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Intermittent diazepam prophylaxis in febrile convulsions. Pros and cons
Insights
Intermittent diazepam prophylaxis effectively reduces febrile convulsions (FC) recurrence in children. This drug-minimizing approach is advisable for high-risk children, offering a selective strategy for managing FC.
Area of Science:
- Pediatrics
- Neurology
- Pharmacology
Background:
- Febrile convulsions (FC) in children generally have an excellent long-term prognosis.
- Traditional treatments include long-term prophylaxis with phenobarbital or valproate, or no prophylaxis.
- Long-term antiepileptic drug prophylaxis is rarely justified due to side effects and favorable prognosis, while no treatment leads to high recurrence rates and family distress.
Purpose of the Study:
- To evaluate the efficacy and safety of intermittent diazepam prophylaxis for managing febrile convulsions (FC) in children.
- To explore alternative treatment strategies beyond long-term prophylaxis or no treatment for FC.
- To identify a risk-stratified approach for managing children with FC.
Main Methods:
- Review of clinical trials on intermittent diazepam prophylaxis.
- Analysis of treatment feasibility, cost-effectiveness, and tolerability.
- Development of a risk index based on clinical factors (age, family history, seizure type, fever frequency) to identify children at risk for recurrent FC.
Main Results:
- Intermittent diazepam prophylaxis significantly reduces FC recurrence by one-half to two-thirds.
- This treatment is feasible, inexpensive, well-tolerated, and accepted by parents, with rare serious side effects.
- A risk profile approach can identify children who would benefit most from selective intermittent diazepam prophylaxis.
Conclusions:
- Intermittent diazepam prophylaxis is a useful, drug-minimizing strategy for managing children with simple or complex febrile convulsions.
- While not strictly mandatory, this treatment is advisable, particularly for high-risk children.
- A selective strategy, offering intermittent diazepam prophylaxis to high-risk children, is rational and effective.
Abstract:
Major cohort studies document that the long-term prognosis for most children with febrile convulsions (FC) is excellent. The 2 main treatment alternatives so far have been long-term prophylaxis with phenobarbital or valproate or no prophylaxis at all. Phenobarbital at times of fever is ineffective and obsolete. Consensus has emerged that long-term prophylaxis with antiepileptic drugs is rarely justified in FC considering the side effects and the favourable prognosis. No treatment at all does not appear quite satisfactory either, as FC have a high recurrence rate, disrupt family life and may have emotional consequences for the family. Moreover, all FC children face a risk, although admittedly low, of subsequent long-lasting potentially central nervous system (CNS)-damaging seizures. However, 2 further options exist: treatment with rapid-acting benzodiazepines solely at times of greatest risk, i.e., at high fever or at renewed seizures. Several clinical trials have confirmed that intermittent diazepam prophylaxis by way of a few doses of the drug per year provides effective seizure control and reduces the recurrence rate by one half or two thirds. The treatment is feasible and cheap, well tolerated by the child and well accepted by the parents. Compliance problems are common and only partly abatable. Trivial side effects are frequent. Transient respiratory apnoea does occur, but 15 years' experience substantiates that serious side effects are remarkably rare. Acute anticonvulsant treatment with rectal diazepam in solution given by the parents to stop ongoing seizures and to prevent immediate recurrences is an attractive alternative. It is feasible, is probably effective and minimizes the use of drugs, but compliance problems are common and protracted seizures are not always controlled. The subsequent management should include a risk profile approach considering a combination of risk factors for new FC rather than a single factor. By means of a risk index, based on simple clinical data including age at onset, family seizure history, seizure type and frequency of fever, children may be identified as being at low, intermediate or high risk for further febrile fits. However, risk factors for new FC and not for subsequent epilepsy should be used. It is concluded that preventing or abbreviating new FC with benzodiazepines appears to be a useful, although not ideal, drug-minimizing approach in managing many children with simple or complex FC. From a health hazard viewpoint, treatment is not strictly mandatory, although advisable. A selective strategy seems rational. Intermittent diazepam prophylaxis may preferably be offered to children at high risk for new FC.(ABSTRACT TRUNCATED AT 400 WORDS)