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American Academy of Pediatrics
From the American Academy of PediatricsClinical Practice Guideline

Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure

Subcommittee on Febrile Seizures
Pediatrics February 2011, 127 (2) 389-394; DOI: https://doi.org/10.1542/peds.2010-3318
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  • Febrile seizures in children under 1 year of age: do not care about immunization
    Gianluca Tornese
    Published on: 06 March 2011
  • simple febrile seizures
    Patricia K. Duffner
    Published on: 24 February 2011
  • Febrile Seizures Defined
    Steve Piecuch, MD, MPH
    Published on: 23 February 2011
  • Published on: (6 March 2011)
    Febrile seizures in children under 1 year of age: do not care about immunization
    • Gianluca Tornese, Resident in Pediatrics
    • Other Contributors:

    Dear Editor,

    reading the clinical practice guidelines for the neurodiagnostic evaluation of the child with a simple febrile seizure (1), we were quite surprised to read the Action Statement 1b which suggests to perform a lumbar puncture in any infant between 6 and 12 months of age who presents with a seizure and fever when the child is considered deficient or undetermined in Haemophilus influenzae type b (Hib)...

    Show More

    Dear Editor,

    reading the clinical practice guidelines for the neurodiagnostic evaluation of the child with a simple febrile seizure (1), we were quite surprised to read the Action Statement 1b which suggests to perform a lumbar puncture in any infant between 6 and 12 months of age who presents with a seizure and fever when the child is considered deficient or undetermined in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations.

    Even though it is reported as an “option”, and the evidence level was declared as low (D, expert opinion, case reports), we do not agree with this statement, since we believe that the few available evidence in this field goes against this recommendation. “Much of the medicine we practice is enshrined in dogma”, wrote Carroll and Brookfield at the beginning of a review on this issue (2).

    The belief that bacterial meningitis in infancy commonly presents with fever and seizures alone stems from one small study conduceted in 1969 (3). The risk of bacterial meningitis in the absence of other clinical signs is extremely small (<1:200), even in children under 1 year of age (2), and in an infant with no signs of meningitis following a febrile convulsion, over 200 lumbar punctures would have performed to detect one case of unsuspected meningitis (4). Furthermore, early lumbar puncture is not a sensitive predictor of meningitis in this group of patients, missing over 40% of cases if performed routinely on admission to hospital (5). Lastly, we have to remember that the great majority of the study conducted on this topic were conducted in pre-Hib and pre- pneumococcal immunization era (2).

    We therefore believe that observation and regular review by the nursing and medical staff in the first few hours after the convulsion, with an emphasis on examination for signs of meningitis, is more likely to detect children with bacterial meningitis and obviates the need for a painful and invasive procedure, which may even be a risk of introduction of organism into the cefalorachidian fluid itself (6).

    References

    1. Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-94.

    2. Carroll W, Brookfield D. Lumbar puncture following febrile convulsion. Arch Dis Child. 2002;87(3):238-40.

    3. Samson JH, Apthorp J, Finley A. Febrile seizures and purulent meningitis. JAMA 1969;210:1918–19.

    4. Sweeney A, Gibbs J, Monteil F, et al. The management of febrile seizures in the Mersey region. Dev Med Child Neurol 1996;38:578–84.

    5. McIntyre PB, Gray SV, Vance JC. Unsuspected bacterial infections in febrile convulsions. Med J Aust 1990;152:183–6.

    6. Fischer GW, Brenz R, Alden ER, et al. Lumbar punctures and meningitis. Am J Dis Child 1975;129:590.

    Gianluca Tornese and Alessandro Ventura

    Department of Pediatrics

    Institute of Child Health IRCCS "Burlo Garofolo", University of Trieste, Trieste, Italy

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (24 February 2011)
    simple febrile seizures
    • Patricia K. Duffner, child neurologist
    • Other Contributors:

    The clinical practice guideline on febrile seizures refers to a first simple febrile seizure and thus implies the child has not had seizures with or without fever previously. Children with a history of afebrile seizures/epilepsy have a lowered seizure threshold and, as such, fever may trigger a seizure. Therefore even if the seizure is short, generalized and once in 24 hours, it would not be classified as a simple febril...

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    The clinical practice guideline on febrile seizures refers to a first simple febrile seizure and thus implies the child has not had seizures with or without fever previously. Children with a history of afebrile seizures/epilepsy have a lowered seizure threshold and, as such, fever may trigger a seizure. Therefore even if the seizure is short, generalized and once in 24 hours, it would not be classified as a simple febrile seizure. We agree that children with a history of afebrile seizures/epilepsy shuld be excluded as they were in the 2008 guideline.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (23 February 2011)
    Febrile Seizures Defined
    • Steve Piecuch, MD, MPH, Pediatrician

    A 2008 AAP Clinical Practice Guideline defined febrile seizures as ".. seizures that occur in febrile children between the ages of 6 and 60 months who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures." [1] This 2011 Clinical Practice Guidleline includes CNS infection as an exclusionary criterion for the diagnosis of febrile seizure but makes no mention of a history of afebrile...

    Show More

    A 2008 AAP Clinical Practice Guideline defined febrile seizures as ".. seizures that occur in febrile children between the ages of 6 and 60 months who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures." [1] This 2011 Clinical Practice Guidleline includes CNS infection as an exclusionary criterion for the diagnosis of febrile seizure but makes no mention of a history of afebrile seizures. I have always thought that the diagnosis of febrile seizures did not apply to patients with a previous history of afebrile seizures.

    1. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures. Pediatrics 2008; 121:1281-1286.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Pediatrics
Vol. 127, Issue 2
1 Feb 2011
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Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure
Subcommittee on Febrile Seizures
Pediatrics Feb 2011, 127 (2) 389-394; DOI: 10.1542/peds.2010-3318

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Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure
Subcommittee on Febrile Seizures
Pediatrics Feb 2011, 127 (2) 389-394; DOI: 10.1542/peds.2010-3318
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  • Article
    • Abstract
    • DEFINITION OF THE PROBLEM
    • TARGET AUDIENCE AND PRACTICE SETTING
    • BACKGROUND
    • METHODOLOGY
    • KEY ACTION STATEMENTS
    • CONCLUSIONS
    • Subcommittee on Febrile Seizures, 2002–2010
    • Staff
    • Oversight by the Steering Committee on Quality Improvement and Management, 2009–2011
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