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50 Years Ago in The Journal of Pediatrics

A Critical Evaluation of Therapy of Febrile Seizures
      Millichap JB, Aledort LM, Madsen JA. J Pediatr 1960;56:364-8
      In the 1950s after a febrile seizure, initiation and continuation of phenobarbital was the norm, although a minority of neurologists hypothesized that anticonvulsant therapy was indicated only at the time of febrile illness. In a landmark paper 50 years ago in The Journal, Millichap et al showed that “continued administration of anticonvulsant drugs is unwarranted in the prophylactic treatment of seizures which occur only in association with fever.” Instead they recommended phenobarbital in “relatively large doses” at the onset of fever, in conjunction with antipyretic therapy.
      In their small, under-powered study of children with febrile seizures who entered the emergency department at Bronx Municipal Hospital between 1956 and 1958 and were treated with “sponging with tepid water, aspirin, and phenobarbital,” no difference was later found between children who received phenobarbital dosed at the time of each fever or children who were continuously treated thereafter. Was this a type II, false-negative, or better yet, did anyone require any treatment?
      Today, we know there is “evidence that both continuous antiepileptic therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with oral diazepam are effective in reducing the risk of recurrence, (but) the potential toxicities associated with antiepileptic medications outweigh the relatively minor risks associated with simple febrile seizures.”
      Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures
      Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures.
      These medications have no effect on long-term outcome. Even sponge baths and antipyretic medications do not make a difference!
      Fifty years ago, it must have been difficult for pediatricians to tell parents that no continuous medication was indicated, particularly in the face of an event as dramatic and terrifying as seizure. In the current era, with so many new antiepileptic medications, it is perhaps even more important to remember primum no nocere. We are reminded of advice from 20 years ago: “Perhaps we should learn to ‘just say no’ to drugs for febrile seizures. Counseling may be our best therapy.”
      • Freeman J.M.
      Just say no! Drugs and febrile seizures.

      References

        • Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures
        Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures.
        Pediatrics. 2008; 121: 1281-1286
        • Freeman J.M.
        Just say no! Drugs and febrile seizures.
        Pediatrics. 1990; 84: 624