treatment of children with simple febrile seizure

7/31/2019 Treatment of Children With Simple Febrile Seizure

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Review Article

Treatment of Children With Simple Febrile

Seizures: The AAP Practice ParameterRobert J. Baumann, MD* and Patricia K. Duffner, MD

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 theissue of whether continuous or intermittent antiepilep-

tic 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 withphenobarbital or valproic acid and intermittent ther-

apy with diazepam are effective in reducing the risk of

recurrence, the potential toxicities associated with an-

tiepileptic therapy outweigh the relatively minor risks

associated with simple febrile seizures. As such, long-

term treatment is not recommended. 2000 by

Elsevier Science Inc. All rights reserved.

Baumann RJ, Duffner PK. Treatment of children withsimple febrile seizures: The AAP practice parameter.Pediatr Neurol 2000;23:11-17.

Introduction

Febrile seizures are the most common seizure disorder inchildhood, occurring in 2-5% of children [1]. Despite their

frequency, there has been little unanimity of opinion regard-ing the appropriate approach to either the neurodiagnosticevaluation or the potential long-term treatment of thesechildren [2]. In 1980 the National Institutes of HealthConsensus Statement, based in large part on work by Nelsonand the National Collaborative Perinatal Project, concluded

that febrile seizures are benign events and, in general,treatment is not recommended [3]. For those children athigher risk of epilepsy (i.e., those with abnormal neurologicdevelopment, complex febrile seizures, or a family history ofafebrile seizures), treatment with phenobarbital might beconsidered. It also may be considered for those childrenwhose first febrile seizure was before 12 months of age andwho had multiple febrile seizures. Despite these recommen-dations, controversy has persisted regarding the appropriateapproach for these children. As a result, the AmericanAcademy of Pediatrics (AAP) and its Committee on QualityImprovement, in collaboration with experts from the Sectionon Neurology, general pediatricians, consultants in the fields

of child neurology and epilepsy, and research methodolo-gists, developed practice parameters to address these issues.The first practice parameter, The Neurodiagnostic Evalua-tion of the Child With a Simple Febrile Seizure, waspublished in 1996 [4]. The second, The Long-Term Treat-ment of the Child With Simple Febrile Seizures, waspublished in 1999 [5]. The purpose of the present report is toexpand on the rationale for the AAP recommendations for thelong-term treatment of children with simple febrile seizures.Tables 1-4 provide details of some of the studies on whichthese recommendations were based and are modified fromthose prepared for the American Academy of Pediatrics.

Patient Population

Both the first and second Practice Parameters providerecommendations solely for children who are neurologi-

From the *Departments of Neurology and Pediatrics; University ofKentucky; and Department of Neurology; Kentucky Clinic; Lexington,Kentucky; and Departments of Neurology and Pediatrics, StateUniversity of New York at Buffalo School of Medicine andBiomedical Sciences, Buffalo, New York.

Communications should be addressed to:Dr. Duffner; Department of Neurology; Childrens Hospital ofBuffalo; 219 Bryant Street; Buffalo, NY 14222.Received November 12, 1999; accepted February 28, 2000.

11 2000 by Elsevier Science Inc. All rights reserved. Baumann and Duffner: Treatment of Simple Febrile SeizuresPII S0887-8994(00)00148-X 0887-8994/00/$20.00


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cally healthy, between 6 months and 5 years of age, andwho have had one or more simple febrile seizures. Asimple febrile seizure was defined as a brief (less than 15minutes) generalized seizure that occurred only once in a24-hour period in a febrile child who did not have eithercentral nervous system infection or a severe metabolicdisturbance. The Practice Parameters were not intendedfor patients who have had complex febrile seizures (pro-longed [i.e., greater than 15 minutes], focal, or recurrentwithin a 24-hour period, or any combination), nor do theypertain to those children with previous neurologic insults,known central nervous system abnormalities, or a historyof afebrile seizures.

Theoretical Risks of Simple Febrile Seizures

The decision of whether to treat children with simplefebrile seizures is determined by an assessment of thepotential risks associated with having one or more simplefebrile seizures. Of most concern is the risk of developingepilepsy. Nelson and Ellenberg [6] reported that neurolog-ically normal children with simple febrile seizures and nofamily history of epilepsy had a 0.9% chance of develop-ing epilepsy by 7 years of age. When Annegers et al. [7]extended the risk analysis up to 25 years of age, thosechildren with multiple simple febrile seizures and a familyhistory of epilepsy had a 2.4% risk of developing a

generalized seizure disorder, twice the incidence of the

general population. However, no data are available to

suggest that this small increase in the risk of epilepsy can

be reduced by prophylactic antiepileptic treatment of

children with simple febrile seizures. The higher incidence

of epilepsy is likely the result of genetic predisposition,

rather than structural damage caused by recurrent simple

febrile seizures.

Another theoretical risk of recurrent simple febrile

seizures is an adverse effect on intelligence. In two large

studies from the United States and Britain, no relationship

was identified between the presence of recurrent febrile

seizures and learning. Ellenberg and Nelson [8] studied

431 children who experienced febrile seizures and ob-

served no significant difference in their intellectual abili-

ties. In a similar British study by Verity et al. [9], 303children with febrile seizures were compared with control

children. No difference in learning was identified, except

in those children who were neurologically abnormal be-

fore their first febrile seizure.

A third theoretical risk of simple febrile seizures is

death caused by aspiration, but to our knowledge, no

deaths associated with simple febrile seizures have been

reported. The only remaining risk of simple febrile sei-

zures is recurrence. The overall risk of a first recurrence is

30%; it is 50% for two or more recurrences and is also

Table 1. Phenobarbital trials

Investigators Design Children (n) SZ type Outcome Comments

Bacon et al. [20], 1981 RC, SB SFS CFS Sig. 2 rec. inchildren 14mo at first SZ

Phenytoinineffective

and phenytoin levels therapeuticin 45% and 44% of youngersubjects

1. 482. Phenytoin 473. Placebo 43

Camfield et al. [10], 1980 RC, DB First SFS more effectivethan

antipyretics

Compliance assessed1. , antipyretics 39

2. Placebo, antipyretics 40Heckmatt et al. [13], 1976 Comparison First SFS not sig. better

than placeboRec. at 6-mo follow-up: 19% no

Rx vs 8% cont. 1. Cont. 492. No Rx 73

Van den Berg andYerushalmy [32], 1971

Cohort study First SFS Early (Gp 1)Sig. 2 riskRec.

Compliance not monitored; oftengiven int. given

1. Within 30 days of SZ 622. 1 mo to 2 yr after SZ 983. No Rx 97

Wolf et al. [11], 1977 RC, NB FS (SFS or CFSnot specified)

No differenceInt. vs no ;Sig. 2 rec.with cont.

1. Cont, 1062. Int. 1403. No Rx 109

Abbreviations:CFS Complex febrile seizureCont. ContinuousDB Double-blindFS Febrile seizureGP GroupInt. IntermittentNB No blinding Phenobarbital

RC Randomized controlledRec. RecurrenceRx TherapySB Single blindSFS Simple febrile seizureSig. SignificantlySpec. SpecifiedSZ Seizure

12 PEDIATRIC NEUROLOGY Vol. 23 No. 1


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50% for those children younger than 12 months of age atthe time of their first febrile seizure [1]

In summary, with the exception of a high rate ofrecurrence, no long-term adverse effects of simple febrileseizures have been identified.

Prevention of Recurrent Febrile Seizures With

Continuous Antiepileptic Therapy

In most studies, phenobarbital has been proved to beeffective in preventing recurrent febrile seizures. Camfieldet al. [10] randomized 79 children who had experienced afirst simple febrile seizure to either phenobarbital orplacebo and monitored compliance. They reported a sig-nificant benefit to phenobarbital because 5% of the treatedchildren had a recurrence compared with 25% in theplacebo group. For the drug to be effective, however, itmust be given daily and blood levels must be within the

therapeutic range. Wolf et al. [11] randomized childrenwith a history of febrile seizures to either continuous,intermittent, or no phenobarbital. Although no significantdifference in recurrence was evident between those chil-dren receiving either intermittent or no phenobarbital,those children who received phenobarbital on a daily basishad a significant reduction in seizures. Studies in whichcontinuous phenobarbital has not been effective generallyhave reflected noncompliance. For example, in the studyof Farwell et al. [12], children whose phenobarbital levelswere therapeutic had a reduction in seizures, but because

noncompliance was high, an overall benefit to phenobar-bital was not identified. In contrast to most studies,Heckmatt et al. [13] did not observe a significant advan-tage to phenobarbital even in those children with thera-peutic levels (although the dropout rate in the phenobar-bital arm was high). Recurrences occurred in 19% of thecontrol children, in 11% of those for whom phenobar-bital was prescribed, and in 8% of those who completedtreatment. Whether larger numbers might have identified asignificant benefit to phenobarbital is unclear.

Carbamazepine has not been demonstrated to be effec-tive in preventing febrile seizure recurrence. Antony andHawke [14] compared children who had been treated withtherapeutic levels of either carbamazepine or phenobarbi-tal. Forty-seven percent of the carbamazepine group hadrecurrence compared with only 10% of the phenobarbitalgroup. Similar results were reported by Camfield et al.[15] who prescribed carbamazepine for those children

with febrile seizures who had either been unable to toleratephenobarbital or in whom phenobarbital had not beeneffective. Despite good compliance, 13 of 16 children hada recurrent febrile seizure within 18 months of beginningcarbamazepine therapy [15].

Several studies have compared valproic acid with phe-nobarbital in the prevention of recurrent febrile seizures.Lee and Melchior [16] evaluated three groups of children:those treated with phenobarbital; those treated with val-proic acid; and those who received no therapy. Valproicacid provided significantly better control than no therapy.

Table 2. Valproic acid trials

Investigators Design Children (n) SZ Type Outcome Comments

Lee and Melchior[16], 1981

RC, NB SFS and CFS did not 2 rec.VPA sig 2 rec.

24% discontinued because of side effects;all tolerated VPA

1. Cont. 332. VPA 32

Mamelle et al. [17],1984

RC, SB First generalized FS Recurrence Sig. difference betweenVPA vs placebo butnot between andplacebo or VPA and

1 Cont. 24 1. 19%2. Cont. VPA 24 2. 4%3. Placebo 25 3. 35%

Ngwane and Bower[18], 1980

Comparison First SFS VPA Both better than placebo

1. VPA 182. 21

Wallace and Smith[19], 1980

Comparison First FS Both VPA and sig. better than no Rx (if

levels therapeutic)

1. VPA 482. 463. No Rx 27

Williams et al. [31],1979

RC, NB Second SFS VPA not effective Two of 21 subtherapeutic1. VPA 302. No Rx 28

Abbreviations:CFS Complex febrile seizureCont. ContinuousDB Double-blind2 DecreasedFS Febrile seizureNB No blinding PhenobarbitalRC Randomized controlled

Rec. RecurrenceRx TherapySB Single blindSFS Simple febrile seizureSig. SignificantSZ SeizureVPA Valproic acid

13Baumann and Duffner: Treatment of Simple Febrile Seizures


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Of interest, significant differences were not identified inseizure prevention between those patients treated withphenobarbital and the control children [16]. Mamele et al.[17] randomized children with a previous febrile seizure tovalproic acid, phenobarbital, or placebo. They found astatistically significant difference among the three groups,with recurrence rates of 4%, 19%, and 35%, respectively.Significant differences (P 0.05) were evident betweenthe treated children (valproic acid and phenobarbital) andplacebo and between children treated with valproic acidand those treated with placebo (P 0.01) [17]. A similarstudy was performed by Ngwane and Bower [18] in whicha randomized double-blind trial was performed on chil-dren between 6 and 18 months of age who had experi-enced a previous simple febrile seizure. Children wererandomized to valproic acid, phenobarbital, or placebo.Treatment with valproic acid and phenobarbital providedsignificantly better results than placebo, and valproic acidwas as effective as phenobarbital in that study [18].

Wallace and Smith [19] also determined that both pheno-barbital and valproic acid were equally effective, and bothwere significantly better than placebo in preventing recur-rence of febrile seizures. As might be anticipated, thosechildren who had less than optimal blood levels did notfare as well because seizures occurred with fever duringeight of 58 6-month periods with phenobarbital and duringsix of 35 periods in those taking valproic acid.

The data on the use of phenytoin in febrile seizures arelimited. In a study by Bacon et al. [20] the efficacy ofphenobarbital, phenytoin, and placebo were compared in

children with febrile seizures. Phenytoin did not offer anadvantage over placebo in 33% of younger subjects or in35% of older subjects. In their study, phenobarbital sig-nificantly reduced the recurrence of febrile seizures inchildren younger than 14 months of age but was noteffective in children beyond that age [20]. The lack ofefficacy of phenytoin in preventing febrile seizures inchildren younger than 3 years was also reported byMelchior et al. [21] in a study in which blood levels weremonitored.

In summary, most studies demonstrate that when eitherphenobarbital or valproic acid are administered continu-ously and maintained in the usual therapeutic range,febrile seizure recurrence can be prevented in up to 90% ofpatients. In actual usage the high rate of noncomplianceleads to more frequent failures. In contrast, carbamazepineand phenytoin are ineffective even when the agents are inthe usual therapeutic range.

Intermittent Therapy

Antipyretic Agents

Antipyretic agents are routinely given to ill childrenwho have a history of febrile seizures to reduce the feverand hence (theoretically) reduce the likelihood of recur-rence. Camfield et al. [10] reported, however, that al-though treatment with acetaminophen and phenobarbitalwas effective in preventing recurrent febrile seizures,acetaminophen and placebo were not. It is even unclear

Table 3. Diazepam trials

Investigators Design Children (n) SZ Type Outcome Comments

Autret et al. [25],1990

RC prospective SFS and CFS Diazepam ineffective Poor comp. with diazepam1. Int. diazepam 932. Placebo 92

Knudsen andVestermark [27],1978

RC SFS and CFS Rec. rate same in bothgroups

15-16% had rec. (poor comp.with diazepam)1. Int. diazepam 99

2. Continuous 96Lee [33], 1986 Comparison, NB Complicated

seizures

VPA Diazepam in 2

rec.

No randomization

1. Int. diazepam 44 No comp. checks for diazepam2. VPA 50

Rosman et al. [23],1993

RC, DB FS Int. by mouth SFS vs CFS not specified1. Int. diazepam 202 Diazepam 2 rec. 50 diazepam and 55 placebo

patients withdrawn2. Int. placebo 204Uhari et al [26], 1995 RC, DB First FS Diazepam

acetaminophenineffective

Low doses of acetaminophen ordiazepam, or both, ineffective1. Int. diazepam* 81 70-73% SFS

2. Placebo 80

* Subjects also received antipyretics, alternating acetaminophen or placebo every other febrile episode (four groups of subjects).

Abbreviations:CFS Complex febrile seizureComp. ComplianceDB Double-blind2 DecreasedFS Febrile seizureInt. IntermittentNB No blinding

PhenobarbitalRC Randomized controlledRec. RecurrenceSZ SeizureSFS Simple febrile seizureVPA Valproic acid



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whether administration of acetaminophen on a routinebasis at the time of a febrile illness is effective in reducingfever episodes. Schnaiderman et al. [22] reported thatadministration of acetaminophen every 4 hours was nomore effective in either reducing the number of febrileepisodes or in reducing the mean duration of the fever thansporadic dosing of acetaminophen when the body temper-ature was greater than 37.9C. Therefore although acet-aminophen may make the child more comfortable, it willnot prevent recurrent febrile seizures.

Diazepam

Rosman et al. [23] compared the use of oral diazepam

with placebo in children who had a history of febrileseizures. Patients were treated during febrile illnesses with0.33 mg/kg of diazepam given orally every 8 hours for 48hours. The intention-to-treat analysis revealed a reductionof 44% in the risk of febrile seizures per person per yearwith diazepam. The cumulative incidence of first recur-rences of febrile seizures in the placebo group was 32%;the incidence of seizures in the diazepam-treated groupwas 21% overall. Thus, in their study, treatment withdiazepam was effective in preventing recurrent febrileseizures. The efficacy of intermittent diazepam had previ-

ously been suggested [24]. Continuous valproic acid was

compared with intermittent diazepam given only during

febrile illnesses. No significant differences were identified

between the recurrence rates in the two treatment groups.

In contrast to these studies, Autret et al. [25] compared

intermittent diazepam with placebo and observed no effi-

cacy for the children treated with diazepam. Recurrent

seizures occurred in 16% of the diazepam group and in

19.5% of the placebo group. The dose of diazepam used in

the study of Autret et al., however, was only 0.2 mg/kg.

Perhaps more importantly, prophylactic treatment was

given correctly to only one of 15 in the diazepam-treated

group and seven of the 18 of the placebo group, suggesting

it may have been a failure of the method rather than a

failure of the agent. Uhari et al. [26] conducted a placebo-

controlled double-blind trial of diazepam 0.2 mg/kg and

placebo, acetaminophen and placebo, diazepam and acet-

aminophen, and two kinds of placebo. The combination of

acetaminophen and low-dose diazepam did not reduce the

incidence of recurrence [26].

In summary, intermittent therapy with diazepam, if

given in sufficient doses, is likely to be effective in

preventing febrile seizure recurrence. Acetaminophen is

ineffective as a preventative agent.

Table 4. Side Effects

Investigators Study Children (n) Side Effects Comments

Antony and Hawke[14], 1983

Comparison 42% side effects (23%discontinued )

CBZ less effective than 1. CBZ 192. 21 CBZ 30% risk effects (17%

stopped CBZ)Camfield et al.

[28], 1979RC, DB 23% transient, 11% dose-

related, 8.6% unacceptableNo difference in IQ after 8-12

mo1. 352. Placebo 30 Placebo 23% side effects 2 comprehension

Farwell et al. [12],1990

RC, DB ? neg. effect on cognition; at2 yr mean IQ 8.4 less thanplacebo; 15% side effects;placebo 11% side effects

No sig. difference in rec. rate1. 2. Control (no SZ)

217 ( or placebo)150

levels at rec. mostlyunavailable

13 noncompliant at time of rec.Vining et al. [29],

1987Comparison, DB 2 performance with More behavior problems with

1. 21 VPA superior to 2. VPA

Wolf and Forsythe[34], 1981

Comparison, matched pairs No sig. difference inpsychometric results vs noRx

1. 252. No Rx 25

Wolf and Forsythe[30], 1978

RC 42% taking cont hadbehavioral problems,especially hyperactivity

No Rx 18% behavior problems1. cont. 1092. int. 1423. No Rx 120 Sig. 1 hyperactivity

vs no

Abbreviations:CBZ carbamazepineCont. ContinuousDB Double-blind2 Decreased1 IncreasedInt. IntermittentIQ Intelligence quotientNeg. Negative

PhenobarbitalRC Randomized controlledRec. RecurrenceRx TherapySig. SignificantSZ SeizureVPA Valproic acid



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Risks of Antiepileptic Therapy

If one concludes that continuous treatment with eitherphenobarbital or valproic acid and intermittent treatmentwith diazepam are effective in preventing the recurrence

of simple febrile seizures, an analysis of the risk factorsassociated with these drugs must also be performed.Phenobarbital is the most commonly used antiepilepticdrug in the prevention of recurrent febrile seizures, but its

side effects can be substantial. These adverse effectsinclude hyperactivity, irritability, and idiosyncratic reac-tions. Antony and Hawke [14] observed that nine of their

subjects (43%) who received phenobarbital as prophylaxishad side effects and five (24%) had problems severeenough to discontinue the agent. Knudsen and Vestermark[27] also observed side effects in 45% of their phenobar-bital-treated group. Side effects included hyperkinesia,irritability, and listlessness; also, side effects were so

severe at times that some of the patients discontinued thestudy [27]. Lee and Melchior [16] evaluated childrentreated with phenobarbital and observed that 21% of

families discontinued the drug because of side effects thatincluded hyperactivity and sleep disturbances. Camfield etal. [28] performed a study comparing the side effects ofphenobarbital and placebo. Transient side effects occurred

in 23% of the children taking a placebo. Unacceptable sideeffects in the phenobarbital group were primarily relatedto sleep disturbances and irritability [28].

Of more concern was a study by Farwell et al. [12], inwhich they determined that phenobarbital might have alasting negative effect on cognitive performance. At 2years of age the mean intelligence quotient (IQ) of the

phenobarbital-treated children was 8.4 points lower than inthe placebo group. Moreover, the changes persisted after

the medication was discontinued, such that the mean IQwas 4 points lower in the phenobarbital-assigned group.Vining et al. [29] also evaluated the effects of phenobar-bital on neuropsychologic function. They observed signif-icant differences when children treated with phenobarbital

were compared with those treated with valproic acid.Patients who received valproic acid had superior results onblock design, performance, full scale IQ (according to theWechsler Intelligence Scale for Children, Revised), and onpaired/association learning tasks compared with thosetaking phenobarbital. Moreover, the patients taking phe-

nobarbital also scored significantly higher on a hyperac-

tivity index score [29]. In contrast, Wolf and Forsythe [30]compared psychometric tests of children receiving pheno-barbital with those receiving no therapy. The initial testingand the 3-month follow-up revealed no significant differ-ences on any of the measures between the two groups [30].The evidence, therefore, suggesting that phenobarbital has

a permanent adverse effect on intelligence (even after theagent is discontinued) is not strong, but reduced perfor-mance while taking therapy has been identified in severalstudies. Good data are also available to suggest that from20% to 40% of phenobarbital-treated children develop

significant behavioral side effects, particularly hyperactiv-ity, irritability, and sleep disorders, and a smaller percent-age may develop idiosyncratic reactions in the form ofrash, including Stevens-Johnson syndrome.

Valproic acid is not generally recommended for chil-dren in the first 2-3 years after birth (without a majorindication) because of the potential for life-threateninghepatotoxicity. Additional complications associated withvalproic acid include thrombocytopenia (particularly in

the face of viral infections), pancreatitis, and weightdisturbances. In those studies in which valproic acid wasgiven to children with febrile seizures, toxicity was limitedto alterations in appetite, vomiting, and increases indaytime activity [16,31]. No cases of hepatic failure wereidentified.

The intermittent use of diazepam has also been associ-ated with side effects. In the study of Rosman et al. [23],25-30% of children developed ataxia, lethargy, and irrita-bility, and approximately one in 20 children had moderateside effects, including speech abnormalities, depressed orheightened activity level, or sleep disorders. Only three of

the 135 children in that study had side effects of suchsignificance to require discontinuation of the agent. Anadditional concern raised by the committee who developedthe Practice Parameter was that diazepam given at the timeof fever could mask a serious underlying infection becausethe family might attribute the lethargy to the diazepam andnot bring the child in for pediatric evaluation.

Conclusions

The committee determined that the major risk of simplefebrile seizures is recurrence. The risk of developingepilepsy is extremely low and, even in these cases, noevidence is available that recurrent simple febrile seizuresproduce structural central nervous system damage. Inaddition, no evidence that recurrent simple febrile seizurescause either learning problems or premature death hasbeen identified. Although data are convincing that contin-uous antiepileptic therapy with phenobarbital or valproicacid and intermittent therapy with diazepam are effectivein reducing the risk of recurrence, the Committee deter-mined that the potential toxicities associated with antiepi-leptic therapy outweigh the relatively minor risks associ-ated with simple febrile seizures.

Recommendation

On the basis of the risks and benefits of the effectivetherapies, neither continuous nor intermittent antiepileptictherapy is recommended for children with one or moresimple febrile seizures. The AAP recognizes that recurrentepisodes of febrile seizures can create anxiety in someparents and their children. As such, appropriate educationand emotional support should be provided. In thosesituations in which parental anxiety associated with febrileseizures is severe, intermittent oral diazepam at the onset



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of febrile illness may be effective in preventing recur-rence. Evidence is not convincing, however, that anytherapy will alleviate the possibility of future epilepsy.Although antipyretic agents may improve the comfort ofthe child, they will not prevent febrile seizures.

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 wasMs. Carla Herrerias, without whose help this Parameter would not have

been possible. We also thank the AAP Committee on Quality Improve-

ment and the Board of Directors for their valuable input. Finally, we

would like to acknowledge the superb secretarial skills of Ms. Marilyn

Thomasula.

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