepam
A double-blind controlled study of patients with a history of febrile seizures demonstrated that administration
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AMERICAN ACADEMY OF PEDIATRICS

of oral diazepam (given at the time of fever) could reduce the recurrence of febrile seizures. Children with a
history of febrile seizures were given either oral diazepam (0.33 mg/kg, every 8 hours for 48 hours) or a
placebo at the time of fever. The risk of febrile seizures
per person-year was decreased 44% with diazepam.25 In
a more recent study, children with a history of febrile
seizures were given oral diazepam at the time of fever
and then compared with children in an untreated control group. In the oral diazepam group, there was an
11% recurrence rate compared with a 30% recurrence
rate in the control group.26 It should be noted that all
children for whom diazepam was considered a failure
had been noncompliant with drug administration, in
part because of adverse effects of the medication.
There is also literature that demonstrates the feasibility and safety of interrupting a simple febrile seizure
lasting less than 5 minutes with rectal diazepam and
with both intranasal and buccal midazolam.27,28 Although these agents are effective in terminating the
seizure, it is questionable whether they have any longterm influence on outcome. In a study by Knudsen et
al,29 children were given either rectal diazepam at the
time of fever or only at the onset of seizure. Twelve-year
follow-up found that the long-term prognosis of the
children in the 2 groups did not differ regardless of
whether treatment was aimed at preventing seizures or
treating them.
A potential drawback to intermittent medication is
that a seizure could occur before a fever is noticed.
Indeed, in several of these studies, recurrent seizures
were likely attributable to failure of method rather than
failure of the agent.
Adverse effects of oral and rectal diazepam26 and both
intranasal and buccal midazolam include lethargy,
drowsiness, and ataxia. Respiratory depression is extremely rare, even when given by the rectal route.28,30
Sedation caused by any of the benzodiazepines, whether
administered by the oral, rectal, nasal, or buccal route,
have the potential of masking an evolving central nervous system infection. If used, the childs health care
professional should be contacted.
BENEFITS AND RISKS OF INTERMITTENT ANTIPYRETICS
No studies have demonstrated that antipyretics, in the
absence of anticonvulsants, reduce the recurrence risk of
simple febrile seizures. Camfield et al11 treated 79 children who had had a first febrile seizure with either a
placebo plus antipyretic instruction (either aspirin or
acetaminophen) versus daily phenobarbital plus antipyretic instruction (either aspirin or acetaminophen). Recurrence risk was significantly lower in the phenobarbital-treated group, suggesting that antipyretic instruction,
including the use of antipyretics, is ineffective in preventing febrile-seizure recurrence.
Whether antipyretics are given regularly (every 4
hours) or sporadically (contingent on a specific bodytemperature elevation) does not influence outcome.
Acetaminophen was either given every 4 hours or only
for temperature elevations of more than 37.9C in 104
children. The incidence of febrile episodes did not differ

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significantly between the 2 groups, nor did the early

recurrence of febrile seizures. The authors determined
that administering prophylactic acetaminophen during
febrile episodes was ineffective in preventing or reducing
fever and in preventing febrile-seizure recurrence.31
In a randomized double-blind placebo-controlled
trial, acetaminophen was administered along with lowdose oral diazepam.32 Febrile-seizure recurrence was not
reduced, compared with control groups. As with acetaminophen, ibuprofen also has been shown to be ineffective in preventing recurrence of febrile seizures.3335
In general, acetaminophen and ibuprofen are considered to be safe and effective antipyretics for children.
However, hepatotoxicity (with acetaminophen) and respiratory failure, metabolic acidosis, renal failure, and
coma (with ibuprofen) have been reported in children
after overdose or in the presence of risk factors.36,37
CONCLUSIONS
The subcommittee has determined that a simple febrile
seizure is a benign and common event in children between the ages of 6 and 60 months. Nearly all children
have an excellent prognosis. The committee concluded
that although there is evidence that both continuous
antiepileptic therapy with phenobarbital, primidone, or
valproic acid and intermittent therapy with oral diazepam are effective in reducing the risk of recurrence, the
potential toxicities associated with antiepileptic drugs
outweigh the relatively minor risks associated with simple febrile seizures. As such, long-term therapy is not
recommended. In situations in which parental anxiety
associated with febrile seizures is severe, intermittent
oral diazepam at the onset of febrile illness may be
effective in preventing recurrence. Although antipyretics
may improve the comfort of the child, they will not
prevent febrile seizures.
SUBCOMMITTEE ON FEBRILE SEIZURES, 20022008

Patricia K. Duffner, MD, Chairperson

Robert J. Baumann, MD, Methodologist
Peter Berman, MD
John L. Green, MD
Sanford Schneider, MD
STEERING COMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT,
20072008

Elizabeth S. Hodgson, MD, Chairperson

Gordon B. Glade, MD
Norman Chip Harbaugh, Jr, MD
Thomas K. McInerny, MD
Marlene R. Miller, MD, MSc
Virginia A. Moyer, MD, MPH
Xavier D. Sevilla, MD
Lisa Simpson, MB, BCh, MPH
Glenn S. Takata, MD
LIAISONS

Denise Dougherty, PhD

Agency for Healthcare Research and Quality
Daniel R. Neuspiel, MD
Section on Epidemiology

Ellen Schwalenstocker, MBA

National Association of Childrens Hospitals and
Related Institutions
STAFF

Caryn Davidson, MA
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Febrile Seizures: Clinical Practice Guideline for the Long-term Management of

the Child With Simple Febrile Seizures
Steering Committee on Quality Improvement and Management, Subcommittee on
Febrile Seizures
Pediatrics 2008;121;1281
DOI: 10.1542/peds.2008-0939
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2008 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Febrile Seizures: Clinical Practice Guideline for the Long-term Management of

the Child With Simple Febrile Seizures
Steering Committee on Quality Improvement and Management, Subcommittee on
Febrile Seizures
Pediatrics 2008;121;1281
DOI: 10.1542/peds.2008-0939

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/121/6/1281.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2008 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on October 18, 2016