Use of Ibuprofen to Prevent Recurrence of Febrile Seizures
ABSTRACT & COMMENTARY
Source: van Stuijvenberg M, et al. Randomized controlled trial of ibuprofen syrup administered during febrile illnesses to prevent febrile seizure recurrences. Pediatrics 1998;102:e51.
Investigators from two institutions in the Netherlands conducted what they claim is the first randomized, placebo-controlled trial to assess the efficacy of antipyretic treatment in the prevention of febrile seizure recurrence. In their double-blind study, van Stuijvenberg and colleagues enrolled patients presenting to the study centers for evaluation following a febrile seizure. Inclusion criteria were febrile seizure within the preceding six months, age between 1 and 4 years, and presence of one or more risk factors for febrile seizure recurrence (positive family history, initial complex febrile seizure, temperature < 40.0°C at initial febrile seizure, and previous febrile seizure recurrences). Patients were excluded if they had previous non-febrile seizures, allergy to ibuprofen, or were currently taking antiepileptic drugs.
The centers enrolled 230 patients into the study. Ibuprofen (5 mg/kg/dose) was to be administered to 111 of the subjects every six hours whenever they developed a rectal temperature greater than or equal to 38.5°C. The remaining 119 participants received placebo. Over the course of follow-up (median of approximately 1 year for each patient), 67 patients had a recurrent febrile seizure (31 in the ibuprofen group and 36 in the placebo group). The two-year estimated risk of recurrence was 32% for ibuprofen and 39% for placebo, with a relative risk for the ibuprofen group of 0.9 times the placebo group. This difference was not statistically significant at a power of 80%. van Stuijvenberg et al conclude that ibuprofen administration during febrile illness does not prevent recurrence of febrile seizures.
Comment by Elliott M. Harris, MD
Febrile seizures are a common reason for children to present to the emergency department (ED). They are defined as convulsions that occur in association with a febrile illness in the absence of intracranial infection or other central nervous system pathology and without history of previous afebrile seizures. Simple febrile seizures are generalized tonic-clonic convulsions that last less than 15 minutes and do not recur during the first 24 hours of the febrile illness. If a febrile seizure does not meet these criteria, it is classified as complex. Approximately 4% of children will develop at least one febrile seizure during their lives, with almost all occurring between the ages of 6 months and 6 years. Approximately one-third of patients will have at least one recurrent febrile seizure, but only a small percentage will develop epilepsy.1
Since most febrile seizures are self-limited and have usually resolved prior to arrival in the ED, the main question of management revolves around prevention of recurrence. Use of prophylactic anticonvulsants is no longer routinely recommended due to concerns about side effects and unproven efficacy.2 Likewise, intermittent use of diazepam during febrile illness has not proven to be of benefit, except possibly for children at high-risk of recurrence.3
It is common practice to use antipyretics around the clock for 24 hours following the febrile seizure to try to prevent recurrence. Although this study does not specifically address the use of antipyretics immediately following a febrile seizure, it is an attempt to determine whether they might be useful in preventing later recurrences during subsequent episodes of fever. One potential flaw in this study is the use of a lower dose of ibuprofen than is commonly used in the United States (7.5-10 mg/kg/dose). van Stuijvenberg et al were not able to prove that antipyretics prevent febrile seizure recurrence. Despite the lack of evidence for preventing recurrence, antipyretics should still be used in these patients to make them more comfortable during the febrile illness. Careful counseling of parents and arrangement for appropriate follow-up remain the most important interventions that can be made by the emergency physician. (Dr. Harris is an Attending in the Pediatric Emergency Department at Temple University Children’s Medical Center in Philadelphia.)
References
1. Gonzalez Del Rey JA. Febrile Seizures. In: Barkin RN, ed. Pediatric Emergency Medicine: Concepts and Clinical Practice, 2nd ed. St. Louis, MO: Mosby; 1997.
2. Camfield PR, Camfield CS. Management and treatment of febrile seizures. Curr Prob Pediatr 1997;27: 6-13.
3. Rosman NP, 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.
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