AAP Practice Guideline Stresses Cause in Children With Febrile Seizure

From Medscape Education Clinical Briefs

News Author: Nancy Fowler
CME Author: Charles P. Vega, MD

February 2, 2010 — Physicians examining infants and young children after simple febrile seizure should contemplate meningitis as a possible cause of fever, according to new American Academy of Pediatrics (AAP) practice guidelines published online January 31 in Pediatrics.

"Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern," write Patricia K. Duffner, MD, of the AAP's Subcommittee on Febrile Seizures, 2002-2010, and colleagues.

Febrile seizure occurs in 2% to 5% of all children ages 6 to 60 months. It is characterized by a fever, or a body temperature of at least 100.4°F or 38°C, taken by any method, in children with no central nervous system infection. Complex febrile seizure is focal (affecting only specific parts of the body), lasts 15 minutes or longer, and/or recurs within 24 hours.

Simple febrile seizure is generalized, lasts for less than 15 minutes, and does not return within 24 hours. In 1980, the National Institutes of Health designated simple febrile seizure as a benign event, with excellent patient prognosis.

The new guidelines, which replace 1996 practice standards, pertain to patients presenting within 12 hours of simple febrile seizure. They are not intended for children who have experienced complex febrile seizure or those with prior neurologic insults, abnormalities of the central nervous system, or a history of seizures not related to fever.

Signs and symptoms of meningitis include stiff neck, Kernig's sign (lower back or posterior thigh pain during knee extension while the patient's hip is flexed and he or she is lying supine), and Brudzinski's sign (knee and hip flexion with flexed neck while in supine position). Lumbar puncture, also known as spinal tap, is used to diagnose meningitis. It involves the removal and examination of cerebrospinal fluid that surrounds the brain and spinal cord.

Updated Guidelines Stem From Comprehensive Review

Before issuing the new guidelines, AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a dearth of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.

The researchers reviewed 372 articles, 169 more than were evaluated for the 1996 guidelines. Key action statements resulting from their investigation, and all pertaining to children presenting with simple febrile seizure, are as follows:

* Children with meningeal signs, or young patients with a suggestion or history of meningitis or intracranial infection, should undergo lumbar puncture, without exception.
* Any infant between the ages of 6 and 12 months should have lumbar puncture as an option when Haemophilus influenzae type b or Streptococcus pneumoniae immunizations are not current, or are not known.
* A child who has been pretreated with antibiotics should have lumbar puncture as an option because antibiotics can mask meningitis.
* In neurologically healthy children, an electroencephalogram (EEG) should never be performed.
* In the quest to identify simple febrile seizure cause, diagnosticians should not perform the following tests: serum electrolytes, calcium, phosphorus, magnesium, or blood glucose measurements; or complete blood cell count.
* Routine evaluation of children with simple febrile seizure should not include neuroimaging.

"In general, a simple febrile seizure does not usually require further evaluation, specifically EEGs, blood studies, or neuroimaging," the authors of the guideline write.

Regarding parental input on the performance of lumbar puncture, the researchers acknowledge that the procedure is invasive, often painful, and frequently costly. However, they point out that observational data and clinical principles are the foundation of their guidelines and that in the instances that they recommend lumbar puncture, the benefits outweigh possible harm.

"Although parents may not wish to have their child undergo a lumbar puncture, health care providers should explain that if meningitis is not diagnosed and treated, it could be fatal," the guideline authors write.

The guideline authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 31, 2011. Abstract

Related Link
A previously released AAP guideline entitled Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures is available online.
Clinical Context

Febrile seizures among young children can provoke significant anxiety among parents, but they rarely result in serious health consequences for the child. The authors of the current review note that 2% to 5% of all children experience a febrile seizure, and simple febrile seizures are defined by duration less than 15 minutes and no recurrence within 24 hours.

Previous research has found that simple febrile seizures are not associated with a higher risk for mortality, hemiplegia, or mental retardation. These seizures are associated with only a modest increase in the risk for epilepsy, but approximately one third of children may experience a recurrence of febrile seizures after a simple febrile seizure.

The AAP last published guidelines regarding the evaluation of children with simple febrile seizures in 1996. The current practice parameter updates that document.