Should a child who presented with a simple febrile seizure, initially managed with midazolam and phenobarbital (phenobarb), continue phenobarbital therapy after being referred to our hospital?

Discontinue Phenobarbital Immediately

Phenobarbital should be discontinued in this child with a simple febrile seizure, as the American Academy of Pediatrics explicitly recommends against continuous anticonvulsant prophylaxis for simple febrile seizures—the potential toxicities clearly outweigh the minimal risks. 1

Why Phenobarbital Was Inappropriately Started

• Simple febrile seizures have an excellent prognosis with no long-term adverse effects on neurocognitive function, and the risk of developing epilepsy remains approximately 1% (identical to the general population). 1
• Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for children with simple febrile seizures, based on high-quality evidence from randomized controlled trials. 1, 2
• The harm-benefit analysis clearly favors no treatment—prophylactic anticonvulsants do not prevent epilepsy development and do not improve long-term outcomes. 1

Significant Risks of Continuing Phenobarbital

Behavioral adverse effects occur in 20-42% of children taking phenobarbital, including:

• Hyperactivity, irritability, lethargy, and sleep disturbances 1, 3
• These behavioral problems typically appear within several months and may necessitate premature discontinuation in up to 20% of treated children 3

Cognitive impairment is a critical concern:

• Mean IQ reduction of 7 points during phenobarbital treatment 1, 4
• Cognitive effects persist with IQ remaining 5.2 points lower even 6 months after discontinuation 1, 4
• This cognitive disadvantage is not offset by any seizure prevention benefit 4

Additional serious risks include:

• Hypersensitivity reactions with fever, rash, lymphadenopathy, and potentially life-threatening thrombocytopenia 1, 5
• These adverse effects occur despite phenobarbital's effectiveness in reducing seizure recurrence from 25 to 5 per 100 subjects per year—the benefit simply does not justify the risks 1

Clinical Approach to Discontinuation

Taper and discontinue phenobarbital as it was inappropriately initiated for a simple febrile seizure. 1

• Recurrent simple febrile seizures cause no harm and do not warrant prophylactic treatment. 1
• Even if this child experiences recurrent febrile seizures (30-50% probability depending on age at first seizure), there is no evidence of structural brain damage, decline in IQ, or adverse neurocognitive outcomes. 1, 2

Parent Education and Reassurance

Educate caregivers about:

• The benign nature of simple febrile seizures with excellent prognosis 1, 2
• Recurrence risk (approximately 30% overall, higher in children younger than 12 months) 2
• Practical home management: position child on side, protect head, remove harmful objects, never restrain or place anything in mouth 1, 2
• When to seek emergency care: seizures lasting >5 minutes, multiple seizures without return to baseline, breathing difficulties 2
• Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they may improve comfort during febrile illness 1, 2

Common Pitfall to Avoid

The most critical error would be continuing phenobarbital based on concern about seizure recurrence. The American Academy of Pediatrics guideline is unequivocal: do not prescribe prophylactic anticonvulsants for simple febrile seizures, as the risks outweigh benefits. 2