When my daughter first got a febrile seizure, it happened fast, and without warning, during the first winter, after COVID restrictions were lifted. Those restrictions had a significant impact — not just on our exposure to viral and bacterial pathogens but also on their circulation in the environment [source]. They largely suppressed common respiratory viruses like flu and RSV, but at the same time, they might have led to reduced immune exposure, which made infections more severe once they returned. This could cause high fevers — and high fevers can trigger febrile seizures.
Children, having missed exposure to common viruses during lockdowns, had stronger immune reactions, when they finally encountered them [source], sometimes leading to sudden, high fevers that could provoke seizures.
My daughter was only a year and a half at the time. We had already been sick for weeks — I believe it had been around three weeks of fighting what seemed like a common cold. The day she had a seizure, I wasn’t at home — I was attending a language course. So, I asked my father to come over and help with babysitting. You know grandads, they barely notice anything. That day was no exception. As I was leaving, he sent me off with his usual words: “Get yourself together and go to your course. You’ll survive this little cold.”
He stayed with Sofie while I was at my course. I kept checking on them from time to time, and at one point, he sent me a photo of her. The moment I saw it, I knew something was wrong. She was sitting on the counch, leaning on the arm halter. Her eyes were closed. She looked like she was sleeping, which was very unusual for her — to be sleeping so early in the morning.
I arrived just five minutes before she had a seizure — like she was waiting for me. I managed to check her temperature just seconds before it happened. It was normal. And for a moment, I felt relief.
And then, it struck.
Her look became distant, and her little hands were lifted up and above her head. I don’t know how long her seizure lasted. But long enough that she turned completely blue. She wasn’t breathing.
My father was lost. He was not even able to call the ambulance. I took care of Sofie, laying her on the couch, on her side. I checked she has free airways. But nothing helped. She was still not breathing. Her skin color was going from blue to gray now.
That is when I decided to start rescue breathing. I didn’t know if her heart had stopped, but I had to try something.
I don’t know when the seizure stopped. I noticed her skin color coming back to normal. She was still not moving or opening her eyes. But at least I knew she was alive. And then I called the ambulance.
When ambulance arrived, they checked her vital signs. All good. They measured her temperature — 37,2°C. They told us we would need to go to the hospital for observation. In the hospital, Sofie was tested for COVID-19 and Influenza A. She tested positive for Influenza A. They didn’t test me, as this was a children’s hospital, and in Germany, when a parent is with their child in the hospital, the only service they provide for a parent is calling an ambulance if needed. They aren’t allowed to give medication — even a basic painkiller. Or they simply don’t want to.
After some initial observations, Sofie was given Tamiflu (Oseltamivir) and antipyretics. The doctor explained that her seizure was likely a febrile seizure, but I was left with some unanswered questions. Sofie hadn’t had a fever when the seizure occurred. Or I missed it?
Understanding Febrile Seizures
Febrile seizures, which occur in approximately 2–5% of children (source) (Japanese population has a bit higher occurrence), are convulsions triggered by a rapid rise in body temperature — often due to a viral infection. In fact, 82% of cases are accompanied with viral infection (source). Interestingly, the risk of febrile seizures is higher with viral infections than with bacterial ones (source).
They are most common with young children, between the ages of 6 months and 5 years. The most of them happening with children in their second year. This is the age when child’s temperature regulatory center is still developing — making them more susceptible to the seizures caused by sudden spikes in body’s temperature or simply high temperatures. We can further define them as: simple and complex.
Simple febrile seizures are considered benign. They are short and self-limiting — meaning they stop on their own. They usually last less than 5 minutes, and do not result in long-term epilepsy (source). But they can stretch up to 15 minutes, and are still considered as simple. And those are the ones we will discuss in this article.
The most common trigger for febrile seizures is a high fever, and how fast it rises. In the past, people thought that a sudden rise in temperature — how fast it goes up — was the main reason seizures happened, no matter how high the fever actually got. But newer studies show that it might be the height of the fever that matters more. Still, there’s no clear answer. Some research says seizures can happen at 38°C, others say 38.4°C, so there’s no exact threshold at how high the fever has to be. And even though a high temperature is often blamed, there’s not enough strong evidence to say it’s more important than how fast the fever rises. So, it looks like both could play a role, and it depends on a person, a child.
Another interesting observation is that some viruses can trigger seizures without high fever. Studies show that rotavirus, RSV, and influenza can cause seizures due to the body’s immune response (source). Influenza A being the worst villain, due to it’s genetic recipe that makes her neurotropic to the brain. This means it can infect and replicate within our nervous system.
With seizures where there is no high fever recorder prior to the seizure, this is usually, or can be, the first sign of a disease. It may be a sudden first spike in the body’s temperature, or as said before, the seizure can be due to the body’s immune response. So the seizure happens before a child even gets a temperature, and a parent notices that a child has an infection.
As we noted before, not all children get them. Some have higher risk of getting a seizure. Why? Let’s explore potential risk factors for febrile seizures.
Risks of getting a febrile seizure — causes
It turns out, genetics plays a significant role. Children with first degree relative, who experienced febrile seizures, are more likely to experience one themselves. While researchers know that some specific genes may contribute to this risk, the exact mechanisms remain unclear.
Sofie has family history linked to febrile seizures — I had them when I was just a few months old. But with one difference — my temperature was high. And my daughter’s temperature was normal.
Another, significant, factor is viral infection. According to the study, the risk of a seizure from being infected with influenza, adenovirus, or parainfluenza is higher than RSV or rotavirus. In some studies researchers showed that majority of children, with febrile seizures, were positive to human herpes virus 6, that causes roseola. Another virus that can cause occurrence of a febrile seizure is Sars-Cov‑2.
Not surprising, the day care attendance, is another risk factor. If the children are attending a daycare, they have increased exposure to various viral or bacterial pathogens. And this can lead to infection and potentially a febrile seizure.
In the literature, we can find more risk factors, but main three are listed here. The children who are genetically predispositioned, and catch viral infection with high fever, have increased risk for getting one compared to the ones who don’t.
Remember, we are talking only about simple febrile seizures here.
Prevention and management
As we can not really prevent it, when the seizure is about to happen, we can be aware of some signs pointing to it. From my experience — this can happen quickly with no real prior warning. My daughter did not have high temperature. But there were other clues that I am now aware of. She was very mellow and down. Before the seizure, she was almost not responding to me, like she would be very very sleepy.
And the infection — we were ill. I felt it too. That day I felt as If I would faint too. My body was aching and I felt some spikes — like flashes coming into my head. Now, I know it was from the flu — influenza A. The most common infection among the children who did have a febrile seizure, was with Influenza, and parainfluenza (source).
So, how to reduce the risk of getting a febrile seizure once your child is sick or feverish?
- Manage fever — use acetaminophen (paracetamol) or ibuprofen when your child is sick to keep the fever under control (source). They might slow down the temperature spikes, although studies show that antipyretics can’t prevent the febrile seizures if they are about to happen,
- dress your child lightly and keep them cool when they have fever,
- keep them hydrated and allow them to rest,
- vaccinate — The flu shot significantly reduces the risk of severe influenza and its complications, like febrile seizures. I would try to avoid the Influenza infection completely until the child gets out of the risk age group,
- know your child’s risk — If they’ve had one before, be extra vigilant about fever control.
I am mainly reducing my child’s temperature once she gets it. Along with that I am being extra careful of infections. This is my primary risk reduction method. I asked her daycare to inform me immediately when they have influenza cases, and I skip daycare when there are recorded influenza cases. She still has enough time to catch the flu when she is older, and out of the risky age of febrile seizures. I hope we have some antibodies left for at least one strain for the next few years.
If the child get a febrile seizure, you should stay calm to be able to help your child. Here are few tips on what to do:
- Stay calm, because most seizures stop within 1–2 minutes,
- lay the child on their side, on a soft surface, to prevent choking,
- do not put anything in their mouth, you have to keep the airways clear,
- time the seizure. If it lasts more than 5 minutes, call emergency services,
- check their breathing. Most children breathe normally after a seizure, but some don’t,
- let them rest. They may be tired or confused after the seizure,
- you can apply the antypiretic analy to reduce the fever,
- you can put a wet cloth on the childs forhead, to keep them cool,
- you can sprey your child with lukewarm water, but some doctors argue that it can be dangerous for choking — if we are not carefull, and water enters the airways.
If it’s their first seizure, or if they have trouble breathing, multiple seizures in one day, or seem very unwell afterward, seek medical attention immediately.
Factors associated with recurrent febrile seizures in children aged 6 months to 5 years.
Now, after my daughter experienced her first febrile seizure, my main concern is it’s reccurence. According to statistics, she has increased risk of getting another one.
Key statistics on recurrence accroding to (aafp.org, pmc.ncbi.nlm.nih.gov), include:
- Approximately one in three children (about 30–35%) experience another febrile seizure in early childhood, once they had the initial seizure,
- the risk is on the lower end (~15–20%) if the first seizure happened in an older toddler (e.g. >3 years old), but it rises to around 50% if the first seizure occurred before one year of age,
- after multiple seizures, the odds rise. Having more than one febrile seizure further increases the likelihood of subsequent seizures. After a second febrile seizure (one recurrence), the risk of a third is roughly double the baseline, in the range of 50–60%,
- overall, most children with recurrences have only one recurrence, but a sizable minority have multiple: in one cohort, 54% of those who recurred had only one additional seizure, 28% had two recurrences, and 18% had three or more recurrences,
- another risk factor is a family history of febrile seizures. If a childs first degree relative had multiple febrile seizures, the risk of recurrence increases,
- the temperature at the onset of a febrile seizure. If the temperature was low, than the risk increases as well. This could mean your child has lower threshold, and can get a febrile seizure even with low fever.
Most recurrent seizures happen relatively soon after the initial episode. Studies indicate that about half of recurrences occur within 6 months of the first seizure, ~75% within 1 year, and 90% within 2 years. (repub.eur.nl)
After age 5, febrile seizures typically cease as the child outgrows the susceptible age range.
In conclusion
Febrile seizures are scary but usually harmless. The best approach to reducing the risk of recurrence is preventing infections — especially influenza in young children — managing high fevers when possible, staying calm if one happens, and knowing when to seek medical help.
On the other hand, we also have to be aware that fever itself is beneficial in fighting infections. Not all fevers are bad. In fact, infections that are accompanied by fever are often associated with a stronger immune response once the child recovers.
To add my personal view: I would call an ambulance immediately — every time my daughter has a febrile seizure.
If your child has had a febrile seizure, talk to your pediatrician about a plan for future fevers. Most of the time, the first febrile seizure is a one-time event.
We have to accept that simple febrile seizures can’t always be prevented if your child is susceptible and one is about to happen. Keep in mind that they are usually benign and don’t cause any long-term adverse effects. They don’t affect your child’s mental development, IQ, or cause epilepsy.
If they happen, make sure your child has clear airways, time the seizure from the onset, and keep them safe. The seizure should stop on its own within five minutes.
