Simple Febrile Seizures:

Perform a Lumbar Puncture?

Amy Lange, M.D. EBM Morning Report

Case Presentation
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2 year old male Fevers x 1 day

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Tmax at home 101-102

At dinner whole body went stiff and eyes rolled back in his head
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Some arm and leg jerking

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Episode lasted about 5 minutes Tmax on arrival to ED: 105

Febrile Seizures
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6 months to 6 years
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Majority in children 12-18 months

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2 4 % of children < 5 years old Commonly seen as temperature rapidly rising

Criteria for Febrile Seizure

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Temperature greater than 38 C Age 6 months to 6 years No CNS infection or inflammation No systemic metabolic abnormality One seizure in 24 hour period No history previous afebrile seizure

Febrile Seizures
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Simple:
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Less than 15 minutes Generalized (no focal features) Not recurring within 24 hours More than 15 minutes Focal features Post-ictal paresis

Complex:
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Management Controversies
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EEG? Blood-work? Treatment? Imaging? Fever Control/Genetic Cause? LP?

Current AAP Guidelines

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Based on SIMPLE febrile seizures Performed medical journal reviews Strongly consider LP for 6mo 12mo Consider LP for 12mo 18mo > than 18 months: not routinely warrented

Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. (1996). Practice Parameter: The Neurodiagnostic

Why These Guidelines?

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Concern for occult meningitis in children presenting solely as febrile seizure Conclusions:
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Less than 18 months less often exhibit clinical signs of meningitis Varying degree of skills of physicians

Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. (1996). Practice Parameter: The Neurodiagnostic

AAP Guidelines Evidence To Support

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Simple febrile seizure cases over 2 year period at Nottingham Childrens Hospital Hospital protocol perform LP on all children presenting with first febrile seizure Ages: 3 months to 6 years, mean 23.5 months Total Cases: 328
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314 successfully had LP performed

Rutter, N. and Smales, O.R.C. (1977). Role of Routine Investigations in Children Presenting With Their First Febrile Convulsion. Archives of

AAP Guidelines Evidence To Support

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Findings:
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310 of 314 cases the CSF was normal 4 cases of meningitis diagnosed by CSF studies and who did not have physical signs suggesting meningitis
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Ages: 8, 12, 14, 15 months 2 unknown viral, 1 mumps, 1 Haemophilus influenzae

Conclusions:
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Routine LP on all children under 18 months with first simple febrile seizure
Rutter, N. and Smales, O.R.C. (1977). Role of Routine Investigations in Children Presenting With Their First Febrile Convulsion. Archives of

Are Physicians Following Guidelines?

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Survey: 73% pediatric and 56% EM residency directors teach LP guidelines for febrile seizures Retrospective Study: 1029 children presenting with simple febrile seizure
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Median age: 21 months

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LP rate: 8.4% in patients 6-18 months, 3.3% in patients over 18 months CT scan rate: 11%
Hampers, L.C., et al. (2006). Febrile Seizure: Measuring Adherence to AAP Guidelines Among Community ED Physicians. Pediatric

Meningitis: Febrile Seizure as Sole Manifestation?

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Retrospective Study 503 cases of meningitis

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Age range: 2 months to 15 years with mean age of 24 months

Green, S.M., et al. (1993). Can Seizures Be the Sole Manifestation of Meningitis in Febrile Children? Pediatrics. 92(4), 527-534.

Total Cases of Bacterial Meningitis (486)

Seizures only after Hospital admit (61)

Presented with Seizures (111)

No Seizures (314)

LOC Obtunded (75)

LOC Relatively Normal (8)

LOC Comatose (28)

Reason to Suspect Meningitis?

Green, S.M., et al. (1993). Can Seizures Be the Sole Manifestation of Meningitis in Febrile Children? Pediatrics. 92(4), 527-534.

Nuchal Rigidity (6) Prolonged Focal Seizure (1) Multiple Seizures, Rash (1) No reason (0)

Meningitis: Febrile Seizure as Sole Manifestation?

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Conclusions:
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No cases of occult bacterial meningitis manifested solely as seizure 93% were obtunded or comatose 79% had complex seizures including 7 of the 8 with relatively normal LOC. 59% had more than one episode seizure 5 of the 8 with relatively normal LOC had been treated with an oral antibiotic

Viral meningitis cases missed?

Green, S.M., et al. (1993). Can Seizures Be the Sole Manifestation of Meningitis in Febrile Children? Pediatrics. 92(4), 527-534.

Re-consider AAP Guidelines?

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Retrospective Study Children ages 6-18 months with simple febrile seizures who had LP performed
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260 total cases

CSF pleocytosis (WBC > 7) in 10 of the 260 cases No pathogen detected in any CSF culture

Kimia, A.A., et al. (2009). Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 Months of Age.

Re-Consider AAP Guidelines? Considerations

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Occurrence of bacterial meningitis is rare Studies reviewed had limited patients in the high risk age group (6-12 months) Is it worth it to risk missing potential fatal diagnosis?

Reasons to Perform LP
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Less than 6 months of age Suspicious findings on physical or neurological exam Prolonged post-ictal states Physician visit within 48 hours prior to seizure Complex febrile seizure

References
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Green, S.M., et al. (1993). Can Seizures Be the Sole Manifestation of Meningitis in Febrile Children? Pediatrics. 92(4), 527-534. Hampers, L.C., et al. (2006). Febrile Seizure: Measuring Adherence to AAP Guidelines Among Community ED Physicians. Pediatric Emergency Care. 22(7), 465-469. Kimia, A.A., et al. (2009). Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 Months of Age. Pediatrics. 123(1), 6-12. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. (1996). Practice Parameter: The Neurodiagnostic Evaluaton of the Child With a First Simple Febrile Seizure. Pediatrics. 97(5). 769-772. Rutter, N. and Smales, O.R.C. (1977). Role of Routine Investigations in Children Presenting With Their First Febrile Convulsion. Archives of Disease in Childhood. 52, 188-191.