OBJECTIVES. American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children.
METHODS. A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006.
RESULTS. First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis.
CONCLUSIONS. The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.
Comments
Lumbar puncture is still necessary for any child with first simple febrile seizure
The article written by Kimia et al. (1) must raise much discussion of an old issue about the necessity of lumbar puncture for young children with first simple febrile seizure (FSFS). FSFS was defined as a first episode of seizure accompanied by fever, manifested as a primary generalized seizure lasting less than 15 minutes and not recurring within 24 hours. In another study from Nepal (2), of the 175 children who presented with first episode of fever and seizure in the age group of 6 months to 5 years, 17% were diagnosed to have meningitis. Cerebrospinal fluid was positive for a bacterial pathogen in 4.5% of the cases. In the age group of 6 months to 12 months, 30% of the children had meningitis as compared to 20 % and 5% in other age groups of 12- 18 months and above 18 months respectively. All children with culture proven bacterial meningitis were in the age group of 6-12 months and had no evidence of meningeal irritation.
It may be true that Hemophilus influenzae type B and pneumococcal vaccines do protect children from the 2 most notorious bacterial meningites in young children. Not all children received adequate immunization. And not all vaccines work perfect for ever. We need more time to see the long-term efficacy of new vaccines.
It's evident that the AAP (American Academy of Pediatrics) guidelines (3) not being followed in some hospitals of certain specific areas (4), many others follow it well. I personally do not favor any change by AAP at present, because the refusal rate of lumbar puncture by caregivers is raising and will raise more. And there is no other way to replace lumbar puncture in diagnosing meningitis.
REFERENCES: 1. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6-12. 2. Joshi Batajoo R, Rayamajhi A, Mahaseth C. Children with first episode of fever with seizure: is lumbar puncture necessary? JNMA J Nepal Med Assoc. 2008;47(171):109-112. 3. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics. 1996;97(5): 769?72 4. Shaked O, Garcia Peña BM, Linares MY, Baker RL. Simple febrile seizures: are the aap guidelines regarding lumbar puncture being followed? Pediatr Emerg Care. 2008 Dec 29. [Epub ahead of print]
Conflict of Interest:
None declared