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

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