Revised AAP Guidelines for Evaluation of Simple Febrile Seizure

Abstract

Source: American Academy of Pediatrics. Subcommittee on Febrile Seizures. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011; 127(2): 389– 394; doi: 10.1542/peds.2010-3318Dr Millichap has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.An American Academy of Pediatrics (AAP) subcommittee on febrile seizures recently revised their practice guidelines for the diagnosis and evaluation of a simple febrile seizure in children 6 months through 60 months of age. These guidelines replace the 1996 AAP practice parameter.1 A simple febrile seizure is a generalized seizure accompanied by fever (temperature >100.4ºF or 38ºC) lasting less than 15 minutes and not recurring within 24 hours. Evidence-based recommendations proposed for the management of a child with a febrile seizure are as follows:The committee notes that these recommendations do not indicate an exclusive course of treatment; variations according to individual circumstances may be appropriate. The guidelines do not apply to children with complex febrile seizures.The 1996 AAP diagnostic guidelines1 recommended that LP should be strongly considered for children younger than 12 months old, considered for those aged 12 to 18 months, and be guided by clinical suspicion of meningitis in older children. In the revised guideline, previous recommendations for LP based on age are replaced by “symptoms of concern” or an “ill-appearing child.” The main reason for this change in recommendation is the decrease in rates of bacterial meningitis because of widespread immunization against H influenza type b and invasive strains of S pneumoniae.While emphasizing indications for LP and discouraging routine laboratory testing, the authors of the guidelines give minimal attention to the relative paucity of bacterial as compared to viral infections associated with simple febrile seizures or to their identification. Rates of bacterial illness in children with simple febrile seizures are low, and are similar to rates for febrile children without seizures.3 In one study of 455 children with first-time febrile seizures treated in the emergency departments of Chicago-area hospitals, blood cultures were positive in only 1.3%, and cerebrospinal fluid cultures were negative in all 135 patients tested.3 In another report of 100 consecutive children treated for febrile seizures in a university-affiliated hospital, bacterial cultures were performed on 64 patients with simple febrile seizures, of which only 3 (5%) were positive.4 Despite this low rate of bacterial disease, antibiotics were prescribed empirically in 65% of patients. Viral cultures were positive in 35% of the 26 patients in whom they were obtained. In a total of 77 patients with simple febrile seizures, only 3.9% underwent an LP, compared with 48% of those with complex seizures. Complex seizure was the chief indication for LP in this febrile seizure patient cohort; age was not a determining factor, and no child had meningitis.The frequency of viral infection in the etiology of febrile seizures is well established, but rapid viral testing is not yet readily available. Early viral diagnosis might lessen the indication for LP and bacterial cultures and reduce empiric antibiotics use.5 Guidelines for the evaluation of a child with a simple febrile seizure will continue to evolve, and indications for LP and other diagnostic tests will be determined by advances in the rapid diagnosis of the source of fever and the mechanism of the febrile seizure.6