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PEDIATRICS Vol. 103 No. 6 June 1999, pp. 1307-1309
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ABSTRACT |
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The Committee on Quality Improvement, Subcommittee on Febrile Seizures, of the American Academy of Pediatrics, in collaboration with experts from the Section on Neurology, general pediatricians, consultants in the fields of child neurology and epilepsy, and research methodologists, developed this practice parameter. This guideline provides recommendations for the treatment of a child with simple febrile seizures. These recommendations are derived from a thorough search and analysis of the literature. The methods and results of the literature review can be found in the accompanying technical report. This guideline is designed to assist pediatricians by providing an analytic framework for the treatment of children with simple febrile seizures. It is not intended to replace clinical judgment or establish a protocol for all patients with this condition. It rarely will be the only appropriate approach to the problem.
The technical report entitled "Treatment of the Child With Simple Febrile Seizures" provides in-depth information on the studies used to form guideline recommendations. A complete bibliography is included as well as evidence tables that summarize data extracted from scientific studies. This report also provides pertinent evidence on the individual therapeutic agents studied including study results and dosing information. Readers of this clinical practice guideline are urged to review the technical report to enhance the evidence-based decision-making process. The report is available on the Pediatrics electronic pages website at the following URL: http://www.pediatrics.org/cgi/content/full/103/6/e86.
This practice parameter provides recommendations for
therapeutic intervention in neurologically healthy infants and children between 6 months and 5 years of age who have had one or more simple febrile seizures. A simple febrile seizure is defined as a brief (<15
minutes) generalized seizure that occurs only once during a 24-hour
period in a febrile child who does not have an intracranial infection
or severe metabolic disturbance. This practice parameter is not
intended for patients who have had complex febrile seizures (prolonged,
ie, >15 minutes, focal, or recurrent in 24 hours), nor does it pertain
to children with previous neurologic insults, known central nervous
system abnormalities, or a history of afebrile seizures.
This practice parameter is intended for use by pediatricians,
family physicians, child neurologists, neurologists, emergency physicians, and other health care professionals who treat children with
febrile seizures.
Possible therapeutic approaches to a child with simple febrile
seizures include continuous anticonvulsant therapy with agents such as
phenobarbital, valproic acid, carbamazepine, or phenytoin; intermittent
therapy with antipyretic agents or diazepam; or no anticonvulsant
therapy.
For a child who has experienced a simple febrile seizure, there
are potentially 2 major adverse outcomes that may theoretically be
altered by an effective therapeutic agent. These are the occurrence of
subsequent febrile seizures or afebrile seizures, including epilepsy.
The risk of having recurrent simple febrile seizures varies, depending
on age. Children younger than 12 months at the time of their first
simple febrile seizure have approximately a 50% probability of having
recurrent febrile seizures. Children older than 12 months at the time
of their first event have approximately a 30% probability of a second
febrile seizure; of those that do have a second febrile seizure, 50%
have a chance of having at least 1 additional recurrence.1
Children with simple febrile seizures have only a slightly greater risk
for developing epilepsy by the age of 7 years than the 1% risk of the
general population.2,3 Children who have had multiple
simple febrile seizures and are younger than 12 months at the time of
the first febrile seizure are at the highest risk, but, even in this
group, generalized afebrile seizures develop by age 25 in only
2.4%.4 No study has demonstrated that treatment for
simple febrile seizures can prevent the later development of epilepsy.
Furthermore, there is no evidence that simple febrile seizures cause
structural damage and no evidence that children with simple febrile
seizures are at risk for cognitive decline.5
Despite the frequency of febrile seizures (approximately 3%), there is
no unanimity of opinion about therapeutic interventions.3 The following recommendations are based on an analysis of the risks and
benefits of continuous or intermittent therapy in children with simple
febrile seizures. The recommendations reflect an awareness of the very
low risk that a simple febrile seizure poses to the individual child
and the large number of children who have this type of seizure at some
time in early life.13-5 To be commensurate, a proposed
therapy would need to be exceedingly low in risks and adverse effects,
inexpensive, and highly effective.
The expected outcomes of this practice parameter include the following:
DEFINITION OF THE PROBLEM
TARGET AUDIENCE AND PRACTICE SETTING
POSSIBLE THERAPEUTIC INTERVENTIONS
BACKGROUND
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Abstract
Background
Methods
Conclusion
Recommendation
References
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METHODOLOGY |
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Methods
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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. Emphasis was placed on articles that differentiated simple febrile seizures from other types of febrile seizures, articles that carefully matched treatment and control groups, and articles that described adherence to the drug regimen. Tables were constructed from 62 articles that best fit these criteria. A more comprehensive review of the literature on which this report is based can be found in the technical report. The technical report also contains dosing information.
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BENEFITS AND RISKS OF CONTINUOUS ANTICONVULSANT THERAPY |
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Phenobarbital
Phenobarbital is effective in preventing the recurrence of simple febrile seizures.6-8 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.6
The adverse effects of phenobarbital include behavioral problems such as hyperactivity and hypersensitivity reactions.69-11
Valproic Acid
In randomized, controlled studies, only 4% of children taking valproate 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.7,12,13 Drawbacks to therapy with valproic acid include its rare association with fatal hepatotoxicity (especially in children younger than 3 years who also are at greatest risk for febrile seizures), thrombocytopenia, weight loss and gain, gastrointestinal disturbances, and pancreatitis.14
Carbamazepine
Carbamazepine has not been shown to be effective in preventing the recurrence of simple febrile seizures.9
Phenytoin
Phenytoin has not been shown to be effective in preventing the recurrence of simple febrile seizures.15
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BENEFITS AND RISKS OF INTERMITTENT ORAL THERAPY |
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Antipyretic Agents
Antipyretic agents, in the absence of anticonvulsants, are not effective in preventing recurrent febrile seizures.6,16
Diazepam
A double-blind, controlled study in patients with a history of febrile seizures demonstrated that administration of oral diazepam (given at the time of a fever) could reduce the recurrence of febrile seizures. Children with a history of febrile seizures were given oral diazepam or a placebo at the time of fever. There was a 44% reduction in the risk of febrile seizures per person-year with diazepam.17 A potential drawback to intermittent medication is that a seizure could occur before a fever is noticed. Adverse effects of oral diazepam include lethargy, drowsiness, and ataxia.17 The sedation associated with this therapy could mask evolving signs of a central nervous system infection.
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SUMMARY |
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Background
Methods
Conclusion
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The Subcommittee has determined that a simple febrile seizure is a benign and common event in children between the ages of 6 months and 5 years. Most children have an excellent prognosis. Although there are effective therapies that could prevent the occurrence of additional simple febrile seizures, the potential adverse effects of such therapy are not commensurate with the benefit. 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. There is no convincing evidence, however, that any therapy will alleviate the possibility of future epilepsy (a relatively unlikely event). Antipyretics, although they may improve the comfort of the child, will not prevent febrile seizures.
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RECOMMENDATION |
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Based on 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. The American Academy of Pediatrics recognizes that recurrent episodes of febrile seizures can create anxiety in some parents and their children, and, as such, appropriate education and emotional support should be provided.
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ACKNOWLEDGMENTS |
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The Committee on Quality Improvement and Subcommittee on Febrile Seizures appreciate the expertise of Richard N. Shiffman, MD, Center for Medical Informatics, Yale School of Medicine, for his input and analysis in development of this practice guideline. Comments were also solicited and received from organizations such as the American Academy of Family Physicians, the American Academy of Neurology, the Child Neurology Society, and the American College of Emergency Physicians.
COMMITTEE ON QUALITY IMPROVEMENT, 1998-1999
David A. Bergman, MD, Chairperson
Richard D. Baltz, MD
James R. Cooley, MD
Gerald B. Hickson, MD
Paul V. Miles, MD
Joan E. Shook, MD
William M. Zurhellen, MD
LIAISONS
Betty A. Lowe, MD National Association for Childrens Hospitals
and Related Institutions
Shirley Girouard, PhD, RN National Association for Children's
Hospitals and Related Institutions
Michael J. Goldberg, MD AAP Sections
Charles J. Homer, MD AAP Section on Epidemiology
Jan E. Berger, MD AAP Committee on Medical Liability
Jack T. Swanson, MD AAP Committee on Practice and Ambulatory
Medicine
SUBCOMMITTEE ON FEBRILE SEIZURES, 1998-1999
Patricia K. Duffner, MD, Chairperson
Robert J. Baumann, MD, Methodologist
Peter Berman, MD
John L. Green, MD
Sanford Schneider, MD
CONSULTANTS
Carole S. Camfield, MD, FRCP(C)
Peter R. Camfield, MD, FRCP(C)
David L. Coulter, MD
Patricia K. Crumrine, MD
W. Edwin Dodson, MD
John M. Freeman, MD
Arnold P. Gold, MD
Gregory L. Holmes, MD
Michael Kohrman, MD
Karin B. Nelson, MD
N. Paul Rosman, MD
Shlomo Shinnar, MD
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
This clinical practice guideline was reviewed by the appropriate councils, committees and sections of the American Academy of Pediatrics including the Committee on Practice and Ambulatory Medicine, the Committee on Pediatric Emergency Medicine, the Committee on Drugs and sections on Emergency Medicine, Clinical Pharmacology, and Neurology. It was also reviewed by the Chapter Review Group, a focus group of practicing pediatricians representing each AAP district: Thomas J. Herr, MD, Gene R. Adams, MD, Charles S. Ball, MD, Diane E. Fuquay, MD, Michael J. Heimerl, MD, Donald T. Miller, MD, Lawrence C. Pakula, MD, William R. Sexson, MD, and Howard B. Weinblatt, MD.
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REFERENCES |
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Abstract
Background
Methods
Conclusion
Recommendation
References
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The following policy statement is a revision:
This article has been cited by other articles:
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 Steering Committee on Quality Improvement and Mana Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures Pediatrics, June 1, 2008; 121(6): 1281 - 1286. [Abstract] [Full Text] [PDF]
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P. Major and E. A. Thiele Seizures in Children: Determining the Variation Pediatr. Rev., October 1, 2007; 28(10): 363 - 371. [Full Text] [PDF]
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 R. E. Ramsay, W. D. Shields, and S. Shinnar Special Issues in the Management of Young Children, Older Adults, and the Developmentally Disabled J Child Neurol, May 1, 2007; 22(5_suppl): 53S - 60S. [Abstract] [PDF]
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 L. G Sadleir and I. E Scheffer Febrile seizures BMJ, February 10, 2007; 334(7588): 307 - 311. [Full Text] [PDF]
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E. Pavlidou, M. Tzitiridou, and C. Panteliadis Effectiveness of Intermittent Diazepam Prophylaxis in Febrile Seizures: Long-Term Prospective Controlled Study J Child Neurol, December 1, 2006; 21(12): 1036 - 1040. [Abstract] [PDF]
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A. Covanis Panayiotopoulos Syndrome: A Benign Childhood Autonomic Epilepsy Frequently Imitating Encephalitis, Syncope, Migraine, Sleep Disorder, or Gastroenteritis Pediatrics, October 1, 2006; 118(4): e1237 - e1243. [Abstract] [Full Text] [PDF]
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K. E. Gordon, J. M. Dooley, E. Wood, P. Brna, and P. Bethune Which Characteristics of Children With a Febrile Seizure Are Associated With Subsequent Physician Visits? Pediatrics, October 1, 2004; 114(4): 962 - 964. [Abstract] [Full Text] [PDF]
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 H. Kayman Management of Fever: Making Evidence-Based Decisions Clinical Pediatrics, June 1, 2003; 42(5): 383 - 392. [PDF]
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P. Camfield and C. Camfield Childhood Epilepsy: What Is the Evidence for What We Think and What We Do? J Child Neurol, April 1, 2003; 18(4): 272 - 287. [Abstract] [PDF]
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D. Hirtz, A. Berg, D. Bettis, C. Camfield, P. Camfield, P. Crumrine, W. D. Gaillard, S. Schneider, and S. Shinnar Practice parameter: Treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology, January 28, 2003; 60(2): 166 - 175. [Abstract] [Full Text] [PDF]
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K. E. Gordon, J. M. Dooley, P. R. Camfield, C. S. Camfield, and J. MacSween Treatment of Febrile Seizures: The Influence of Treatment Efficacy and Side-Effect Profile on Value to Parents Pediatrics, November 1, 2001; 108(5): 1080 - 1088. [Abstract] [Full Text] [PDF]
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P. K. Duffner and R. J. Baumann A Synopsis of the American Academy of Pediatrics' Practice Parameters on the Evaluation and Treatment of Children with Febrile Seizures Pediatr. Rev., August 1, 1999; 20(8): 285 - 287. [Full Text]
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