Review article
Treatment of children with simple febrile seizures: the aap practice parameter

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Abstract

Febrile seizures are the most common seizure disorder in childhood, occurring in 2-5% of children. Despite their frequency, there has been little unanimity of opinion regarding the need for long-term antiepileptic therapy. As such, the American Academy of Pediatrics formulated a subcommittee to study the subject. A Practice Parameter was developed that addressed the issue of whether continuous or intermittent antiepileptic therapy is necessary for children with simple febrile seizures. The committee determined that with the exception of a high rate of recurrence, no long-term adverse effects of simple febrile seizures have been identified. The risk of developing epilepsy is extremely low and, even in those patients who do, there is no evidence that recurrent simple febrile seizures produce structural central nervous system damage. Also, there is no evidence that recurrent simple febrile seizures cause either learning problems or premature death. The committee concluded that although there is the evidence that continuous antiepileptic therapy with phenobarbital or valproic acid and intermittent therapy with diazepam are effective in reducing the risk of recurrence, the potential toxicities associated with antiepileptic therapy outweigh the relatively minor risks associated with simple febrile seizures. As such, long-term treatment is not recommended.

Introduction

Febrile seizures are the most common seizure disorder in childhood, occurring in 2-5% of children [1]. Despite their frequency, there has been little unanimity of opinion regarding the appropriate approach to either the neurodiagnostic evaluation or the potential long-term treatment of these children [2]. In 1980 the National Institutes of Health Consensus Statement, based in large part on work by Nelson and the National Collaborative Perinatal Project, concluded that febrile seizures are benign events and, in general, treatment is not recommended [3]. For those children at higher risk of epilepsy (i.e., those with abnormal neurologic development, complex febrile seizures, or a family history of afebrile seizures), treatment with phenobarbital “might be considered.” It also may be considered for those children whose first febrile seizure was before 12 months of age and who had multiple febrile seizures. Despite these recommendations, controversy has persisted regarding the appropriate approach for these children. As a result, the American Academy of Pediatrics (AAP) and its Committee on Quality Improvement, in collaboration with experts from the Section on Neurology, general pediatricians, consultants in the fields of child neurology and epilepsy, and research methodologists, developed practice parameters to address these issues. The first practice parameter, “The Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure,” was published in 1996 [4]. The second, “The Long-Term Treatment of the Child With Simple Febrile Seizures,” was published in 1999 [5]. The purpose of the present report is to expand on the rationale for the AAP recommendations for the long-term treatment of children with simple febrile seizures. Table 1 Table 2 Table 3 Table 4 provide details of some of the studies on which these recommendations were based and are modified from those prepared for the American Academy of Pediatrics.

Section snippets

Patient population

Both the first and second Practice Parameters provide recommendations solely for children who are neurologically healthy, between 6 months and 5 years of age, and who have had one or more simple febrile seizures. A simple febrile seizure was defined as a brief (less than 15 minutes) generalized seizure that occurred only once in a 24-hour period in a febrile child who did not have either central nervous system infection or a severe metabolic disturbance. The Practice Parameters were not

Theoretical risks of simple febrile seizures

The decision of whether to treat children with simple febrile seizures is determined by an assessment of the potential risks associated with having one or more simple febrile seizures. Of most concern is the risk of developing epilepsy. Nelson and Ellenberg [6] reported that neurologically normal children with simple febrile seizures and no family history of epilepsy had a 0.9% chance of developing epilepsy by 7 years of age. When Annegers et al. [7] extended the risk analysis up to 25 years of

Prevention of recurrent febrile seizures with continuous antiepileptic therapy

In most studies, phenobarbital has been proved to be effective in preventing recurrent febrile seizures. Camfield et al. [10] randomized 79 children who had experienced a first simple febrile seizure to either phenobarbital or placebo and monitored compliance. They reported a significant benefit to phenobarbital because 5% of the treated children had a recurrence compared with 25% in the placebo group. For the drug to be effective, however, it must be given daily and blood levels must be within

Antipyretic agents

Antipyretic agents are routinely given to ill children who have a history of febrile seizures to reduce the fever and hence (theoretically) reduce the likelihood of recurrence. Camfield et al. [10] reported, however, that although treatment with acetaminophen and phenobarbital was effective in preventing recurrent febrile seizures, acetaminophen and placebo were not. It is even unclear whether administration of acetaminophen on a routine basis at the time of a febrile illness is effective in

Risks of antiepileptic therapy

If one concludes that continuous treatment with either phenobarbital or valproic acid and intermittent treatment with diazepam are effective in preventing the recurrence of simple febrile seizures, an analysis of the risk factors associated with these drugs must also be performed. Phenobarbital is the most commonly used antiepileptic drug in the prevention of recurrent febrile seizures, but its side effects can be substantial. These adverse effects include hyperactivity, irritability, and

Conclusions

The committee determined that the major risk of simple febrile seizures is recurrence. The risk of developing epilepsy is extremely low and, even in these cases, no evidence is available that recurrent simple febrile seizures produce structural central nervous system damage. In addition, no evidence that recurrent simple febrile seizures cause either learning problems or premature death has been identified. Although data are convincing that continuous antiepileptic therapy with phenobarbital or

Recommendation

On the basis of the risks and benefits of the effective therapies, neither continuous nor intermittent antiepileptic therapy is recommended for children with one or more simple febrile seizures. The AAP recognizes that recurrent episodes of febrile seizures can create anxiety in some parents and their children. As such, appropriate education and emotional support should be provided. In those situations in which parental anxiety associated with febrile seizures is severe, intermittent oral

Acknowledgements

The AAP Subcommittee that formulated the Practice Parameter included Patricia K. Duffner, MD (Chair), Robert Baumann, MD (methodologist), Peter Berman, MD (child neurologist), John Green, MD (pediatrician), and Sanford Schneider, MD (child neurologist). Our AAP liaison was Ms. Carla Herrerias, without whose help this Parameter would not have been possible. We also thank the AAP Committee on Quality Improvement and the Board of Directors for their valuable input. Finally, we would like to

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