Management of Pediatric Febrile Seizures in the Emergency Department

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Publication Date: September 2025 (Volume 22, Number 9)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 09/01/2028.

Authors

Peer Reviewers

Abstract

Febrile seizures are a common presentation to emergency departments. While established guidelines exist, variation in the management and treatment of febrile seizures persists across emergency departments. This issue reviews the definition of pediatric febrile seizure and discusses the presentation, differential diagnosis, management, and prognosis. Anticipatory guidance for families and disposition considerations are also provided.

Case Presentations

A 12-month-old girl presents to the emergency department after 2 seizures in the last 12 hours…

• The girl’s mother explains both events were approximately 3 minutes in length and consisted of generalized full-body shaking that resolved spontaneously. She tells you the girl is fully vaccinated, with a history of a prior febrile seizure. The girl’s measured maximum temperature at home was 101.3°F.
• The girl’s vital signs are: temperature, 39.1°C; heart rate, 140 beats/min; blood pressure, 80/50 mm Hg; respiratory rate, 30 breaths/min; and oxygen saturation, 100%. On examination, the child is well-appearing and at baseline neurologically. Her mucous membranes are moist, and she has normal capillary refill. She has had a history of loose watery stools and 3 days of intermittent fevers, responsive to acetaminophen and ibuprofen. She has normal urinary output.
• What type of workup is indicated in the ED? What guidance should you provide to the family?

A 10-month-old boy presents after a 2-minute generalized seizure episode at home...

• The boy’s parents tell you that today is his third day of fever >101.3°F at home, and that he has had decreased oral intake. He has been on antibiotics for acute otitis media for the last 3 days. They also tell you the infant was born at full term and that he is unvaccinated.
• The boy’s vital signs are: temperature, 40°C; heart rate, 180 beats/min; blood pressure, 84/55 mm Hg; respiratory rate, 35 breaths/min; and oxygen saturation, 98%. The boy is sleeping in his father’s arms. The parents tell you he has been less active than usual. The infant is minimally arousable on examination and does not appear to have focal neurologic deficits. His capillary refill is 2 seconds. The examination is otherwise without obvious signs of infection. While in the ED, the boy vomits twice after trying to drink oral rehydration solution.
• The patient’s unvaccinated status and current antibiotic use increase his risk for serious infection. Which types of infection do you want to exclude in this patient?

A 4-year-old boy with a history of developmental delay and febrile seizures presents to the ED after a 17-minute generalized tonic-clonic febrile seizure...

• Upon arrival to the ED, the seizure activity has stopped. The boy is looking for his father and is now back to baseline. The boy’s vital signs are: temperature, 38.3°C; heart rate, 130 beats/min; blood pressure, 100/65 mm Hg; respiratory rate, 25 breaths/min; and oxygen saturation, 100%. The patient is observed in the ED for several hours and remains at baseline aside from moderate congestion. A respiratory viral panel is positive for respiratory syncytial virus. He has been tolerating oral intake and does not have any respiratory distress.
• The boy’s temperature has improved after antipyretic treatment, and his family is preparing for discharge.
• The patient’s family members are asking about starting medication to decrease future seizures. What type of prognosis for seizures does this patient have? How should you counsel the family?

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