Are benzodiazepines (benzos) used to treat febrile seizures?

Benzodiazepines for Febrile Seizures

Benzodiazepines are not recommended for routine treatment of simple febrile seizures, as the potential toxicities associated with these medications outweigh the relatively minor risks of febrile seizures. 1

Understanding Febrile Seizures

Febrile seizures are benign events occurring in approximately 4% of children between 6 and 60 months of age. They have an excellent prognosis with normal neurological, motor, intellectual, and cognitive long-term outcomes and carry a low risk (2-4%) of later epilepsy development 2.

Types of Febrile Seizures:

• Simple febrile seizures: Brief (less than 15 minutes), generalized, and occur once during a febrile illness
• Complex febrile seizures: Prolonged (>15 minutes), focal, or recurrent within 24 hours

Evidence-Based Management Approach

Acute Management

• For ongoing febrile seizures (especially if prolonged or status epilepticus):
  • Benzodiazepines may be used for immediate termination of the seizure
  • IV lorazepam or diazepam is preferred when IV access is available 3
  • When IV access is unavailable, rectal diazepam (0.5mg/kg up to 20mg) is recommended 3
  • Newer alternatives include buccal or nasal midazolam 4

Prophylactic Treatment

• Antipyretics alone (acetaminophen, ibuprofen): Ineffective in preventing febrile seizure recurrence 1
• Daily anticonvulsant therapy: Not recommended due to potential toxicities outweighing the benign nature of febrile seizures 1
• Intermittent oral diazepam during febrile illness:
  • Not very successful and has significant side effects
  • Number needed to treat to prevent one recurrence is 14 2
  • May be considered only in highly selected cases with:
    • Multiple recurrent febrile seizures
    • Complex febrile seizures (especially focal or prolonged)
    • History of febrile status epilepticus
    • Severe parental anxiety 5

Rescue Medication Approach

• Rescue benzodiazepines (rectal diazepam solution or buccal/nasal midazolam) may be considered for:
  • Children with history of prolonged febrile seizures
  • Poor access to medical care 2
  • This approach allows parents to administer medication at seizure onset to prevent prolonged recurrences 6

Important Considerations

Benzodiazepine Administration

• IV administration should be done slowly (over 1-2 minutes) to avoid respiratory depression 3
• Respiratory monitoring is crucial during benzodiazepine administration
• Risk of respiratory depression increases when combined with other sedative agents 3

Potential Side Effects

• Sedation and cognitive impairment
• Paradoxical excitation (reported in 10-30% of pediatric patients under 8 years) 7
• Respiratory depression
• Tolerance with prolonged use 8

Key Pitfalls to Avoid

1. Overtreatment of simple febrile seizures with daily anticonvulsants
2. Failure to recognize and promptly treat prolonged seizures
3. Inadequate parental education about the benign nature of febrile seizures
4. Excessive focus on preventing recurrence rather than preventing complications

Conclusion

While benzodiazepines play a critical role in terminating ongoing febrile seizures (especially prolonged ones), they are not indicated for routine prophylaxis of simple febrile seizures. A selective approach focusing on rescue medication for high-risk cases is more appropriate than widespread prophylactic use.