Prophylactic Diazepam for Febrile Seizures: Not Recommended
The American Academy of Pediatrics explicitly recommends against both continuous and intermittent anticonvulsant prophylaxis, including diazepam, for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 1, 2, 3
Guideline-Based Recommendation
The evidence is unequivocal: prophylactic diazepam should not be prescribed for febrile seizures, whether simple or complex. 1, 2, 3
Why Prophylaxis Is Not Recommended
No improvement in long-term outcomes: Prophylactic diazepam does not prevent the development of epilepsy or reduce any meaningful clinical outcomes related to morbidity or mortality. 1, 3
Significant side effects outweigh benefits: Intermittent diazepam causes lethargy, drowsiness, ataxia, and irritability in 36-40% of children, and may mask evolving CNS infections. 1, 3, 4
Excellent prognosis without treatment: Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or structural brain damage, with epilepsy risk remaining at approximately 1% (identical to the general population). 2, 3
If Prophylaxis Were Considered (Against Guidelines)
Despite clear recommendations against its use, if clinicians encounter situations where prophylaxis has been prescribed or is being considered, the research literature provides the following dosing information:
Intermittent Oral Dosing During Fever
- Children <12 months: 2.5 mg twice daily during febrile illness 5
- Children 12 months to 3 years: 5 mg twice daily during febrile illness 5
- Children >3 years: 7.5 mg twice daily during febrile illness 5
Alternative dosing from clinical trials: 0.33 mg/kg orally every 8 hours during febrile episodes 4, or 0.5 mg/kg initially, then 0.20 mg/kg every 12 hours when temperature >38°C 6
Evidence Limitations
The research evidence on prophylactic diazepam efficacy is contradictory:
- One trial showed 82% reduction in seizure recurrence when medication was actually taken during fever 4
- Another trial showed recurrence reduction from 30.7% to 11.1% with prophylaxis 7
- However, two other trials showed no significant benefit 8, 6
Critical pitfall: Poor compliance is a major issue, as seizures often occur as the first manifestation of fever before parents can administer medication. 6
What Should Be Done Instead
Educate caregivers about the benign nature of simple febrile seizures and practical home management during seizures. 1, 2, 3
Treat fever for comfort only with acetaminophen or ibuprofen, understanding these do not prevent seizure recurrence. 1, 2
Consider rescue medications for prolonged seizures: rectal diazepam or buccal midazolam may be prescribed for home use if seizures last >5 minutes. 3
Reassure families that recurrence risk is approximately 30% overall (50% if first seizure before 12 months), but recurrent seizures cause no harm. 2, 3