Clinical Practice Guideline Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure

Updated Guidelines Stem From Comprehensive Review

AAP investigators examined evidence-based literature made available from 1996 to February 2009. They gave preference to population-based studies. However, a lack of such research necessitated inclusion of information from hospital-based studies and data gathered from various groups of young children with febrile and other illnesses.

Introduction Simple Febrile Seizure: Clinical Practice Guidelines

CRITERIA FOR THE DIAGNOSIS OF SIMPLE FEBRILE SEIZURE 1.Between 6 months and 5 years of age 2. Fever (>38oC) present prior to the seizure 3.Seizure lasting less than 15 minutes 4.Non-focal, generalized seizure, involving all limbs 5.No more than a single seizure per 24-hour period 6.No severe metabolic disturbance 7.No evidence of intracranial infection 8.No other neurologic diagnoses or history of afebrile seizures

Evaluation and Treatment

The laboratory, radiographic, and neurologic evaluation should be aimed at diagnosing the etiology of fever not for evaluation of the seizure activity itself

Lumbar Puncture
Perform if the patient has a history or physical exam suggestive of meningitis or intracranial infection Perform if the patient has fever, seizure, and meningeal signs or symptoms Consider if the patient is between 6 and 12 months of age and has not received the recommended doses of HIB or Streptococcus pneumoniae vaccines OR if the immunization status cannot be accurately determined Consider if the patient has fever, seizure, and antibiotic pretreatment

In General
EEG is not indicated. NEUROIMAGING is not indicated unless focal abnormalities on physical exam are identified.

Laboratory Evaluation
Should not be performed routinely for the sole purpose of identifying the etiology of the simple febrile seizure, but maybe indicated if the source of fever is uncertain or if the diagnosis is unclear.
If you decide to do the workup for the seizure, consider CBC, blood culture, serum glucose, electrolytes, magnesium, calcium, phosphorous, urinalysis, and urine culture.

Parental Education
The risk of febrile seizure in the general population is between 2% and 5%. Simple febrile seizures are benign, and the longterm prognosis is excellent.
There is no evidence that treating simple febrile seizures with anti-epileptic drugs decreases the incidence of epilepsy later in life or results in improved cognitive outcomes. First episode - <12 mo 50% recurrence - >12 mo 30% recurrence Second episode 50% for all age groups

Parental Educationcontd
The risk of epilepsy is minimally increased from 1% to 2.4% in patients who have a simple febrile seizure and is highest in patients with recurrent simple febrile seizures whose initial simple febrile seizure occurred prior to 12months of age.
In rare situations, extreme parental anxiety about recurrent, severe simple febrile seizures warrants prophylaxis at the beginning of each febrile illness. This is not routinely recommended. Oral diazepam (0.33 mg/kg Q8hours at the beginning of a febrile illness) is the only medication recommended in such circumstances. Antipyretics and anti-epileptics have not been recommended for prevention of simple febrile seizures.

Parental Educationcontd
Rectal diazepam can be prescribed for use during prolonged (over 5 minutes) febrile seizures in selected cases.

How does this vary from 1996 guidelines?

1996 guidelines for LP in simple febrile seizures:
Strongly consider for infants under 12 months Consider for ages 12 to 18 months Usually unwarranted for ages greater than 19 months in absence of meningeal signs Strongly consider for children pretreated with antibiotics

In 1996, blood studies, EEG, and imaging were not routinely recommended

What changes in practice occurred in the intervening period between 1996 and 2011?
Widespread administration of Hib and pneumococcal vaccines Decreased incidence of bacterial meningitis

Risk of bacterial meningitis presenting as first simple febrile seizure in this age group: very low
Kimia, et al. PEDIATRICS Vol. 123 No. 1 January 2009.

704 cases of first simple febrile seizure ages 618 mos LP performed in 38% of these No patient was diagnosed as having bacterial meningitis

Questions
1. At what ages do febrile seizures occur? How common is this problem?
- 6 months to 5 years. It occurs in 2-5% of all children and is the most common reason for convulsions in children less than 5 years of age.

2. In what percentage of patients will febrile seizures occur a second time? - 33%.

Questions
3. What are the differences between simple and

complex febrile seizures? Why is it important to know this distinction (think of recurrence risk of febrile seizures, development of epilepsy, and work-up)?
- Simple seizures are characterized by being less than 15 min. duration and generalized. Complex febrile seizures are greater than 15 min. duration, multiple within 24 hours, and focal. Simple febrile seizures have a higher risk for febrile seizures. Complex febrile seizures have a higher risk for epilepsy. One should have a lower threshold for performing tests and hospitalization in cases of complex febrile seizures.

Questions
4. A febrile seizure is a diagnosis of exclusion. What
other diagnoses should be considered in a child with fever and seizures?

- Meningitis, encephalitis, Shigella gastroenteritis,

medications and toxins, hypoglycemia, electrolyte abnormalities, shaken baby syndrome, accidental head trauma, and epilepsy.

5. According to the guidelines put forth by the American

Academy of Pediatrics' Practice Parameter, who should be strongly considered to receive a lumbar puncture?

- Infants less than 12 months of age.

Questions
6. Most patients with febrile seizures can be discharged home. What are three indications for a child who should be hospitalized for overnight observation?
- Unstable clinical situation, possibility for meningitis, and parents unreliable or unable to cope with the child developing another seizure.

Questions
7. Although diazepam (Valium) can be used to prevent recurrences when given at the start of a febrile illness, what are its disadvantages?
- Disadvantages include lethargy, drowsiness, ataxia, and masking of a CNS infection.

8. A key part to management is reassurance. What are three ways parents should be reassured and educated?
- 1) Seizure will not cause brain damage and the risk of the child developing epilepsy is small. 2) Possibility that it can happen again, especially in the first 24 hours. One third of children will have at least another febrile seizure with most occurring within one year of the episode. 3) If seizure occurs again, child should be kept on his or her side. If seizure does not stop within 3 minutes, then emergency medical services should be contacted.