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

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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 inter- est 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 immuniza- tions as recommended), or when immunization status cannot be de- termined, because of an increased risk of bacterial meningitis. A lum- bar 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 October 1, 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,
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