Therapy for the cause of the fever is the main goal. A simple febrile seizure does not warrant treatment with AEDs. Information from the NIH collaborative study pointed out the lack of benefit of chronic AED use, the greater likelihood of AED-related side effects, and the good prognosis in untreated patients. If a child exhibits repetitive seizures with this or prior febrile seizures, then phenobarbital can be administered and maintained until the child improves. Chronic AED prophylaxis with phenobarbital or valproate is limited to children with (1) complex febrile seizures (prolonged or focal), (2) a preexisting neurologic deficit, e.g., cerebral palsy, (3) onset under 6 months of age, (4) repeated seizures in the same illness, (5) prior nonfebrile seizures, and (6) more than three febrile seizures in 6 months.
Rectally or orally administered diazepam has been used successfully to prevent seizures when given at the onset of a febrile illness. Usual dosage is 0.2 to 0.5 mg/kg as a single dose.
If acute treatment is warranted, the following protocol is recommended:
1. Interrupt the fever gradually with tepid baths (no alcohol) and acetaminophen or ibuprofen administration.
2. Identify the source of infection and perform a lumbar puncture if meningitis or encephalitis is suspected.
3. If indicated, administer a loading dose of phenobarbital 15 mg/kg IV, followed by 4 to 6 mg/kg/day to attain therapeutic levels of 15 to 40 pg/mL.
4. Arrange for follow-up studies with the child's family physician.
5. Admit the ill child without an easily treatable problem or one in whom recurrent seizures have occurred within several hours or 1 day.
6. Obtain an EEG when appropriate. An EEG may be helpful (if abnormal) as an indication of a convulsive disorder.
An alternative AED regime has been the administration of oral or rectal diazepam at the onset of a febrile illness prior to the onset of seizures. The Tufts University study by Rosman and colleagues4 proved diazepam efficacy in seizure prevention when oral diazepam 0.33 mg/kg was administered every 8 h during all febrile illnesses in at-risk children. Importantly, 39 percent experienced side effects such as lethargy, ataxia, and irritability.
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