EVIDENCE-BASED NURSING

I. CLINICAL QUESTION:

Among paediatric clients, is an anti-pyretic drug more preferable than a continuous anti-
epileptic drug in treatment for febrile seizures?

II. CITATION:

Evidence-Based Management of seizure associated with fever. (Offringa, M & Moyer, V.)

III. STUDY CHARACTERISTICS:

a) Patients Included (population and sample)

406 children patients with a mean age with the age of 24 months who had at least one
febrile seizure.

b) Interventions compared

To determine whether prophylactic treatment with an antiepileptic drug or an antipyretic as

compared with no treatment decreases the likelihood of future febrile seizures, you are
looking for studies in which patients with febrile seizures were randomized to different
treatment regimens and followed over time to see how many developed subsequent febrile
seizures.

Anti-pyretic drugs are drugs that reduce fever. They will not normally lower body
temperature if one does not have a fever. Antipyretics cause the hypothalamus to override
an interleukin-induced increase in temperature. The body will then work to lower the
temperature and the result is a reduction in fever e.g. Ibuprofen.
The anticonvulsants/ anti-epileptic drugs (AED’s) are a diverse group of pharmaceuticals
used in the treatment of epileptic seizures. Anticonvulsants are also increasingly being used
in the treatment of bipolar disorder, since many seem to act as mood stabilizers. The goal of
an anticonvulsant is to suppress the rapid and excessive firing of neurons that start a
seizure e.g. Diazepam.

c) Outcomes monitored

To avoid the adverse effects of giving antiepileptic drugs for prolonged periods, rapidly
acting anticonvulsants given only during fever periods have been used in an attempt to
reduce the risk of recurrent febrile seizures. Phenobarbitone given at times of fever has
been proved ineffective, probably because of the delay in achieving appropriate serum and
tissue concentrations. Thus far, only prophylactic diazepam, given orally or rectally, has
been studied in placebo controlled trials. To assess whether antipyretic drugs given
intermittently prevent recurrence of febrile seizures, a randomized placebo controlled trial
was conducted in the Netherlands

d) Does the study focus on a significant problem in clinical practice?

The study didn’t focus on the significant problem for clinical practice because the research
we had gathered encompasses a lot of researches that they barely able to conduct a
thorough study in each one i.e. the relation to meningitis of febrile seizure, can physical
examination determine solely the diagnosis of the disease, and the possible occurrences of
febrile seizures in a certain population.

IV. METHODOLOGY/ DESIGN:

a) Methodology used:

The methodology used is meta-analyses of randomized clinical trials and also other reports
of randomized clinical trials conducted outside of the study which is connected to the
research being studied.
 b) Design:

The design used in conducting the research is a quantitative study with a randomized,
double blind, placebo controlled trial

c) Setting:

Emma Children's Hospital, Academic Medical Center, University of

Amsterdam, 1105 AZ Amsterdam, Netherlands

Department of Pediatrics, University of Texas, Houston Health Science Center,

Houston, Texas, 77030, USA

d) Data Sources:

PubMed: Clinical queries®therapy®sensitivity “seizures and fever and recurrence”

Medline (PubMed: www.ncbi.nih.gov/entrez/ static/clinical.html): Clinical

queries®aetiology® sensitivity: “fever and seizures and meningitis”

e) Subject Selection:

a. Inclusion Criteria:

1. Children 1 month – 13 yrs. old.

2. Have a history of at least one (1) febrile seizure

b. Exclusion Criteria:

1. Have a history of bacterial meningitis.

2. Children 14 – 18 yrs. old.

f) Has the original study been replicated?

The original study has been replicated, as I have said earlier, this study is a compilation of
all the meta-analyses of randomized clinical trials.

g) What were the benefits of the nursing intervention tested in the

study?

This will depend on the values they place on different out comes such as risk of a
subsequent seizure and the adverse effects of use of anticonvulsants. You counsel these
parents that the risk of recurrence declines rap idly after six months from the previous
seizure and instruct them to position the child for optimal airway patency in case of a new
seizure, which is especially important in the event of vomiting.

V. RESULTS OF THE STUDY:

Diazepam - Rosman et al conducted a randomized, double blind, placebo controlled trial

among 406 children with a mean age of 24 months who had had at least one febrile seizure,
comparing diazepam (0.33 mg per kg body weight), given orally every eight hours during
febrile illnesses, with placebo. 11 During a mean follow up of two years, the relative risk of
subsequent febrile seizures per person year was 0.56 (0.38 to 0.81). Many parents did not
give the treatment as directed, and an analysis restricted to children who had seizures while
definitely receiving the study drug showed an 82% reduction in the risk of febrile seizures
with diazepam. Between 25% and 30% of the children in the study by Rosman were irritable,
lethargic, or ataxic after taking diazepam, which might interfere with parents' and clinicians'
ability to distinguish benign childhood febrile illness from more serious disease; one in every
3.54 children taking diazepam develops these symptoms (number needed to harm= 3.54).
The decision to recommend this treatment will depend on balancing these potential harms
against the potential benefits to each specific child, and on the family's values.

Ibuprofen - To assess whether antipyretic drugs given intermittently prevent recurrence of

febrile seizures, a randomized placebo controlled trial was conducted in the Netherlands. 12
Children aged 1 to 4 years who had at least one risk factor for recurrence of a febrile seizure
(see below) were randomly assigned to receive either ibuprofen syrup, 5 mg per kg body
weight per dose, or placebo every six hours during fever, defined as a temperature >
38.4°C. Median follow up time was 12 months. The relative risks for recurrence in the two
groups did not differ significantly.
 VI. AUTHOR’S CONCLUSION/ RECOMMENDATION:

a) What contribution to the client health status does the nursing

action/intervention make?

The health care team should decide with the patient and his/her support system that the
evidence does not support using a daily anticonvulsant like phenobarbitone or sodium
valproate, and that intermittent diazepam or an antipyretic agent during fever are not
effective in pre venting recurrence of seizures. Both parties know that the patient with
febrile seizure will need to spend time with the parents to help them overcome the fears and
anxiety that seizures provoke and to educate them about the clinical course of febrile
seizures and their consequences. (Offringa, M & Moyer, V.)

b) What overall contribution to nursing knowledge does the study

make?

This will depend on the values they place on different outcomes such as risk of a subsequent
seizure and the adverse effects of use of anticonvulsants. You counsel these parents that
the risk of recurrence declines rapidly after six months from the previous seizure and
instruct them to position the child for optimal airway patency in case of a new seizure, which
is especially important in the event of vomiting. A prescription for rectal diazepam should
also be given, and the parents should be instructed how to administer it in the rare event of
a prolonged recurrence lasting > 15 minutes.17 18 This approach, it has been suggested,
also reduces parental fear.

VII. APPLICABILITY:

a) Does the study provide a direct enough answer to your clinical

question in terms of type of patients, interventions and outcomes?

The study does not provide a direct answer to the clinical question being asked, in terms of
interventions and outcomes, but the patients included are in the same terms.
 b) Is it feasible to carry out the nursing action in the real world?

The study conducted above is not yet feasible enough to be carried out as a nursing action
due to the fact that it doesn’t directly answer the clinical question being asked.

VIII. REVIEWER’S CONCLUSION/ COMMENTARY:

The research above is good in terms of generability but is not good enough and needs more
research to be applicable to nursing action and application in the real world and not feasible
to be carried out in the nurse and patient setting. The research conducted was only based
on meta-analyses of randomized clinical trials which are only the compilation of researches
with conducted clinical trials in different settings that come up a study.