Practice Parameter: The Neurodiagnostic Evaluation of the Child With a First Simple Febrile Seizure Pediatrics 1996;97;769

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1996 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Practice

Parameter

The First

Neurodiagnostic Simple
on Quality

Evaluation Seizure
Subcommittee on

of

the

Child

With

Febrile
Improvement,

Provisional

Committee

Febrile

Seizures

its Provisional collaboration ogy, general

radiographs, computed tomograAcademy of Pediatrics and 4. Neuroimaging-skull Quality Improvement, in phy (CT), and magnetic resonance imaging. with experts fromthe Section on Neurolpediatricians, consultants in the fields of BACKGROUND neurology and epilepsy, and research methodologists, A febrile seizure is broadly defined as a seizure developed this practice parameter. This parameter proby fever without central nervous sysvides recommendations for the neurodiagnostic evalua- accompanied tem infection, occurring in infants and children betion of a child with a first simple febrile seizure. These 6 months and 5 years of age. Febrile seizures recommendations derive fromboth a thorough review of tween in 2% to 5% of all children and, as such, make the literature and expert consensus. Interventions of di-occur rect interest include lumbar puncture, electroencephalogup the most common convulsive event in children raphy, blood studies, and neuroimaging. The methods younger than 5 years of age. In 1976, Nelson and and results of the literature review and data analyses can Ellenberg, using data from the National Collaborabe found in the technical report that is available from thetive Perinatal Project, further defined febrile seizures
ABSTRACT. The American
Committee

on

Publications
Pediatrics.

of as being either simple or complex. Simple febrile seizures were defined as primary generalized seiclans by providing an analytic framework for the evaluzures lasting less than 15 minutes and not recurring ation and treatment of this condition. It is not intended to within 24 hours. Complex febrile seizures were dereplace clinical judgment or establish a protocol allfor as focal, prolonged (>15 minutes), and/or ocpatients with this condition. It rarely will be the onlyfined appropriate approach to the problem. curring in a flurry. Those children who had simple This
febrile DEFINITION OF THE PROBLEM seizures had no evidence of increased mortal-

Department parameter

of the American Academy is designed to assist pediatri-

1/

mental retardation. During folThis practice parameter provides recommendathe risk of epilepsy after a simple tions for the neurodiagnostic evaluation of neurologfebrile seizure was shown to be only slightly higher ically healthy infants and children between 6 months than that of the general population, whereas the chief risk associated with simple febrile seizures was reand 5 years of age who have had their first simple febrile seizures and present within 12 hours of the currence in one third of the children. The report that simple febrile seizures are benign event. This practice parameter is not intended for concluded patients who have had complex febrile seizures (pro- events with excellent prognoses, a conclusion reaflonged, focal, and/or recurrent), nor does it pertain firmed in the 1980 National Institutes of Health Conto those children with previous neurologic insults, sensus Statement.2 known central nervous system abnormalities, or hisDespite progress in understanding febrile seizures and the development of consensus statements about tories of afebrile seizures. their diagnostic evaluation and management, a reTARGET AUDIENCE AND PRACTICE SETFING view of practice patterns of pediatricians indicates that a wide variation persists in physician interpreThis practice parameter is intended for use by tation, evaluation, and treatment of children with pediatricians, family physicians, child neurologists, seizures.3 neurologists, emergency physicians, and other pro- febrile viders who treat children for febrile seizures. This parameter is not intended for the evaluation of patients who have had complex febrile seizures, INTERVENTIONS OF DIRECT INTEREST previous neurologic insults, known or brain abnormalities. The parameter also does not address treat1 Lumbar puncture; ment. 2. Electroencephalography (EEG); The expected outcomes of this practice parameter 3. Blood studies-serum electrolytes, calcium, phosphothe following. rus, magnesium, and blood glucose, and a complete include blood count (CBC); and 1. Optimizing practitioner understanding of the scientific basis for the neurodiagnostic evaluation of children with simple febrile seizures; The recommendations in this statement do not indicate an exclusive course 2. Using a structured framework to aid the practitioof treatment or serve as a standard of medical care. Variations, taking into ner in decision making; account individual circumstances, may be appropriate. 3. Optimizing evaluation of the child who has had a PEDIATRICS (ISSN 0031 4005). Copyright 1996 by the American Academy of Pediatrics. simple febrile seizure by ensuring that underlying
.

ity, hemiplegia, low-up evaluation,

or

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5 May

1996

769

diseases such as meningitis are detected, minimizing morbidity, and enabling the practitioner reassure the anxious parents and child; and 4. Reducing costs of physician and emergency department visits, hospitalizations, and unnecessary testing.
METHODOLOGY

febrile seizures. In approximately 13% to 16% of to children with meningitis, seizures are the presenting sign of disease, and in approximately 30% to 35% of these children (primarily children younger than 18 months), meningeal signs and symptoms may be
lacking.4 brospinal On the basis of published fluid is more likely to be evidence, cere-

dren initially seen Two hundred three medical journal articles ad-had: (1) suspicious dressing the diagnosis and evaluation of febrile rologic examinations (particularly meningeal signs); seizures were identified. Each article was subjected (2) complex febrile seizures; (3) physician visits to formal, semistructured review by committee within 48 hours before the seizures; (4) seizures on members. These completed reviews, as well as thearrival to emergency departments; (5) prolonged original articles, were then reexamined by epide- postictal states (typically most children with simple miologic consultants to identify those populationfebnile seizures recover quickly); and initial (6) seibased studies limited to children with simple fezures after 3 years of age.67 An increased risk of brie seizures that examined the usefulness of failure to diagnose meningitis occurs in children: (1) specific diagnostic studies. Given the scarcity of younger than 18 months who may show no signs such studies, data from hospital-based studies and and symptoms of meningitis; (2) who are evaluated comparable groups were also reviewed. Tables by a less-experienced health care provider; or (3) were constructed using data from 28 articles. A who may be unavailable for follow-up.8 A recogsecond literature search failed to disclose pertinent nized source of fever, eg, otitis media, does not exarticles containing data on brain imaging in chil-dude the presence of meningitis. All recommendadren with febrile seizures. tions, induding those for lumbar puncture, are also A summary of the technical report describing thegiven in the Algorithm. analyses used to prepare this parameter begins on page 773. EEG
RECOMMENDATIONS Lumbar

abnormal in cM!with fevers and seizures who have findings on physical and/or neu-

Puncture The American Academy (AAP) recommends, on the basis evidence and consensus, that after with fever in infants younger performance of a lumbar of Pedi-

Recommendation.

Recommendation. the published not be performed cally healthy

seizure.

The AAP recommends, based on evidence and consensus, that EEC in the evaluation of a neurologichild with a first simple febrile

atrics lished seizures months,

of

the pubthe first

than 12 puncture

strongly symptoms

Although the incidence of abnormal EEGs increases with meningitis may be mmimal or absent in this age group. In a child between over time after asimple febnile seizure, no evidence 12 and 18 months of age, a lumbar puncture should exists that abnormal EEGs after the first febrile seibe considered, because clinical signs and symp- zure are predictive for either the risk of recurrence of toms of meningitis may be subtle. In a child older febrile seizures or the development of epilepsy. Even studies that have included children with complex than 18 months, although lumbar a puncture is not routinely warranted, isit recommended in the presfebrile seizures and/or those with preexisting neurologic disease (a group at higher risk of having ence of meningeal signs and symptoms (ie, neck stiffness and Kernig andBrudzinski signs), which epilepsy develop) have not shown EEC to be predicare usually present with menIngitis, or for any child tive of the development of epilepsy.9#{176} whose history or examination result suggests the Blood Studies presence of intracranial infection. In infants and cliiiRecommendation. On the basis of published evichen who have had febrile seizures and have received prior antibiotic treatment, clinicians should e aware b dence,7A1 the AAP recommends that the followmg that treatment can mask the signs and symptoms of determinations not be performed routinely in the evaluation of a child with a first simple febrile meningitis. As such, a lumbar puncture should be seizure: serum electrolytes, calcium, phosphorus, strongly considered. The clinical evaluation of young febrile children magnesium, CBC, or blood glucose. requires skills that vary among examiners. MoreThere is no evidence to suggest that routine blood studies are of benefit in the evaluation of the child with over, published data do not address the quantification of such skills adequately. Because thispractice a first febrile seizure. Although some children initially seen with febrile seizures are dehydrated and have parameter is for practitioners with a wide range of serum electrolyte values, their conditions training and experience, the committee chose a con- abnormal be identifiable by obtaining appropriate histoservative approach with an emphasis on the value of should

considered, associated

because

the

clinical

signs

No published study demonstrates that EEC performed either at the time of presentation after a be simple febrile seizure or within the following month and will predict the occurrence of futureafebnile seizures.

lumbar puncture The committee regarding the

children younger

in diagnosing recognizes the need for routine

than 18 to

meningitis. diversity lumbar

24 months

of opinion puncture
with

ries and performing careful blood glucose determination, needed, should be obtained in first period of postictal obtundation.

physical examinations. A although not routinely if the child has a prolonged CBCs may be useful in

770

PRACTICE

PARAMETER Downloaded from pediatrics.aappublications.org by guest on May 18, 2011

the

evaluation

of

fever,

particularly

in younghildren, c

because younger seizures

the incidence ofacteremia b in children than 2years of age with or without febrile is the same.12 When fever is present, the decision regarding the need for laboratory testing should be directed toward identifying the source of the fever rather than as part of the routine evaluation of the seizure itself. Neuroimaging
Recommendation. On the basis of the available evidence and consensus, the AAP recommends that neuroimaging not be performed in theoutine r evaluation of the child with a first simple febnile seizure. The literature does not support the use of skull films in the evaluation of the child with a febnile first

LIAIsoN REPRESENTATIVES Michael J. Goldberg, Sections Liaison

MD

Charles J. Homer, MD, MPH Section on Epidemiology Thomas F. Tonniges, MD AAP Board of Directors
SUBCOMMITTEE FEBRILE ON SEIZURES, DIAGNosIs
AND TREATMENT OF

1992

TO

1995

Thomas Robert

A Rienmenschneider, J. Baumann, MD
MD
MD

MD,

Chair

Patricia K. Duffner, John L. Green, MD

Sanford
CoNsui.Trrs

Schneider,

James David
Patricia

R. Cooley, L. Coulter,
K. Crumnine,

MD, MD

Clinical
MD

Algorithm

Although no data have been published that either support or negate the need for CT or magnetic resonance imaging in the evaluation of children with simple febrile seizures, extrapolation of data from the literature on the use of CT in cM!dren who have generalized epilepsy has shown that clinically important intracranial structural abnormalities in this patient population are uncommon.45
seizure.73 CONCLUSION

Sandra DAngelo, PhD, Methodology w. Edwin Dodson, MD John M. Freeman, MD

Michael

Consultant

Kohrman,

MD

James Kanin
N. Paul Shlomo

0. McNamara, B. Nelson, MD
Rosman, MD

MD

Shinnar,

MD

Physicians
after first evaluations childrens

evaluating simple febnile

toward fevers.

infants or young children seizures should direct their

the causes of the

REFERENCES
1. Nelson KB, experienced Ellenberg JH. Predictors of epilepsy in children febrile seizures. N Engi I Med. 1976295:1029-1033 statement.

who

have

should be dren with fever-associated seizures. Pediatrics. 198066:1009-1012 strongly considered in a child younger than 12 Hirtz DC, Lee YJ, Ellenberg 3. jH, Nelson KB. Survey on the management months and should be considered in children be- of febrile seizures. Am J Dis Child. 1986;140:909-914 caused meningitis by in tween 12 and 18 months of age. In children older 4. Ratcliffe JC, Wolf SM. Febrile convulsions young children. Ann Neurol. 1977;1:285-286 than 18 months, the decision to do a lumbar puncture 5. Rutter N, Smales OR. Role of routine investigations in children rests on the clinical suspicion of meningitis. The sei- presenting with their first febrile convulsion. Arch Dis Child. 1977; zure usually does not require further evaluation52:188-191 6. Joffe A, McCormick M, eAngelis D C. Which children with febrile seispecifically EEG, blood studies, or neuroimaging.
zures need lumbar

the diagnosis of A lumbar puncture

2. Consensus

Febrile

seizures:

long-term management

of chil-

puncture?
G, Tirosh

A decision
E. Fever nd a

analysis

approach.

Am Dis I

The practice the Child With the appropriate

Chapter

parameter, TheNeurodiagnostic a First Simple Febrile Seizure,

and
a AAP sections focus

Evaluation

of

was

committees Review Group,

of the
group f o

AAP, induding

cians representing
M. Corwin,
MD; Howard

each

district
MD;

MD;

Lawrence
Diane Fuquay, MD. Comments
The

Gene C. Pakula,
MD;
were also

office-based R. Adams, MD; Barbara

MD;

reviewed the pediatriMD; Robert

M. Harley, Kenneth E

by

B. Weinblatt,

Thomas J. Herr,

convulsions-indications for 198157:fl9-731 8. Gerber MA, Berliner BC. The child with a simple febrile seizure: appropriate diagnostic evaluation. Am I Dis Child. 1981;135:431-433 9. Frantzen E, Lennox-Butchthal M, Nygaard A. Longitudinal EEG and clinical study of children with febrile convulsions. Electroencephalogr
laboratory investigations. Pediatrics. Clin 10. Thorn
sions.

Child. 1983;137:1153-1156 7. Jaffe M, Bar-Joseph

Matthews, MD; Delosa A Young,

outside Michael organizations.

Robert

D.

dinical

solicited algorithm was

and MD; from relevant developed by

Mines,
R.

Neurophysiol. I. The
In: Aidmoto

1968;24:197-212 significance
H,

of electroencephalography
Kwmatsuri H, Seino M, Ward

in

febrile
A,

convul-

eds. Advances

Cooley, The

Kohrman, MD, Harvard supporting

MD, data
which

Buffalo
Community begins

Childrens Health

analyses are

Hospital, and James Plan. contained inthe summary

773.

in

Epileptology: Press;

XIIIth 1982:93-95

Epilepsy

International

Symposium. New

York,

NY:

Raven

of

11. HeijbelJ,

Blom 5, Bergfors

PG. Simple

the technical

report,

on page
ON

incidence study and an evaluation Neuropaediatrie. 1980;11:45-56 IMPROVEMENT,

febrile convulsions: a prospective ofnvestigations i initially needed.

PROVISIONAL

COMMIrFEE

QUALITY

1993
David

TO

1996
Bergman, MD, Chair

A.

Richard

D. Baltz,

James
John
Lawrence

R. Cooley,
B. Coombs,

MD MD
MD

12. Chamberlain JM, Gorman RL. Occult bacteremia in children with sianple febrile seizures. Am I Dis Child. 1988;142:1073-1076 13. Nealis GT, McFadden SW, Asnes RA, Ouellette EM.Routine skull roentgenograms in the management of simple febrile seizures. I Pediatr.
197790:595-596

F. Nazarian, MD Thomas A. Riemenschneider, Kenneth B. Roberts, MD Daniel W. Shea, MD

MD

14. Yang PJ, Berger PE, Cohen ME, Duffner PlC Computed tomography and ChildhOOd seizure disorders. Neurology. 197%29:1084-1088 15. Bachman DS, Hodges FJ, Freeman JM. Computerized axial tomography in chronic seizure disorders of childhood. Pediatrics. 1976;58:
828-832

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OF

PEDIATRICS

771

ALGORITHM The
2

Neurodiagnostic Evaluation of the Child With a First Simple Febrile Seizure

Does
(1) (2) (3) (4) (5)

the thUds presentaSon meet these criteria? Fever present; AND SeIzure generalized; AND SeIzure duration < 15 mInutes; AND ChIld has normal neurologlc exam; AND ChIld has no history of previous neurologic insuft or CNS abnormality.

Perform appropriate evaluation and treatment for child with seizure that may not meet criteria for

a simple

febrile

seizure.

(1) Perform appropriate evaluation to Identity source of fever. (2) Treat any Infection found with appropriate therapy. (3) Treat fever with antlpyretlcs. (4) Do not routinely obtain serum electrolytes. glucose, calcium.

phosphate.

(5) Do not routinely obtain

or magnesium. unless specific Indications skull films. head CT or MRI.

are present.

I Strongly

consIder performIng a lumbar puncture. given that absence of menlngeal signs In a child lesshan I t of age does not rule out meningItIs.

Strongly consider performing a lumbar puncture, given that prior antibiotic treatment could mask meningeal signs and symptoms

22

patIent to routine care. (2) Educate parents concerning febrlle seizures. (3) Do not obtain follow-up EEG.
(1) DIscharge

772

PRACTICE

PARAMETER

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Practice Parameter: The Neurodiagnostic Evaluation of the Child With a First Simple Febrile Seizure Pediatrics 1996;97;769
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1996 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on May 18, 2011