Do you give Valium (diazepam) to a child with a febrile seizure?

Diazepam Use in Febrile Seizures

Do not give prophylactic diazepam routinely to children with simple febrile seizures, but do use acute benzodiazepines (IV lorazepam preferred, or rectal diazepam if no IV access) for actively seizing children, and consider intermittent diazepam prophylaxis only for complex febrile seizures or high-risk recurrent cases.

Acute Management During Active Seizure

For a child actively having a febrile seizure, benzodiazepines are indicated for seizures lasting >5 minutes:

• Administer IV lorazepam 0.05-0.1 mg/kg (maximum 4 mg) at 2 mg/min as first-line treatment 1
• Use rectal diazepam when IV access is unavailable 2, 1
• Never use IM diazepam due to erratic absorption 2, 1
• Rectal diazepam in solution is effective in 80% of cases overall, with 96% efficacy when given early (seizures ≤15 minutes) 3

Supportive care during seizure:

• Position the child on their side and protect the head from injury 1
• Never restrain the child or place anything in the mouth 2, 1
• Assess airway, breathing, and circulation immediately 1

Long-Term Prophylaxis: The Evidence is Clear

The American Academy of Pediatrics explicitly recommends against both continuous and intermittent anticonvulsant prophylaxis for simple febrile seizures 2, 4, 1. This recommendation is based on:

• The harm-benefit analysis clearly favors no treatment 2
• Potential harms include valproic acid's rare fatal hepatotoxicity, phenobarbital's hyperactivity and irritability, and intermittent diazepam's lethargy (occurring in 39% of children) and risk of masking evolving CNS infection 2
• Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, or neurocognitive function 1

When to Consider Intermittent Diazepam Prophylaxis

For complex febrile seizures (prolonged >15 minutes, focal, or multiple within 24 hours), WHO guidelines suggest intermittent diazepam during febrile illness may be considered 2. This is the only scenario where prophylaxis has any role:

• Oral diazepam given during fever reduces recurrence risk by 44% overall, and 82% when actually taken during febrile episodes 5
• Dosing: 0.33 mg/kg every 8 hours on day 1 of fever >38.5°C, then every 12 hours on day 2 5, 6
• High-risk patients (age <15 months at first seizure, positive family history, complex features, frequent febrile illnesses) show 83% recurrence without prophylaxis versus 38% reduction with diazepam 6
• Side effects (ataxia, lethargy, irritability) occur in 39% but are reversible with dose reduction 5

Critical Pitfalls to Avoid

• Never prescribe prophylactic anticonvulsants for simple febrile seizures—the AAP guideline is unequivocal that risks outweigh benefits 2
• Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they improve comfort 2, 1
• Do not delay antibiotics for diagnostic procedures when bacterial meningitis is suspected (fever with non-blanching rash, altered consciousness) 4
• Consider lumbar puncture in children <18 months with febrile seizures, especially with meningeal signs, after complex seizures, or if systemically ill 1

Home Management Alternative

An attractive alternative to prophylaxis is parent-administered rectal diazepam at seizure onset to prevent febrile status epilepticus 7. This approach:

• Provides short-term seizure control without continuous medication exposure
• Empowers parents with immediate intervention capability
• Avoids daily medication side effects while addressing the primary concern of prolonged seizures