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A 1 year old child is admitted following their first febrile seizure (FS). We wish to prevent recurrences during further febrile episodes. The nursing staff ask you to prescribe an antipyretic. Later you come to advise the parents on methods of preventing further febrile seizures.
Structured clinical question
In children who have experienced a febrile seizure [patient] does prescribing antipyretics [intervention] reduce recurrences of febrile seizures [outcome]?
Cochrane Library and DARE—“febrile convulsions/seizures and antipyretics”, “febrile convulsions/seizures and paracetamol”, “febrile convulsions/seizures and ibuprofen”; one systematic review found (paracetamol for treating fever in children); two protocols.
Prodigy Evidence Based Clinical guidance—“febrile convulsions”; nil relevant found.
Pubmed clinical queries (1966 to Jan 2003): “antipyretics and febrile convulsions”—80 references. Of these, three were randomised controlled trials but one was irrelevant (investigating antipyretic effects rather than subsequent seizure reduction).
As the essential precursor of a febrile seizure is a fever, physicians and paediatric nurses have concluded that antipyretic measures should prevent febrile seizures. Antipyretics continue to be among the most commonly prescribed medications, especially for children at risk of such seizures. Parents are usually advised that the administration of antipyretics to at risk children may reduce the risk of further convulsions. When asked, the majority of medical trainees and paediatric nurses in our unit replied that the reason for giving paracetamol to children who were at risk of febrile seizure recurrence was to prevent further convulsions. However, the evidence suggests that antipyretics have no effect on preventing further febrile seizures. At this hospital, 13% of children admitted with their first FS subsequently developed repeated FS soon after admission despite the routine administration of paracetamol to control fever prior to the seizure.1
Children with high risk of recurrences of FS (complex features of FS, family history of FS, age less than 1 year, low grade fever at the onset of FS) develop recurrences in at least 80% while those without these risk factors rarely develop recurrences. Antipyretics are used for both groups of children, suggesting that it is these risk factors, and not antipyretics, which are the crucial determinants of the risk of recurrence.
Controlled studies of antipyretic medications, given during the original acute illness following a febrile seizure or during subsequent febrile episodes have failed to show a preventive effect in children at risk of FS (table 3). A randomised, placebo controlled trial in children at risk of FS found no evidence that paracetamol, with or without diazepam, was effective in preventing FS during subsequent febrile episodes.2 A second randomised trial compared the antipyretic effectiveness of paracetamol administered at regular intervals (group 1) versus paracetamol administered at the time of fever (group 2) in children presenting with an FS. Early recurrences of FS (within the first 24 hours) were similar in both groups.3 Ibuprofen was also evaluated in a randomised, double blind, placebo controlled trial in children at risk of FS. The recurrence rate was similar in both groups.4 In another open trial, children at risk of FS were offered either ibuprofen or paracetamol during subsequent febrile episodes or else no medication. The recurrence risk of FS was similar in all groups.5 These four studies concluded that the antipyretics paracetamol and ibuprofen had no preventive effect on the recurrence of FS. A recent review6 of trials assessing the effects of paracetamol on the clearance time of fever and on FS identified 12 randomised or quasi-randomised controlled trials. It concluded that the trials failed to show any convincing evidence that paracetamol is effective in reducing fever or preventing FS.
While antipyretics may have a role in improving comfort and general wellbeing, we should surely not be advocating medication for purposes that have been shown not to work.
CLINICAL BOTTOM LINE
There is no evidence that antipyretics reduce the risk of subsequent febrile convulsions in at risk children.
Prescription of paracetamol following febrile seizures may provide comfort and symptomatic relief, but should not be recommended to prevent further febrile convulsions.