Published online October 1, 2004
PEDIATRICS Vol. 114 No. 4 October 2004, pp. 962-964 (doi:10.1542/peds.2003-0650-F)
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Which Characteristics of Children With a Febrile Seizure Are Associated With Subsequent Physician Visits?

Kevin E. Gordon, MD*,{ddagger}, Joseph M. Dooley, MB*,{ddagger}, Ellen Wood, MD*,{ddagger}, Paula Brna, MD* and Peggy Bethune, MD*,§

* Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
{ddagger} Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
§ Department of Pediatrics, Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective. To reanalyze an existing data set to determine which children with an initial febrile seizure have excessive subsequent physician visits.

Methods. Individual data from a regional cohort of 75 children with a first febrile seizure and 150 febrile and 150 afebrile control subjects were linked to a comprehensive physician services database. The impact of study variables on subsequent physician utilization over the following 6 years was modeled using analysis of variance.

Results. Children with a known family history of febrile seizures at the time of study entry had 24% fewer physician visits. Control children with a known family history of afebrile seizures had 7% fewer visits than those with negative family histories. Children with an initial febrile seizure had 45% more physician visits when they knew of a relative with afebrile seizures than those with negative family histories.

Conclusions. Knowing the family history of seizures is probably a marker of reduced physician utilization. At the time of an initial febrile seizure, knowing the family history of afebrile seizures defines a group of patients with excessive subsequent physician visits.

Key Words: febrile seizures • seizures • family history • physician utilization

Febrile seizures are emotionally traumatic for parents. Many parents think that their child is dying during the seizure.1–4 After an initial febrile seizure, families subsequently report altered parental behavior and disruption of family routines5,6 with a persistent fear of fevers and of febrile seizures.3,4

The recent practice parameter of the American Academy of Pediatrics has recommended against either continuous or intermittent anticonvulsant therapy for children with 1 or more simple febrile seizures.7 Ultimately, recommendations for such treatment hinge on the issue of prevention of parental anxiety and family disruption, among other issues.8,9 One of the most cited reasons for physicians initiating medication management is parental anxiety.10,11 This anxiety after an initial febrile seizure4–6 does not seem to be long lasting, as subsequently these children do not have any more frequent health care contacts than matched control subjects.12,13 Despite this, we recently demonstrated that a few parents assign a tremendous value to the prevention of recurrent febrile seizures.14 This prompted us to reanalyze our data13 to determine whether there exist subpopulations of children who have febrile seizures and have excessive numbers of physician visits.


   METHODS
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 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Design
This study involved the exploration of a previously described data set,13 which involved the linking of a population-based cohort of children of initial febrile seizures (N = 75) and age-matched febrile control subjects (N = 150) and afebrile (N = 150) control subjects15 with the Nova Scotia Medical Services Insurance Physician's Services database. The province of Nova Scotia provides universal health care coverage for all hospital and physician services. The provincial database includes all outpatient and inpatient physicians' fee-for-service claims and therefore documents virtually every physician–patient encounter. We examined the total number of physician contacts by physician specialty for original study participants from study entry (October 15, 1989, to March 15, 1991) for the following 6 years. As in our original study, both control groups were amalgamated for analysis.13

Data Linkage
The original data set was examined for factors that might predict health care utilization and were available for both children with an initial febrile seizure and their control subjects. These factors were classified as demographic, validation, and factors specific to febrile seizures (Table 1). Linkage was accomplished for 369 (98%) with the Medical Services database (73 of 75 febrile seizures, 147 of 150 febrile control subjects, and 149 of 150 afebrile control subjects) by using patient health card numbers for the 375 original study participants. We elected to examine all linked study participants for a follow-up of 6 years after their study entry, because, as a result of the sequential study entry, this allowed virtually all participants to be studied for the same follow-up period. We were able to document that only 8 children had moved away from the province during the study period (2 with febrile seizures and 6 afebrile control subjects). For these individuals, we used all of their available data.


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  		TABLE 1. Clinical Features Evaluated as Potential Predictors of Physician Utilization

 
Statistical Analysis
Data manipulation and processing were performed using Systat version 7.0.16 Physician visits were modeled using analysis of variance by classification of individual (febrile seizure or control), predictive factor, and the interaction term of classification versus predictive factor. When an interaction term was not believed to be significant, it was removed from the model. This reanalysis of an existing data set did not involve any correction for multiple testing. The Research Ethics Board of the IWK Health Centre approved the original study.13


   RESULTS
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 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Demographics
Median age at study entry was 1.3 years (range: 0.1–4.4 years); 55% were boys. There was no difference in age or gender composition between the children with a first febrile seizure and the control group. There were 17 034 physician contacts: 66% to general practitioners, 20% to pediatricians, and 14% to other specialists.

Physician Contact Rates
The gender of the child significantly predicted the rate of overall physician visits and visits to general practitioners, with girls having 18% fewer overall visits (P = .01) and 17% fewer visits to general practitioners (P = .02). Maternal age and education were not associated with physician visit rates.

Reporting problems during pregnancy, labor/delivery, or infancy was associated with increased visits to pediatricians (P = .01), whereas a prior hospitalization was associated with increased visits overall (P < .001) and specifically to specialists (P < .001). Neither parental report of their child's development nor enrollment in child care was associated with altered physician utilization.

Parents who knew of and reported a positive family history of febrile seizures at the time of study entry had 24% fewer overall physician visits (P = .04) and fewer visits to general practitioners (P = .06), suggesting that the knowledge of family history of febrile seizures may be associated with decreased health care utilization.

When parents who knew of and reported a positive family history of afebrile seizures at the time of study entry were reviewed, a significant and challenging interaction was revealed. Although control children with a known family history of afebrile seizures had 7% fewer visits than control children with either an unknown or a negative family history, children with an initial febrile seizure went on to have 45% more physician visits when their parents knew of a first- or second degree relative with epilepsy at the time of their first febrile seizure (P = .04; Fig 1). This same interaction was manifest for general practitioner visits (P = .02) and specialist visits (P = .04) but not for visits to pediatricians.


Figure 1
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  		Fig 1. Number of physician visits during 6-year follow-up for all children related to whether at the time of study entry the family history was negative/unknown or known to be positive for febrile seizures in first- and second-degree relatives (P < .04; a) and all children broken down into control subjects and children with an initial febrile seizure related to whether at the time of study entry the family history was negative/unknown or known to be positive for afebrile seizures in first- and second-degree relatives (P < .04; b).

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
These findings are perplexing and challenging. Having a family history of febrile seizures and knowing about it at the time of study presentation seem to be associated with subsequent reduced health care use. This was the case for children who presented to the emergency department with a febrile seizure, with a fever, or for an afebrile complaint. We suspect that knowledge of family history is associated with other variables that are predictive of health care utilization. Our data were not set up to test this, as in our study a negative history comprised both those whose history was known to be negative and those who reported it as negative.

Having a family history of afebrile seizures and knowing about it at the time of study presentation are also associated with subsequent reduced physician contacts but only for children who present without febrile seizures. For children who present with febrile seizures, this information is associated with an excess of 57% more physician visits than would have been predicted, standardizing for the control rate of physician utilization. The reason for this discrepancy between those with febrile seizures and those who present to the emergency department for other reasons is unclear. We suspect that most parents of children with febrile seizures are ultimately adequately reassured about the benign nature of their child's condition; however, it may be easy for a parent to confuse the familiar epileptic seizure with the phenotypically similar but prognostically more benign febrile seizure.

A word of caution is needed concerning our findings, which are derived from a reanalysis of data. Despite multiple statistical testing, we did not adjust for this, raising the possibility of type I error. The goal of the study was to generate hypotheses about the identity of a subset of parents and children who visited physicians more frequently presumably related to some long-lasting anxiety surrounding their children's febrile seizure.

Febrile seizures are anxiety provoking for families. This anxiety seems to have limited impact but remains one of the most cited reasons for physicians' initiating medication management of febrile seizures.10,11 Additional studies are required to characterize further these persistently apprehensive families and to develop effective interventions for them.


   ACKNOWLEDGMENTS
 
We thank Dr Peter Camfield, Dr Carol Camfield, and Edie Smith for contributions in developing the original data set.


   FOOTNOTES
 
Accepted Mar 16, 2004.

Reprint requests to (K.E.G.) Department of Pediatrics, IWK Health Centre, Box 3070, Halifax, Nova Scotia, Canada B3J 3G9. E-mail: kegor{at}dal.ca


   REFERENCES
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 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Rutter N, Metcalfe DH. Febrile convulsions—what do parents do? Br Med J. 1978;2 :1345 –1346
  2. Baumer JH, David TJ, Valentine SJ, Roberts JE, Hughes BR. Many parents think their child is dying when having a first febrile convulsion. Dev Med Child Neurol. 1981;23 :462 –464[ISI][Medline]
  3. Balslev T. Parental reactions to a child's first febrile convulsion. A follow-up investigation. Acta Paediatr Scand. 1991;80 :466 –469[ISI][Medline]
  4. van Stuijvenberg M, de Vos S, Tjiang GC, Steyerberg EW, Derksen-Lubsen G, Moll HA. Parents' fear regarding fever and febrile seizures. Acta Paediatr. 1999;88 :618 –622[CrossRef][ISI][Medline]
  5. Bethune P, Gordon K, Dooley J, Camfield P, Camfield C. The use of an educational slide-tape program for parents in the emergency room management of a first febrile seizure. Clin Invest Med. 1990;13 :105
  6. Wirrell E, Turner T. Parental anxiety and family disruption following a first febrile seizure in childhood. Paediatr Child Health. 2001;6 :139 –143
  7. Practice parameter: long-term treatment of the child with simple febrile seizures. American Academy of Pediatrics. Committee on Quality Improvement, Subcommittee on Febrile Seizures. Pediatrics. 1999;103 :1307 –1309[Abstract/Free Full Text]
  8. van Stuijvenberg M, Derksen-Lubsen G, Steyerberg EW, Habbema JD, Moll HA. Randomized, controlled trial of ibuprofen syrup administered during febrile illnesses to prevent febrile seizure recurrences. Pediatrics. 1998;102 (5). Available at: www.pediatrics.org/cgi/content/full/102/5/e51
  9. Baumann RJ. Technical report: treatment of the child with simple febrile seizures. Pediatrics. 1999;103 (6). Available at: www.pediatrics.org/cgi/content/full/103/6/e86
  10. Millichap JG, Colliver JA. Management of febrile seizures: survey of current practice and phenobarbital usage. Pediatr Neurol. 1991;7 :243 –248[CrossRef][ISI][Medline]
  11. Rantala H, Tarkka R, Uhari M. A meta-analytic review of the preventive treatment of recurrences of febrile seizures. J Pediatr. 1997;131 :922 –925[CrossRef][ISI][Medline]
  12. Forsgren L, Sidenvall R, Blomquist HK, Heijbel J, Nystrom L. An incident case-referent study of febrile convulsions in children: genetical and social aspects. Neuropediatrics. 1990;21 :153 –159[ISI][Medline]
  13. Gordon KE, Camfield PR, Camfield CS, Dooley JM, Bethune P. Children with febrile seizures do not consume excess health care resources. Arch Pediatr Adolesc Med. 2000;154 :594 –597[Abstract/Free Full Text]
  14. Gordon KE, Dooley JM, Camfield PR, Camfield CS, MacSween J. Treatment of febrile seizures: the influence of treatment efficacy and side effect profile on value to parents. Pediatrics. 2001;108 :1080 –1088[Abstract/Free Full Text]
  15. Bethune P, Gordon K, Dooley J, Camfield C, Camfield P. Which child will have a febrile seizure? Am J Dis Child. 1993;147 :35 –39[Abstract]
  16. SYSTAT. Chicago, IL: SPSS Inc; 1997
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics




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