CNSP TECHNICAL REVIEW COMMITTEE

CLINICAL PRACTICE GUIDELINE ON

Marissa B. Lukban, MD FIRST SIMPLE FEBRILE SEIZURE
Marilyn H. Ortiz, MD
Madeleine M. Sosa, MD Convened by: Child Neurology Society Philippines, Inc and Philippine Pediatric
lgnacio V. Rivera, MD Society

PANELISTS REPORT OF THE TECHNICAL REVIEW COMMITTEE (EVIDENCE BASED

DRAFT)
Child Neurology Society Phils. Inc
Lillian V. Lee, MD I. DISCLAIMER:
Aida M. Salonga, MD The recommendations contained in the document are intended to GUIDE
Filipino practitioners in the management of pediatric patients with a FIRST SIMPLE
FEBRILE SEIZURE. In no way should the recommendations be regarded as absolute
Philippine Pediatric Society
Genesis Rivera, MD rules, since nuances and peculiarities in individual cases or particular communities may
entail differences in the specific approach. In the end, the recommendations should
Municipal Health Department supplement, and NOT replace, sound clinical judgment made on a case-to-case basis.
Bernadette S. Maniebo, MD
Rochelle C. Paulino, MD H. INTRODUCTION
A. OBJECTIVE
Angel A. de Guzman, MD
General Objective:
This practice guideline will provide recommendations for the performance of
Philippine Infectious Disease Society of the Philippines
Doris Chua, MD neurodiagnostic tests and treatment of healthy normal infants aged 3 months to 6 years
with a first simple febrile seizure.
Philippine Ambulatory Pediatrics Association Specific Objectives:
Edna Sarah Mora'da, MD 1. This guideline will clarify the role of neurodiagnostic procedures (lumbar
puncture and neuroimaging studies) in the evaluation of children with first
Philippine Society of Developmental & Behavioural Pediatrics simple febrile seizures to provide health providers with a rational approach to
the diagnosis of simple febrile seizures.
Rhandy Pe Benito MD.
2. This guideline will evaluate the effectiveness of antipyretics and antiepileptic
Philippine Neurological Association/Philippine League Against Epilepsy drugs (given continuously or intermittently) as a prophylaxis for future febrile
Fe. E. Bacsal, MD seizures.
Leonor Cabral-Lim, MD 3. This guideline will clarify the role of electroencephalogram in predicting the
risk of epilepsy in children with simple febrile seizures.

B. TARGET USERS AND PRACTICE SETTING

This practice guideline is intended for the use of general practitioners, family
physicians, emergency room physicians, pediatricians, neurologists and other health
providers who manage children with simple fcbiiie seizures.
Tliis piactice parameter is not intended for those with complex febrile seizures nor
for those children with previous neurological abnormalities or history of afebrile
seizures.

C. IMPORTANCE OF THE TOPIC

Simple febrile seizure is defined as seizure occurring in healthy children ages 3
months to 6 years, with axillary temperature of 37.8 Celsius or greater, characterized as
generalized tonic-clonic seizures, lasting for less than 15 minutes and which does not
recur within the same febrile illness. Among these children, the neurologic examination
iy
1
is normal and there is no underlying CNS infection or abnormality. This is
differentiated from complex febrile seizures wherein the seizures are characterized as
focal, prolonged (lasting for more than 15 minutes) and recurrent (with repeated
seizures in the same febrile illness).
The prevalence of simple febrile seizures in the Philippines is unknown. ' '•"
However it accounts for one of the most frequent cause of emergency room
consultations and even hospital admissions locally. Its occurrence in young children is
a source of severe anxiety for parents and even physicians.
In 1998, the American Academy of Pediatrics produced its first clinical practice
guideline for febrile seizures and largely this has been the basis of recommendations by
most pediatricians and child neurologists. In 2000, the Child Neurology Society Phils.
Inc. created a task force to review the recommendations for febrile seizures, which was
presented during the 2nd Scientific Convention of the Child Neurology Society
Philippines in October 2000. It basically affirmed the recommendations of AAP. In
2002, CNSP conducted a survey on 16 fellows of the CNSP, which was presented
during the First Congress of the Philippine League Against Epilepsy. This report shows
that even among child neurologists, the definition of febrile seizures and its
management have some variations and remain highly individualized.
The main controversies identified during the previous attempts to come up with
the Philippine recommendation are as follows:
a. The age definition of febrile seizure - based on foreign literature, the lower
age limit for the diagnosis of febrile seizure has decreased from 5 months,
to 3 months, to 1 month.
b. The lower limit of age wherein a mandatory lumbar puncture to rule out
meningitis is recommended - this has varied from <12 months to < 18 months.
Among general practitioners, there is still a controversy on the role of lumbar
puncture, neuroimaging studies and electroencephalogram in the evaluation of a child
with febrile seizures. ' In addition, there is continued wide use of antiepileptic drugs
such as Phenobarbital in children with febrile seizures.2
In summary, a practice guideline adapted for the Philippine setting with a
consensus from a wider group of health providers is thus essential.
ni METHODOLOGY OF CPG DEVELOPMENT
This will be the first Philippine clinical practice guideline produced using a
combination of a comprehensive evidence based approach and multisectoral expert
opinion consensus on febrile convulsions.
This technical report is the summary of the reviewed scientific articles on the
neurodiagnostic evaluation and treatment of simple febrile seizures.
In order to find studies addressing the clinical issues as detailed below, a
computerized search of the Medline database for foreign articles and Herdin database
for local articles was conducted. The Medline search of published articles was divided
into two. Using MeSH terms and free text search, articles on issues on neurodiagnostic
procedures were retrieved dating back to 1966 using the terms "febrile seizure",
"lumbar puncture," " meningitis" "EEG" and "neuroimaging" On issues regarding
treatment the terms "antipyretics", "anticonvulsant", "prophylaxis", "diazepam" and
"phenobarbital" was used. Available abstracts and full articles for these studies were
reviewed. The bibliographies of the technical review committee report of the American
Academy of Pediatrics sub-committee on Febrile Seizures were also retrieved. Local
studies conducted in the Philippines were retrieved from the book of abstracts filed by
the Philippine Pediatric Society as well as thru personal communications with principal
authors. The Technical Review committee objectively and comprehensively searched
and critically appraised the literature
Based on the clinical evidence from the scientific literature, a set of draft
recommendation statements as provided below were provided and served as a jumping
board for discussion and consensus gathering by the first set of multisectoral panelists
who met last February 2004. These draft recommendations will further be disseminated
to other health providers for further comments and revisions, which will then be the
basis for the final recommendation.
IV. CLINICAL ISSUES
A. Diagnostic Procedures
1. Lumbar puncture
Among children with a first simple febrile seizure, is lumbar puncture
recommended to aile out meningitis?
2. Neuroimaging
Among children with a first simple febrile seizure, do we need to perform
neuroimaging studies (cranial ultrasound, computed tomography scan (CAT) and
magnetic resonance imaging (MRI)?
B. Medications for febrile seizures
1. Antipyretic drugs
In children with a simple febrile seizure, can prophylactic treatment with
antipyretic drugs decrease the likelihood of recurrence of febrile seizures?
2. Antiepileptic drugs
In children with a simple febrile seizure, can prophylactic treatment with
antiepileptic drugs (whether continuous or intermittent) decrease the likelihood of
recurrent febrile seizures?
Definition of terms:
1 Prophylactic treatment is defined as the use of any medication to prevent
the occurrence of the condition being treated even before it occurs
2. Continuous treatment with antiepileptic drugs is defined as the use of an
antiepileptic drug daily for a prolonged period of iime.
?. Intermittent treatment with antiepileptic drugs is defined as the use of an
antiepileptic drug only during the duration of the febrile illness.
C. Prognostic Procedures:
1. Electroencephalography (EEG)
Among children with a first simple febrile seizure, is EEG recommended to
predict the risk of epilepsy or afebrile seizure?
 children with meningitis. The presence of atleast one of the complex features of a
V. DRAFT RECOMMENDATIONS: febrile seizure (partial, multiple or prolonged), atleast one of the history feature for
suspecting meningitis (febrile illness for atleast for three days, vomiting or
drowsiness at home, a physician visit in the previous 48 hours) or minor signs of
A. NEURODIAGNOSTIC PROCEDURES
meningitis (dubious nuchal rigidity, persisting drowsiness, paresis or paralysis on
examination in the emergency room) identified 74%, 78% and 71% of children
I. LUMBAR PUNCTURE (LP)
with meningitis respectively.9
A. DRAFT RECOMMENDATION STATEMENT:
Lumbar puncture should be performed in all children below 18 months for
3. Recommendation of Others
a first simple febrile seizure. For those children > 18 months of age, lumbar
The AAP Subcommittee on febrile seizures recommends, "that after the first
puncture should be performed in the presence of clinical signs of meningitis seizures with fever in infants younger than 12 months, performance of a lumbar
(eg., presence of meningeal signs, sensorial changes).
Grade of Recommendation: A puncture be strongly considered, because the clinical signs and symptoms
associated with meningitis may be minimal or absent in this age group. In children
Level of Evidence: 3
between 12-18 months of age. a lumbar puncture should be considered, because
clinical signs and symptoms of meningitis may be subtle. In a child older than 18
B. SUMMARY OF EVIDENCE:
months, although a lumbar puncture is not routinely warranted, it is recommended
1. Burden of illness
One of the critical decisions that must be made in the evaluation of a child in the presence of meningeal signs and symptoms (i.e. neck stiffness and Kernig
and Brudzinski signs). In infants and children who have had febrile seizures and
who has had a first febrile seizure is whether to perform a lumbar puncture to
have received prior antibiotic treatment, clinicians should be aware that treatment
identify children with CNS infection. Seven retrospective studies that were done in
the urban hospital emergency rooms in the United States yielded 2,100 cases of could mask the signs and symptoms of meningitis. As such, lumbar puncture
should be strongly considered. " l0
febrile seizures.7 An overall meningitis prevalence of 1.2% (range 0-4%) was
found. In Denmark, two hospital based studies showed a prevalence of bacterial or
viral meningitis of 7%. The same prevalence was seen in a study by AI-Eissa in 4. Considerations for the draft recommendation for the Philippine setting
Saudi Arabia. A retrospective study by Green et al of 503 patients with the Because of the potential detrimental outcome of missing CNS infections in
our population of which majority belong to the low income group, poorly
diagnosis of bacterial or aseptic meningitis (115 or 23% of those had a seizure)
nourished and without access to vaccinations against meningitis, the draft
aged 2 months to 15 years found no cases of meningitis presenting as an isolated
seizure. recommendation is suggesting to increase the cut - off for recommending
lumbar puncture to all infants less than 18 months.
Locally, an unpublished retrospective study by Mangubat and Robles
In addition, this guideline is intended for health providers with varying
involving 198 children 3 months to 6 years old with new onset febrile seizure
showed a 1% prevalence of meningitis.8 A higher prevalence of 7% was seen in clinical acumen, skills, training and experience, thus the need to emphasize the
the study of Dilangalen and Perez, which was conducted at Cotabato Regional and value of not missing meningitis in our population.
Medical Center involving 339 cases.'
2. NEUROIMAGING (CRANIAL ULTRASOUND, CT SCAN, MRI)
2. Accuracy of the test
In children with febrile seizures, lumbar puncture for cerebrospinal fluid A. DRAFT RECOMMENDATION STATEMENT:
(CSF) analysis is performed to rule out an alternative diagnosis of meningitis. CSF Neuroimaging studies should not be routinely performed in children for a
analysis (cell count, sugar and protein levels and cultures) is the gold standard for first simple febrile seizure.
the diagnosis of meningitis. Spinal fluid examination is not a test that makes a Grade of Recommendation. C
Level of evidence: 4
diagnosis of febrile seizures per se.
The age of the patient plays a crucial role in the decision to perform LP. The
B. SUMMARY OF EVIDENCE
younger the patient is, meningeal signs become less obvious or are absent.
Obvious meningeal signs if present regardless of age are definitely an indication to 1. Accuracy of the test:
do lumbar puncture. No study has been done investigating the utility of neuroimaging, whether
One study tried to identify discriminate factors in the clinical signs and cranial ultrasound, CT scan or MRI, in children with simple febrile seizures.
symptoms that will differentiate children presenting with febrile seizures into those
with and without meningitis. The presence of one or more major signs of
meningitis (nuchal rigidity, coma, presence of petechiae) identified 70% of
4
 2. Recommendation of Others:
The AAP practice parameter recommends, "that neuroimaging not be
performed in the routine evaluation of the child with a first simple febrile
seizure. '"'0
3. Considerations for the draft recommendation for the Philippine setting
Because of the absence of evidence, the draft recommendation does not
recommend the performance of neuroimaging in patients with a first simple
febrile seizure. In addition, these examinations are not readily available and
may be costly.
B. THERAPEUTIC INTERVENTION
2.
I. ANTIPYRETIC USE
A. DRAFT RECOMMENDATION STATEMENT:
Antipyretic drugs are used to lower fever and should not be relied upon to
prevent the recurrence of febrile seizures.
Grade of Recommendation: C
Level of Evidence: 2
B. SUMMARY OF EVIDENCE:
1. Availability of effective treatment
Acetaminophen and ibuprofen are effective antipyretic agents in reducing
fever in children with febrile seizures. However there is little evidence in literature
that the prophylactic use of antipyretics has any effect in reducing the incidence of
febrile convulsions The use of sporadic (prn) vs regular dosing of antipyretics in
one study did not show any significant difference in terms of the number of febrile
convulsions, the range of temperatures or the mean duration of fever. Most other
studies reviewed also showed that even with regular use of antipyretics, febrile
seizure recurrences were not reduced. The authors concluded that educational
interventions aimed at reducing parental fear and helping them care for their
children during febrile illnesses may be more efficacious. "
A randomized controlled trial using ibuprofen involving 230 children failed to
demonstrate a preventive effect of intermittent antipyretic treatment during fever
on the number of febrile seizure recurrences in children at increased risk. The
study concluded that there is no evidence supporting intermittent antipyretic
treatment to prevent febrile seizure recurrences. ;:.
In a randomized, non-placebo multiple-dose, double blind crossover study
comparing Ibuprofen (5 mg/kg'dose q 6h) and acetaminophen (10 mg/kg/dose q
6h), the study showed that these two drugs were found to be effective antipyretic
agents. Ibuprofen yielded significantly greater fever reduction than did
acetaminophen four hours after the first dose. However due to the low number of
recurrences of febrile seizures and no placebo groups were used, seizure
prophylaxis could not be evaluated. "
2. Recommendation of Others:
The American Academy of Pediatrics recognized the role of antipyretics to
comfort the child but concludes that antipyretics in the absence of anticonvulsants
are not effective in preventing recurrent febrile seizures l4
3. Considerations for the draft recommendation for the Philippine setting
Because of the absence of evidence, the draft recommendation emphasizes
that the use of oral antipyretics is for the control offerer alone and may not be
relied upon to prevent the recurrence of febrile seizures. Its role is to give
comfort to the child with the febrile illness.
ANTIEPILEPTIC DRUG USE - continuous anticonvulsant (phenobarbital
or valproic acid)
A. DRAFT RECOMMENDATION STATEMENT:
The use of continuous anticonvulsant is not recommended in children after
a first simple febrile seizure. Although anticonvulsants can reduce the
recurrence of febrile seizures, the adverse side effects of these do not warrant
their use in this benign disorder.
Grade of Recommendation: C
Level of Evidence: 2
B. SUMMARY OF EVIDENCE:
1. Burden of illness:
There are only two important outcomes that may be altered by the use of
anticonvulsant treatment for children with simple febrile seizures. These are the
occurrence of subsequent febrile seizures and/or epilepsy or afebrile seizures
If not treated, the recurrence of febrile seizures varies with age. Children who
had their first simple febrile seizure before the age of 12 months have 50%
probability of having recurrent febrile seizure compared to 30% for those older
than 12 months. ' Children with simple febrile seizure have only a slightly
greater risk of developing epilepsy by the age 7 years compared with that of the
general population, which is 1%. 17 Children with multiple simple febrile seizures
and are younger than 12 months at the time of the first febrile seizure are at the
highest risk, but, even in this group, generalized afebrile seizure develop by age 25
in only 2.4%. 18
A different picture surfaces in children with seizures that are complex,
recurrent, with a family history of febrile seizures and those with underlying
neurological abnormalities. The risk for an afebrile seizure or epilepsy is slightly
higher at 6% Sapir on the other hand reports a 27% chance of epilepsy for
children with complex febrile seizures
2. Availability of Effective Treatment.
a. Treatment for Recurrent Febrile Seizures
Pooled data on four non-British randomized controlled clinical trials using
continuous phenobarbital showed an overall odds ratio of 0.45 (95% CI 0.33-0.90
p = 0.017). The risk of recurrence was lower in children taking continuous
Phenobarbital compared to placebo. Eight children would have to be given
continuous phenobarbital for two years to prevent a single febrile seizure (NNT =
8.5-27)20
Pooled data on seven British randomized controlled clinical trials using
continuous phenobarbital showed an overall odds ratio for recurrent febrile
seizures of 0.8. One article using valproic acid showed an odds ratio of 1.42.
However both studies were not statistically significant21
One randomized controlled trial using valproic acid showed an odds ratio of
0.09 (95% CI 0.01-0.78) favoring treatment. 22
b. Treatment for the Prevention of Epilepsy
No study has demonstrated that treatment can prevent the development of
epilepsy. Likewise, there is no evidence that will show that children with simple
febrile seizures are at risk for cognitive decline.
3. Recommendation of Others
The AAP Practice Parameters does not recommend the use of continuous
anticonvulsant therapy for children with one or more simple febrile seizures based
on the risks and benefits of effective therapies. The AAP recognizes that recurrent
episodes of febrile seizures can create anxiety in some parents, thus appropriate
education and emotional support should be provided.
4. Considerations for the draft recommendation for the Philippine setting
The draft recommendation does not recommend the prophylactic use of
continuous anticonvulsant for the prevention of seizure recurrence because of
the side effects of these drugs and the benign nature of simple febrile seizures.
ANTIEPILEPTIC DRUG USE - intermittent anticonvulsant (Phenobarbital
or diazepam)
A. DRAFT RECOMMENDATION STATEMENT:
The use of intermittent anticonvulsant (whether Phenobarbital or diazepam)
is not recommended for the prevention of recurrent febrile seizures.
Grade of Recommendation: C
Level of Evidence: 2
B. SUMMARY OF EVIDENCE
1. Availability of effective treatment
Knudsen was among the first who investigated the role of diazepam for
seizure prevention.23 However although some of his earlier studies that favored
treatment were randomized some were not blinded and there were considerable
patients lost to follow-up. More recent three randomized controlled clinical trials
8
using intermittent diazepam were pooled and the data showed an overall odds ratio
of 0.81 (95% CI 0.54-1.22 p ■ 0.31). This suggests that there is no difference in
the risk of seizure recurrence in children receiving intermittent diazepam versus
placebo.
Thefe are two local studies conducted on the use of oral diazepam for seizure
prevention. Although both studies are randomized trials there are however several
methodological flaws that make the results inconclusive.24 2?
2. Recommendation of Others:
At the time the AAP made its clinical practice guideline in 1999, only one
study, that of Rosman's was reviewed which showed a 44% reduction in the risk
of febrile seizures per person-year with diazepam. However, based on the risks
and benefits of intermittent oral diazepam, it was not recommended for use as
prophylaxis.
3. Considerations for the draft recommendation for the Philippine setting
Because there is no difference in the risk of seizure recurrence in children
receiving intermittent diazepam and placebo, the draft recommendation does not
recommend the use of intermittent anticonvulsants to prevent seizure
recurrences.
C. PROGNOSTIC EVALUATION
1. ELECTROENCEPHALOGRAM (EEG)
A. DRAFT RECOMMENDATION STATEMENT:
Electroencephalogram should not be routinely requested in children with a
first simple febrile seizure.
Grade of Recommendation: C
Level of Evidence: 4
B. SUMMARY OF EVIDENCE:
I. Accuracy of the test
An abnormal EEG after the first unprovoked or afebrile seizure predicts
recurrence for another epileptic attack. Patients with afebrile seizures, which show
epileptiform activity on EEG, have a 54% recurrence rate. However in patients
with new onset febrile seizures, doing an EEG does not reliably predict who
among them would have another febrile seizure or who would develop epilepsy in
the future. Most of the studies done where paroxysmal EEG changes were
recorded included not only children with simple febrile seizures, but also those
with complex febrile seizures and a preexisting neurological disability. A study by
Maytal showed EEG abnormalities of 8.6% or less in post-ictal patients with
complex febrile seizures. Heijbel et.al. limited their study to simple febrile seizures
and two subjects who subsequently developed epilepsy had normal EEGs.27
2. Recommendation of Others
The AAP Practice Parameter recommends that "EEG not be performed in the
evaluation of a neurologically healthy child with a first simple febrile seizure."
3. Considerations for the draft recommendation for the Philippine setting
Because there is no evidence that EEG can predict future incidence of
epilepsy, it does not recommend its use for prognosticating children with simple
febrile seizures. Likeivise the presence of paroxysmal abnormalities in the EEG
does not change the recommendation that these children with febrile seizures
should not be treated anticonvulsants.
10
VI. SUMMARY OF RECOMMENDATIONS
1. Lumbar puncture should be performed in all children below 18 months for a first
simple febrile seizure. For those children >/= 18 months of age, lumbar
puncture should be performed in the presence of clinical signs of meningitis
(e.g., presence of meningeal signs, sensorial changes).
2. Neuroimaging studies should not be routinely performed in children for a first
simple febrile seizure.
3. Antipyretic drugs are used to lower fever and should not be relied upon to
prevent the recurrence of febrile seizures.
4. The use of continuous anticonvulsants not recommended in children after a first
simple febrile seizure. Although anticonvulsants can reduce the recurrence of
febrile seizures, the adverse side effects of these do not warrant their use in this
benign disorder.
5. The use of intermittent anticonvulsant (whether Phenobarbital or diazepam) is
not recommended for the prevention of recurrent febrile seizures.
6. Electroencephalogram should not be routinely requested in children with a first
simple febrile seizure.
11
 APPENDIX
GRADES OF RECOMMENDATION
Grade A: Based on the current evidence, the consensus is that the
diagnostic test SHOULD BE USED be used for screening or diagnosing the
disease of interest (or the medication SHOULD BE used to treat the disease of
interest).
Grade B: The test MAY OR MAY NOT BE USED for screening or
diagnosing the disease in interest (or the medication MAY OR MAY NOT BE
USED for treatment), either because the evidence in lacking, equivocal or
conflicting; or a consensus could not be reached
Grade C: Based on the current evidence, the consensus is that the test
SHOULD NOT BE USED for screening or diagnosing the disease of interest (or
the medication SHOULD NOT BE USED to treat the disease of interest)
LEVEL OF EVIDENCE
1. Effectiveness of treatment for the asymptomatic condition must have been
assessed by well designed RCT evaluating the effect of treatment on clinical
outcomes
2. The prevalence of the symptomatic condition must be based on locally
conducted community based studies
3. The accuracy and reliability of the screening test must be based on validation
studies done in the community
4. Cost effectiveness of the screening test and the treatment should be evaluated in
properly conducted economic analysis
CLASSIFYING THE LEVEL OF EVIDENCE
Level 1 - evaluation satisfies all the above criteria
Level 2 - evaluation satisfies #1 only, but not #2, #3, #4
Level 3 - evaluation satisfies #2, #3 or #4 but not #1
Level 4 - evaluation satisfies none of the criteria
12
REFERENCES
1. Perez VV. Incidence of Febrile Convulsion among School Children at
Atimonan FJememary School. Philippine Pediatric Society (Abstract)
2. Vicencio RN, Ante CA, Rivera GI, Salonga AM. Incidence of Febrile Seizure
among grade 1 Public School Children at District V of the City of Manila.
Medical Center Manila. Philippine Pediatric Society (Abstract)
Dilangalen ND, Perez LE. Profile ofl-'ebrile Seizures admitted at Colobato
Regional and Medical Center. Colobato City 1992-1995. Philippine Pediatric
Society (Abstract).
4. Calilao MC, Rivera IV. A study on the incidence and clinical profile of febrile
seizures among grade I students at Salapin Elementary School, University of
the East Ramon Magsaysay Memorial Medical Center, Philippines.
(unpublished)
Llanos CC. A Sun>ey of Practice in the Management of Benign Febrile
Seizures. Philippine Pediatric Society. (Abstract)
Villanueva RT, Manaloto C, Navarro JC, de Sagun RQ. A Survey on the
Management Strategies of Febrile Convulsions by different Physicians.
Philippine Pediatric Society (Abstract)
Offringa M, Mover VA. Evidence based management of seizures associated
with fever. BMJ 2001; 323: 1111-4.
8. Dizon JG, de Guzman M, Mangubat R, Robles JA Simple febrile seizures: to
do or not to do LP. Philippine Pediatric Society (Abstract)
9. Offringa M, Belshuizen A, et al. Seizures and fever: can we rule out
meningitis on clinical ground alone9 Clin Pediatr 1992; 9:514-22
10. American Academy of Pediatrics. The neurodiagnostic evaluation of the child
with first simple febrile seizure. Pediatrics 1996; 97(5): 769-774.
11. Pursell E. The use of antipyretic medications in the prevention of febrile
convulsions in children. Journal of Clinical Nursing 2000; 9(4): 473-480.
12. Van Stuijvenberg M, Derksen-Lubsen G Randomized controlled trial of
Ibuprofen syrup administered to prevent febrile recurrences. Pediatrics 1998;
102(5): pE51
13. Van Esch. Antipyretic Efficacy of Ibuprofen and Acetaminophen in Children
with Febrile Seizures Archives of Pediatrics and Adolescent Medicine 1995;
149(6): 632-637.
14. American Academy of Pediatrics. Practice parameter: Long-term treatment
of the child with simple febrile seizures. Pediatrics 1999; 103(6): 1307-1309.
15. Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures.
Pediatrics 1978;61:730-7
16. Berg AT, Shinnar S, Darefsky AS, Holford TR, Shapiro ED. Predictors of
recurrent febrile seizures: A Prospective Cohort Study. Arch Pediatric
AdolescMed. 1997; 151:371-378
17 Verity CM, Golding J. Risk of epilepsy after febrile convulsions. A national
cohort study. Br Med J 1991; 303: 1373-76.
Annegers JF, Hauser WA. Shirts SB et al. Factors prognostic of unprovoked
seizures after febrile convulsions. N Engl J Med 1987: 316: 493-8.
13