Clinical Practice Guideline—Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child with a Simple Febrile Seizure

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all Children Clinical Practice Guideline—Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure

SUBCOMMITTEE ON FEBRILE SEIZURES KEY WORD abstract seizure OBJECTIVE: To formulate evidence-based recommendations for health ABBREVIATIONS care professionals about the diagnosis and evaluation of a simple AAP—American Academy of Pediatrics Hib—Haemophilus influenzae type b febrile seizure in infants and young children 6 through 60 months of EEG—electroencephalogram age and to revise the practice guideline published by the American CT—computed tomography Academy of Pediatrics (AAP) in 1996. The recommendations in this report do not indicate an exclusive METHODS: This review included search and analysis of the medical course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be literature published since the last version of the guideline. Physicians appropriate. with expertise and experience in the fields of neurology and epilepsy, This document is copyrighted and is property of the American pediatrics, epidemiology, and research methodologies constituted a Academy of Pediatrics and its Board of Directors. All authors subcommittee of the AAP Steering Committee on Quality Improvement have filed conflict of interest statements with the American and Management. The steering committee and other groups within the Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American AAP and organizations outside the AAP reviewed the guideline. The Academy of Pediatrics has neither solicited nor accepted any subcommittee member who reviewed the literature for the 1996 AAP commercial involvement in the development of the content of practice guidelines searched for articles published since the last this publication. guideline through 2009, supplemented by articles submitted by other committee members. Results from the literature search were provided to the subcommittee members for review. Interventions of direct interest included lumbar puncture, electroencephalography, blood studies, and neuroimaging. Multiple issues were raised and discussed itera- tively until consensus was reached about recommendations. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed by the committee member most experienced in informatics and epidemiology and graded according to AAP policy. www.pediatrics.org/cgi/doi/10.1542/peds.2010-3318 doi:10.1542/peds.2010-3318 CONCLUSIONS: Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless the cause of the child’s fever. Meningitis should be considered in the reaffirmed, revised, or retired at or before that time. differential diagnosis for any febrile child, and lumbar puncture should PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). be performed if there are clinical signs or symptoms of concern. For Copyright © 2011 by the American Academy of Pediatrics any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended), or when immunization status cannot be determined, because of an increased risk of bacterial meningitis. A lumbar puncture is an option for children who are pretreated with antibiotics. In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography, blood studies, or neuroimaging. Pediatrics 2011;127:389–394

PEDIATRICS Volume 127, Number 2, February 2011 389 Downloaded from www.aappublications.org/news by guest on September 29, 2021 DEFINITION OF THE PROBLEM simple febrile seizure was shown to be tee on Quality Improvement and Manage- This practice guideline provides recom- only slightly higher than that of the gen- ment; members of the AAP Section on Ad- mendations for the neurodiagnostic eral population, whereas the chief risk ministration and Practice Management, evaluation of neurologically healthy in- associated with simple febrile seizures Section on Developmental and Behav- fants and children 6 through 60 months was recurrence in one-third of the chil- ioral Pediatrics, Section on Epidemiol- of age who have had a simple febrile sei- dren. The authors concluded that simple ogy, Section on Infectious Diseases, Sec- zure and present for evaluation within 12 febrile seizures are benign events with tion on Neurology, Section on Neurologic hours of the event. It replaces the 1996 excellent prognoses, a conclusion reaf- Surgery, Section on Pediatric Emergency practice parameter.1 This practice firmed in the 1980 consensus statement Medicine, Committee on Pediatric Emer- guideline is not intended for patients from the National Institutes of Health.3,4 gency Medicine, Committee on Practice who have had complex febrile seizures The expected outcomes of this practice and Ambulatory Medicine, Committee on (prolonged, focal, and/or recurrent), guideline include the following: Child Health Financing, Committee on In- and it does not pertain to children with fectious Diseases, Committee on Medical 1. Optimize clinician understanding of previous neurologic insults, known cen- Liability and Risk Management, Council the scientific basis for the neurodi- tral nervous system abnormalities, or on Children With Disabilities, and Council agnostic evaluation of children with history of afebrile seizures. on Community Pediatrics; and members simple febrile seizures. of outside organizations including the TARGET AUDIENCE AND PRACTICE 2. Aid the clinician in decision-making Child Neurology Society, the American SETTING by using a structured framework. Academy of Neurology, the American Col- This practice guideline is intended for 3. Optimize evaluation of the child who lege of Emergency Physicians, and mem- use by pediatricians, family physicians, has had a simple febrile seizure by bers of the Pediatric Committee of the child neurologists, neurologists, emer- detecting underlying diseases, min- Emergency Nurses Association. gency physicians, nurse practitioners, imizing morbidity, and reassuring A comprehensive review of the evidence- and other health care providers who anxious parents and children. based literature published from 1996 to evaluate children for febrile seizures. 4. Reduce the costs of physician and February 2009 was conducted to dis- BACKGROUND emergency department visits, hospi- cover articles that addressed the diag- talizations, and unnecessary testing. nosis and evaluation of children with A febrile seizure is a seizure accompa- simple febrile seizures. Preference was nied by fever (temperature Ն 100.4°F or 5. Educate the clinician to understand that a simple febrile seizure usually given to population-based studies, but 38°C2 by any method), without central given the scarcity of such studies, data nervous system infection, that occurs in does not require further evaluation, from hospital-based studies, groups of infants and children 6 through 60 specifically electroencephalography, young children with febrile illness, and months of age. Febrile seizures occur in blood studies, or neuroimaging. comparable groups were reviewed. 2% to 5% of all children and, as such, METHODOLOGY Decisions were made on the basis of a make up the most common convulsive systematic grading of the quality of evi- event in children younger than 60 To update the clinical practice guideline dence and strength of recommendations. months. In 1976, Nelson and Ellenberg,3 on the neurodiagnostic evaluation of 1 using data from the National Collabora- children with simple febrile seizures,1 In the original practice parameter, 203 tive Perinatal Project, further defined fe- the American Academy of Pediatrics medical journal articles were reviewed brile seizures as being either simple or (AAP) reconvened the Subcommittee on and abstracted. An additional 372 arti- complex. Simple febrile seizures were Febrile Seizures. The committee was cles were reviewed and abstracted for defined as primary generalized seizures chaired by a child neurologist and con- this update. Emphasis was placed on ar- that lasted for less than 15 minutes and sisted of a neuroepidemiologist, 3 addi- ticles that differentiated simple febrile did not recur within 24 hours. Complex tional child neurologists, and a practic- seizures from other types of seizures. Ta- febrile seizures were defined as focal, ing pediatrician. All panel members bles were constructed from the 70 arti- prolonged (Ն15 minutes), and/or recur- reviewed and signed the AAP voluntary cles that best fit these criteria. rent within 24 hours. Children who had disclosure and conflict-of-interest form. The evidence-based approach to guide- simple febrile seizures had no evidence No conflicts were reported. Participation line development requires that the evi- of increased mortality, hemiplegia, or in the guideline process was voluntary dence in support of a recommendation mental retardation. During follow-up and not paid. The guideline was reviewed be identified, appraised, and summa- evaluation, the risk of epilepsy after a by members of the AAP Steering Commit- rized and that an explicit link between

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likely be fatal or cause significant long-term disability if left untreated. ● Harms/risks/costs: Lumbar puncture is an invasive and often painful procedure and can be costly. ● Benefits/harms assessment: Pre- ponderance of benefit over harm. ● Value judgments: Data on the incidence of bacterial meningitis from before and after the existence FIGURE 1 of immunizations against Hib and Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms if a policy is carried out leads to designation of a policy as a strong recommendation, S pneumoniae were used in making recommendation, option, or no recommendation. RCT indicates randomized controlled trial; Rec, this recommendation. recommendation. ● Role of patient preferences: Although parents may not wish their child to undergo a lumbar puncture, health evidence and recommendations be de- ● Benefits/harms assessment: Pre- care providers should explain that in fined. Evidence-based recommendations ponderance of benefit over harm. the absence of complete immuniza- reflect the quality of evidence and the ● Value judgments: Observational data balance of benefit and harm that is antic- tions, their child may be at risk of hav- and clinical principles were used in ing fatal bacterial meningitis. ipated when the recommendation is fol- making this judgment. lowed. The AAP policy statement “Classi- ● Exclusions: This recommendation ● Role of patient preferences: Although fying Recommendations for Clinical applies only to children 6 to 12 parents may not wish to have their Practice Guidelines”5 was followed in months of age. The subcommittee child undergo a lumbar puncture, designating levels of recommendations felt that clinicians would recognize health care providers should explain (see Fig 1). symptoms of meningitis in children that if meningitis is not diagnosed and older than 12 months. KEY ACTION STATEMENTS treated, it could be fatal. ● Intentional vagueness: None. ● Exclusions: None. Action Statement 1 ● Policy level: Option. ● Intentional vagueness: None. Action Statement 1a ● Policy level: Strong recommendation. Action Statement 1c A lumbar puncture should be performed in any child who presents Action Statement 1b A lumbar puncture is an option in the child who presents with a sei- with a seizure and a fever and has In any infant between 6 and 12 meningeal signs and symptoms months of age who presents with a zure and fever and is pretreated (eg, neck stiffness, Kernig and/or seizure and fever, a lumbar puncture with antibiotics, because antibi- Brudzinski signs) or in any child is an option when the child is consid- otic treatment can mask the signs whose history or examination sug- ered deficient in Haemophilus influ- and symptoms of meningitis. gests the presence of meningitis or enzae type b (Hib) or Streptococcus ● Aggregate evidence level: D (rea- intracranial infection. pneumoniae immunizations (ie, has soning from clinical experience, ● Aggregate evidence level: B (over- not received scheduled immuniza- case series). whelming evidence from observa- tions as recommended) or when im- ● Benefits: Antibiotics may mask men- tional studies). munization status cannot be deter- ingeal signs and symptoms but may ● Benefits: Meningeal signs and symp- mined because of an increased risk be insufficient to eradicate meningi- toms strongly suggest meningitis, of bacterial meningitis. tis; a diagnosis of meningitis, if bacte- which, if bacterial in etiology, will ● Aggregate evidence level: D (expert rial in etiology, will likely be fatal if left likely be fatal if left untreated. opinion, case reports). untreated. ● Harms/risks/costs: Lumbar punc- ● Benefits: Meningeal signs and symp- ● Harms/risks/costs: Lumbar puncture is an invasive and often painful toms strongly suggest meningitis, ture is an invasive and often painful procedure and can be costly. which, if bacterial in etiology, will procedure and can be costly.

PEDIATRICS Volume 127, Number 2, February 2011 391 Downloaded from www.aappublications.org/news by guest on September 29, 2021 ● Benefits/harms assessment: Pre- ther obtunded or comatose when evalu- ● Aggregate evidence level: B (over- ponderance of benefit over harm. ated by a physician for the seizure, and whelming evidence from observa- ● Value judgments: Clinical experience the remainder most often have obvious tional studies). and case series were used in making clinical signs of meningitis (focal sei- ● Benefits: One study showed a pos- this judgment while recognizing that zures, recurrent seizures, petechial sible association with paroxysmal extensive data from studies are rash, or nuchal rigidity).9–11 Once a deci- EEGs and a higher rate of afebrile lacking. sion has been made to perform a lumbar seizures.12 puncture, then blood culture and serum ● Role of patient preferences: Although ● Harms/risks/costs: EEGs are costly glucose testing should be performed parents may not wish to have their and may increase parental anxiety. concurrently to increase the sensitivity child undergo a lumbar puncture, ● for detecting bacteria and to determine Benefits/harmsassessment: Prepon- medical providers should explain that if there is hypoglycorrhachia character- derance of harm over benefit. in the presence of pretreatment with istic of bacterial meningitis, respectively. ● Value judgments: Observational data antibiotics, the signs and symptoms were used for this judgment. of meningitis may be masked. Menin- Recent studies that evaluated the out- ● Role of patient preferences: Although gitis, if untreated, can be fatal. come of children with simple febrile seizures have included populations with a an EEG might have limited prognostic ● Exclusions: None. high prevalence of immunization.7,8 Data utility in this situation, parents should ● Intentional vagueness: Data are in- for unimmunized or partially immunized be educated that the study will not al- sufficient to define the specific treat- children are lacking. Therefore, lumbar ter outcome. ment duration necessary to mask puncture is an option for young children ● Exclusions: None. signs and symptoms. The committee who are considered deficient in immuni- ● Intentional vagueness: None. determined that the decision to per- zations or those in whom immunization ● Policy level: Strong recommendation. form a lumbar puncture will depend status cannot be determined. There are on the type and duration of antibiot- also no definitive data on the outcome of There is no evidence that EEG readings ics administered before the seizure children who present with a simple fe- performed either at the time of presen- and should be left to the individual brile seizure while already on antibiotics. tation after a simple febrile seizure or clinician. The authors were unable to find a defini- within the following month are predic- ● Policy level: Option. tion of “pretreated” in the literature, so tive of either recurrence of febrile seizures or the development of afebrile The committee recognizes the diversity they consulted with the AAP Committee seizures/epilepsy within the next 2 of past and present opinions regarding on Infectious Diseases. Although there is years.13,14 There is a single study that the need for lumbar punctures in chil- no formal definition, pretreatment can found that a paroxysmal EEG was associ- dren younger than 12 months with a sim- be considered to include systemic antibi- ated with a higher rate of afebrile sei- ple febrile seizure. Since the publication otic therapy by any route given within the zures.12 There is no evidence that inter- of the previous practice parameter,1 days before the seizure. Whether pre- ventions based on this test would alter however, there has been widespread im- treatment will affect the presentation outcome. munization in the United States for 2 of and course of bacterial meningitis cannot be predicted but will depend, in part, the most common causes of bacterial Action Statement 3 meningitis in this age range: Hib and S on the antibiotic administered, the dose, pneumoniae. Although compliance with the route of administration, the drug’s The following tests should not be per- all scheduled immunizations as recom- cerebrospinal fluid penetration, and the formed routinely for the sole pur- mended does not completely eliminate organism causing the meningitis. Lum- pose of identifying the cause of a sim- the possibility of bacterial meningitis bar puncture is an option in any child ple febrile seizure: measurement of serum electrolytes, calcium, phos- from the differential diagnosis, current pretreated with antibiotics before a sim- phorus, magnesium, or blood glu- data no longer support routine lumbar ple febrile seizure. cose or complete blood cell count. puncture in well-appearing, fully immunized children who present with a simple Action Statement 2 ● Aggregate evidence level: B (over- febrile seizure.6–8 Moreover, although An electroencephalogram (EEG) whelming evidence from observa- approximately 25% of young children should not be performed in the eval- tional studies). with meningitis have seizures as the pre- uation of a neurologically healthy ● Benefits: A complete blood cell count senting sign of the disease, some are ei- child with a simple febrile seizure. may identify children at risk for bacte-

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remia; however, the incidence of bac- than as part of the routine evaluation of literature on the use of CT in neurologi- teremia in febrile children younger the seizure itself. cally healthy children who have general- than 24 months is the same with or ized epilepsy has shown that clinically Action Statement 4 without febrile seizures. important intracranial structural abnor- ● Harms/risks/costs: Laboratory tests Neuroimaging should not be per- malities in this patient population are may be invasive and costly and pro- formed in the routine evaluation of uncommon.22,23 vide no real benefit. the child with a simple febrile seizure. CONCLUSIONS ● Benefits/harmsassessment: Prepon- ● Clinicians evaluating infants or young derance of harm over benefit. Aggregate evidence level: B (over- whelming evidence from observa- children after a simple febrile seizure ● Value judgments: Observational data tional studies). should direct their attention toward were used for this judgment. identifying the cause of the child’s fe- ● Benefits: Neuroimaging might pro- ● ver. Meningitis should be considered Role of patient preferences: Although vide earlier detection of fixed struc- in the differential diagnosis for any fe- parents may want blood tests per- tural lesions, such as dysplasia, or brile child, and lumbar puncture formed to explain the seizure, they very rarely, abscess or tumor. should be reassured that blood tests should be performed if the child is ill- ● Harms/risks/costs: Neuroimaging should be directed toward identifying appearing or if there are clinical signs tests are costly, computed tomogra- the source of their child’s fever. or symptoms of concern. A lumbar phy (CT) exposes children to radia- ● Exclusions: None. puncture is an option in a child 6 to 12 tion, and MRI may require sedation. months of age who is deficient in Hib ● Intentional vagueness: None. ● Benefits/harmsassessment: Prepon- and S pneumoniae immunizations or ● Policy level: Strong recommendation. derance of harm over benefit. for whom immunization status is un- There is no evidence to suggest that rou- ● Value judgments: Observational data known. A lumbar puncture is an option tine blood studies are of benefit in the were used for this judgment. in children who have been pretreated evaluation of the child with a simple fe- ● Role of patient preferences: Although with antibiotics. In general, a simple brile seizure.15–18 Although some chil- parents may want neuroimaging per- febrile seizure does not usually re- dren with febrile seizures have abnor- formed to explain the seizure, they quire further evaluation, specifically mal serum electrolyte values, their should be reassured that the tests EEGs, blood studies, or neuroimaging. condition should be identifiable by ob- carry risks and will not alter outcome taining appropriate histories and per- for their child. SUBCOMMITTEE ON FEBRILE forming careful physical examinations. It SEIZURES, 2002–2010 ● Exclusions: None. should be noted that as a group, children Patricia K. Duffner, MD (neurology, no ● Intentional vagueness: None. conflicts) with febrile seizures have relatively low Peter H. Berman, MD (neurology, no conflicts) serum sodium concentrations. As such, ● Policy level: Strong recommendation. Robert J. Baumann, MD (neuroepidemiology, physicians and caregivers should avoid The literature does not support the use no conflicts) Paul Graham Fisher, MD (neurology, no 18 overhydration with hypotonic fluids. of skull films in evaluation of the child conflicts) Complete blood cell counts may be use- with a febrile seizure.15,19 No data have John L. Green, MD (general pediatrics, no ful as a means of identifying young chil- been published that either support or conflicts) Sanford Schneider, MD (neurology, no dren at risk of bacteremia. It should be negate the need for CT or MRI in the conflicts) noted, however, that the incidence of evaluation of children with simple fe- bacteremia in children younger than 24 brile seizures. Data, however, show that STAFF months with or without febrile seizures CT scanning is associated with radia- Caryn Davidson, MA is the same. When fever is present, the tion exposure that may escalate future OVERSIGHT BY THE STEERING decision regarding the need for labora- cancer risk. MRI is associated with COMMITTEE ON QUALITY tory testing should be directed toward risks from required sedation and high IMPROVEMENT AND MANAGEMENT, identifying the source of the fever rather cost.20,21 Extrapolation of data from the 2009–2011

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