I have read this paper from Israel carefully, and I am not at all happy with either the methods
or the conclusion for several reasons.
1. There is an assumption that any child who is still fitting on admission must have been
fitting for 10 minutes for geographical reasons.
2. Only 3 children from their cohort (47, I think) were excluded as they had stopped fitting by
the time treatment was contemplated.
3. There is no mention of the standard treatment for febrile convulsions which is to reduce the
core temperature.
4. The midazolam stopped the fitting later than the diazepam (hopefully emulsion) did.
5. Intranasal midazolam needs to be compared with intramuscular midazolam or rectal diazepam
as both are preferable treatments to intravenous diazepam - for many of the reasons Lahet et al
give.
I am analysing a convenience sample of the last 50 or so children who presented over the last
6 months to our A&E with an diagnosis on leaving A&E of febrile convulsion. Only 4 were
still fitting on admission, and this suggests that the total number of children being dealt with
by the Israeli group must be astronomical. If 4 out of a total attendance in that period (6
months) of approximately 3,600 children were fitting and Lahet gathered his in a year it
suggests that either he sees approximately 72,000 children annually or there is something very
strange about either his patient population or mine. Furthermore, the group still fitting in my
sample were much older than the mean (sorry, figures still being worked on but it is
screamingly obvious) and I suspect 2 at least would have a different final diagnosis as they
were both already taking epilim.
I do not see the point of this paper. It does not advance our knowledge on the
pharmacodynamics of the agent, and as Ray McGlone points out, the technique has already
been described. I am not convinced that it is the treatment of choice, with the options I have
described above already preferable. I am concerned that the patient population seems
inexplicably atypical, and I would like some assurance on the assumptions made. I distinguish
this from Ray's work which is useful, and his published work honestly shows that ketamine is
probably preferable.
What is the general view?
Best wishes,
Rowley Cottingham
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