Correspondence
Diazepam to Prevent Febrile Seizures
N Engl J Med 1993; 329:2033-2035December 30, 1993
- Article
To the Editor:
As practicing pediatricians in a medium-sized urban setting, we were disturbed to read the article by Rosman et al. (July 8 issue)1 on the use of diazepam to prevent febrile convulsions. We physicians need to do more talking and less medicating. As frightening as febrile seizures are, a good primary care physician should be able to put parents and patients at ease with the proper education and calm compassion. Most children with febrile seizures can be treated conservatively without hospitalization or invasive medical techniques. After a simple febrile seizure, these children typically do not appear ill, and invasive disease can be ruled out without intervention involving the laboratory or hospital. The use of diazepam will impair the clinical assessment; 24.2 to 30 percent of the children in this study were irritable, lethargic, or had ataxia after taking diazepam. In all likelihood, costly forms of medical technology would be required in order to evaluate these premedicated children, increasing the financial as well as the psychological toll on the whole family.
Do simple febrile seizures need to be prevented? Probably not, but we need to be caring and understanding to help families through this frightening ordeal.
1 ReferencesCharles A. Fischbein, M.D.
I. Jeffrey Berg, M.D.
Pediatric Associates of Connecticut, Waterbury, CT 067081
Rosman NP ,Colton T ,Labazzo J , et al. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med 1993;329:79-84
Full Text | Web of Science | Medline
To the Editor:
Rosman et al. found that 39 percent of 153 children given diazepam for the prevention of febrile seizures had moderate neurologic side effects, and an unspecified number of additional subjects had the same symptoms to a mild degree. Lethargy, irritability, and ataxia, though not themselves harmful, are key indicators whose absence or presence helps parents and clinicians alike to distinguish benign childhood febrile illness from more serious disease. One wonders how many diagnoses of meningitis would be delayed if subtle early manifestations were simply attributed to the drug.
Steven Leiner, M.S., C.F.N.P., P.A.-C.
Mission Neighborhood Health Center, San Francisco, CA 94110To the Editor:
Seizures are frightening, largely because of ignorance. It is this fear that led to the centuries-old stigma against people with seizures. Education costs little, can be effective in almost everyone,1 and can do far more to reduce fear than a modestly effective therapy to prevent recurrent seizures.
The costs associated with seizures are not substantiated by Rosman et al. They have not factored in the cost of treating all fevers or the fact that only about a third of recurrences are prevented by oral diazepam. Among children with initial febrile seizures, the two thirds who will never have another seizure2 would be treated unnecessarily. Furthermore, recent evidence indicates that even idiopathic febrile status epilepticus does no permanent harm3.
A related issue recently addressed elsewhere by Rosman4 concerns the risk of injury to a child during a seizure. There are many situations, far more common than seizures, in which a child could be seriously injured (e.g., while bathing), and children should be supervised at such times. Pharmacologic therapy is no substitute for proper parental supervision.
Education, reassurance, and common sense will go much further than pharmacologic treatment in reducing the morbidity (i.e., the fear and anxiety) associated with this very common childhood disorder.
4 ReferencesAnne T. Berg, Ph.D.
Yale University School of Medicine, New Haven, CT 065101
Freeman JM . The best medicine for febrile seizures. N Engl J Med 1992;327:1161-1163
Full Text | Web of Science | Medline2
Berg AT ,Shinnar S ,Hauser WA , et al. A prospective study of recurrent febrile seizures. N Engl J Med 1992;327:1122-1127
Full Text | Web of Science | Medline3
Maytal J ,Shinnar S . Febrile status epilepticus. Pediatrics 1990;86:611-616
Web of Science | Medline4
Rosman NP . The case for treating febrile seizures. Contemp Pediatr 1992;9:12-34
To the Editor:
In children with inherited epilepsy or structural brain disease, the first seizure is often precipitated by fever, and thus such children would have been included in the study by Rosman et al., because electroencephalograms do not seem to have been obtained in the study population either at study entry or later. If children with substantial focal or paroxysmal abnormalities on the electroencephalogram had been excluded from entry into the study, perhaps greater efficacy would have been demonstrated for intermittent diazepam in treating simple febrile seizures, or at least a more meaningful recommendation could have been made to pediatricians, and of course the public. . . .
Taranath Shetty, M.D., F.R.C.P.(C)
Brown University School of Medicine, Providence, RI 02903To the Editor:
Rosman et al. list three reasons for using diazepam: reducing anxiety, reducing health care expenditures, and preventing severe seizures. The study addresses none of these outcomes. First, the insistence on the detection of fever is likely to create phobia about fever, and it may increase parental anxiety1. “Seizure phobia” may be replaced by fever phobia. Second, a reduction in expenses must be demonstrated (and must take into account the frequent calls and medical contacts). Third, severe, prolonged febrile seizures apparently did not occur in either the placebo group or the diazepam group.
There is overwhelming evidence that the vast majority of febrile seizures do no biologic harm. Their only proved major adverse effect is parental anxiety. The best treatment for children with a first febrile seizure is education and reassurance for the parents2-4. Most children need no medication. The child who is at high risk or who lives far from medical care could have diazepam available for rectal administration if a prolonged febrile seizure were to occur5. We do not believe in prophylactic medication for febrile seizures.
These opinions are endorsed by Drs. Olivier Dulac (Paris), John Freeman (Baltimore), Karin Nelson (Bethesda, Md.), Martin Offringa (Rotterdam), Shlomo Shinnar (New York), Matti Sillanpaa (Turku, Finland), and Patricia Vining (Baltimore).
5 ReferencesPeter Camfield, M.D.
Carol Camfield, M.D.
Dalhousie University Medical School, Halifax, NS B3J 3G9, Canada1
Schmitt BD . Fever phobia: misconceptions of parents about fevers. Am J Dis Child 1980;134:176-181
Web of Science | Medline2
Nelson KB, Ellenberg JH. Febrile seizures. New York: Raven Press, 1981.
3
Freeman JM . The best medicine for febrile seizures. N Engl J Med 1992;327:1161-1163
Full Text | Web of Science | Medline4
Camfield CS ,Camfield PR . Febrile seizures: a Rx for parent fears and anxieties. Contemp Pediatr 1993;10:26-445
Knudson FU . Rectal administration of diazepam in solution in the acute treatment of convulsions in infants and children. Arch Dis Child 1979;54:855-857
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Author/Editor Response
The authors reply:
To the Editor: Several correspondents question the merit of preventing febrile seizures, an issue that continues to provoke debate. Our study was based on the assumption that such prevention does have merit. The correspondents' comments challenge this assumption but not the scientific validity of our findings.
Initial febrile seizures can be terrifying. Nearly 80 percent of parents think that their child undergoing a seizure is dying or already dead1. The contention that the best management is parental support and education has not been substantiated. Rather, recent findings show that the parents of an affected child continue to be anxious, even after speaking with physicians, viewing videotapes, and reading educational materials, and there is often familial disruption1.
The letters from Fischbein and Berg and from Leiner express concern that side effects of diazepam may delay the diagnosis of underlying illness. Although there was at least one moderate side effect in 39 percent of the 153 children given diazepam, those children had 661 fevers, with moderate side effects in only 111 (16.8 percent). Although underlying meningitis must always be considered with febrile seizures,2 meningeal symptoms can be masked or mimicked by many prescribed medications, including diazepam. Conversely, such symptoms can be absent when meningitis is present. When the clinician is uncertain, a lumbar puncture should be performed.
Dr. Berg and Drs. Camfield and Camfield request substantiation of the costs of febrile seizures. Evaluations by physicians in offices and emergency rooms, laboratory tests, and follow-up examinations are surely more costly than a few tablets of diazepam and a few telephone calls. Camfield and Camfield mistakenly state that prolonged febrile seizures did not occur in our patients. Of 22 complex febrile seizures, 7 were prolonged: 4 for 20 minutes, 2 for 30 minutes, and 1 for 45 minutes. All seven patients were receiving placebo. Camfield and Camfield and Berg stress the lack of biologic harm, including brain damage, resulting from prolonged febrile seizures. A large literature supports the opposite view3-5.
Shetty questions whether diazepam works less well in children with abnormal electroencephalograms. Among electroencephalograms obtained in 145 children before entry, only four were abnormal. Two of the four children had no fevers during the study; the other two, both receiving diazepam, had a total of 16 fevers, with only one recurrence of febrile seizure (when diazepam had not been given).
Camfield and Camfield worry about creating fever phobia among parents. One must always take fevers in childhood seriously, not because they are damaging, but because they may signal underlying illness requiring treatment. Also, fevers can cause seizures.
We maintain that optimal management of febrile seizures involves preventing their recurrence. Many physicians agree and prescribe medication for that purpose. This can be done most effectively and safely with intermittent oral diazepam.
5 ReferencesN. Paul Rosman, M.D.
New England Medical Center, Boston, MA 02111Theodore Colton, Sc.D.
Boston University School of Public Health, Boston, MA 02118Jan Labazzo, R.N.C., M.S.
New England Medical Center, Boston, MA 021111
Camfield CS ,Camfield PR . Febrile seizures: a Rx for parent fears and anxieties. Contemp Pediatr 1993;10:26-442
Rosman NP . The case for treating febrile seizures. Contemp Pediatr 1992;9:12-343
Brett EM. Paediatric neurology. Edinburgh, Scotland: Churchill Livingstone, 1983:283-9.
4
Wallace SJ. The child with febrile seizures. Kent, England: John Wright, 1988:85-93.
5
Cendes F ,Andermann F ,Dubeau F , et al. Early childhood prolonged febrile convulsions, atrophy and sclerosis of mesial structures, and temporal lobe epilepsy: an MRI volumetric study. Neurology 1993;43:1083-1087
Web of Science | Medline
