Is a febrile seizure an emergency?

How do you tell when something just looks like an emergency? |  Zhen Hu  on  Unsplash

How do you tell when something just looks like an emergency? | Zhen Hu on Unsplash

Tucked way in the back of my trusty copy of Caring for Your Baby and Young Child, behind 26 chapters with advice for the first 5 years of your child's life, is this description of febrile seizures: "The entire convulsion usually lasts less than one minute, and may be over in a few seconds, but it can seem like a lifetime to a frightened parent."

It doesn't matter that febrile seizures are, as the entry concludes, generally benign. It doesn't matter that they don't lead to brain damage, epilepsy, or death. It doesn't matter that, shortly after a seizure, a child will be sleepy, but fine. 

Those things don't matter because "lifetime" is an accurate measurement of how time passes if it's your child having the seizure, as I learned when my son had one at 18 months. Those three minutes were enough time to panic about my lack of medical training, as well as envision my child's funeral and a future in which my husband left me because I failed to use the right lifesaving technique. But my son didn't need to be saved, nor had he ever been in an emergency. 15 minutes later, he was back to being an exhausted kid with an ear infection, annoyed by the EMTs who were observing him. 

I wish I had known beforehand that this was not a medical emergency. I wish I had known how common febrile seizures are (as many as 1 in 20 kids will have at least one). I wish I had known that while they look terrifying, febrile seizures generally have no lasting effects. I wish I had known that I didn't need to rush my child to the ER when he would have been more comfortable snuggling on the couch. 

What does a febrile seizure look like?

Had I read that description of fever tucked way in the back of Chapter 27, I would have learned what a febrile seizure looks like: "Children may look "peculiar" for a few moments, then stiffen, twitch, and roll their eyes. They will be unresponsive for a short time, and their skin may appear to be a little darker than usual during the episode."

Some parents have uploaded videos of their children's febrile seizures to YouTube so that other parents can understand what a febrile seizure looks like and how to deal with one. This video is a strong example because it captures the classic features of a febrile seizure: a short period of convulsions, a groggy but otherwise fine child...and a terrified parent. Febrile seizures look like a medical emergency, and in some cases they can be, but in the majority of cases, there's nothing to do but wait it out safely and follow up with a pediatrician. 

Simple vs. Complex

The medical literature divides febrile seizures into two basic categories: simple and complex. The American Academy of Pediatrics defines a simple febrile seizure as one that involves the whole body, lasts for less than 15 minutes, and does not recur within 24 hours. A febrile seizure is considered complex if it is either focal (meaning that only one part of the body is affected), prolonged (over fifteen minutes) or recurrent (meaning that multiple seizures occur within 24 hours). 

The majority of febrile seizures (between 70-75%) are simple, while 20-25% are complex. Astute observers will notice that the math doesn't quite add up. That's because those simple and complex categories have recently been expanded to include two more types of seizures: febrile status epilepticus (epileptic seizures lasting more than 30 minutes) and febrile seizure plus (simple febrile seizures that occur multiple times within 24 hours). 

What are the risks of simple febrile seizures?

Given how terrifying a febrile seizure looks, it's surprising that the seizure itself is unlikely to cause damage. Parents seem to worry about brain function post-seizure, but in the case of healthy children with simple febrile seizures, there is no evidence that seizures cause brain damage. The AAP Guidelines recommend against brain imaging after a simple febrile seizure.

The only thing a simple febrile seizure is predictive of is another febrile seizure: children who have had one febrile seizure have about a 30% chance of having another one. Children with more risk factors for febrile seizures (aged under 18 months, with a family member who also had febrile seizures, with fever just a short while before the seizure and/or a fever that is lower than 104) are more likely to have another one. One study found that the risk of recurrent seizure for a child with all four of those risk factors was greater than 70%. 

Which kids have simple febrile seizures?

Depending on which estimate you read, 2-5% of children will have a febrile seizure. If we take the high estimate, that's 1 in every 20 kids, making febrile seizures unusual, but relatively common.

A child's age, more than any other risk factor, makes him at risk for febrile seizure. They occur between 6 months and 5 years, with the peak time being about 2 years old

One study found that children with family history of seizures and long neonatal hospital stays were more prone to febrile seizures. It also found a correlation between febrile seizures and daycare attendance. The daycare didn't cause the seizure, but children in daycares do tend to spread illnesses around, and illnesses lead to fever. 

Likewise, recently vaccinated children are slightly more prone to seizures. As with the daycare example, it's unlikely that the vaccines themselves are the culprits. Instead, a child who runs a fever because of normal responses to a vaccine may also have a febrile seizure. Put differently, the vaccination did not cause the seizure. The vaccination caused the immune response, which caused the fever, which caused the seizure. 

Should you call your pediatrician, or the ER?

A simple febrile seizure is short. During it, you will think that your child is not breathing, but he is. You will think he's choking on mucus, but if you place him on his side he will not. After the seizure, you'll be concerned that he looks too sleepy that you can't rouse him, but that's normal. Your child will still be sick with whatever illness brought on the fever in the first place, so the best course of action is to let him rest and treat the illness as you normally would. 

If you can see through your panic in the moment, call the pediatrician instead of 911. There are a few good reasons to do this. First, even though what you witnessed looked terrifying, if the seizure is over and your kid looks tired but otherwise okay, there is no medical emergency. Second, it's the consensus opinion of pediatricians that most febrile seizures can be evaluated at home, sometimes with follow-up from the pediatrician. 

If the seizure is localized (meaning that it's only in one part of the body), or if the seizure lasts for more than 10 minutes, your child may need more immediate medical attention. 

What is your pediatrician is looking for when evaluating a seizure?

Even though a simple febrile seizure is not a medical emergency requiring immediate attention, it is important to follow-up with your pediatrician, first to verify a fever and then identify a cause of that fever.

If your child just had a simple febrile seizure, the first thing your pediatrician is likely to do is look for the fever. If your child did not have a fever before the seizure, or if you're unsure about the fever, your pediatrician is probably looking for signs of bacterial meningitis. Meningitis is an infection of the membranes surrounding the brain and spinal cord. Screening for meningitis is the AAP's first guideline for evaluating a febrile seizure. This disease is rare, but dangerous, so your pediatrician will want to rule it out entirely before determining simple febrile seizure. Two routine childhood vaccinations reduce the risk for contracting bacterial meningitis, so if your child is not up-to-date on vaccinations your pediatrician may want to get a lumbar puncture to rule out meningitis. 

If your pediatrician has ruled out meningitis, she will probably not test for other infections, because the infection itself doesn't really matter. If your child currently has the flu, or an ear infection, or some other common infection, and does not have another seizure within 24 hours, your child is likely to be feeling better far sooner than you are. He'll be sleeping peacefully, but you will be panicking about another seizure for at least a few more nights (or the next few years).

You might be frustrated that you've just witnessed what looked like your child dying, and your pediatrician (or EMT, or emergency room attending) appears to be doing nothing. But doing nothing just means that your child is fine, and that he will have forgotten this experience long before you do. 

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