(Last Updated On: April 2, 2018)

We continue the series with Knowledge Bomb #16. The purpose and motivation for this series is outlined in the first entry and extensively in an ALiEM IDEA series blog entry.

Background

Simple febrile seizures are common in the pediatric population, ages 6 months to 5 years. However, complex febrile seizures are more rare, affecting less than 1% of children. The work up becomes more complicated when a patient presents with a complex febrile seizure.  There is controversy about the need for a lumbar puncture (LP) in this population given the low prevalence of bacterial meningitis and Herpes Simplex Virus meningoencephalitis (HSV-ME) in children.

In the pediatric population, complex febrile seizures remain an uncommon presentation for meningitis. Current American Academy of Pediatrics (AAP) guidelines for simple febrile seizure recommend performing or considering a LP for any child who presents with a febrile seizure and meningeal signs/symptoms, immunocompromised or unimmunized, or exam suggesting the presence of meningitis or intracranial infection. As of this publication, there are no specific recommendations for complex febrile seizures. Do otherwise well appearing children after complex febrile seizures need a lumbar puncture in the emergency department (ED)?

Article

Guedj, Romain et al. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture?. Annals of Emergency Medicine. 2017; 70 (1) 52-62.e6.

Study Design

Multicenter, retrospective study collecting data from 7 pediatric EDs in Paris, France from 2007 to 2011.

Charts were reviewed looking for specific wording to identify children who met diagnostic criteria for complex febrile seizure. Subgroups were established for patients whose clinical exam was suggestive of meningitis or encephalitis vs those whose exam was not.

  1. Informatics tool used to identify infant with possible seizure.
  2. Manual review: potential visits children 6 months to 5 years with complex febrile seizures (2103).
  3. Standardized analysis: confirmed visit of children 6 month to 5 years of age with complex febrile seizures (839).
  4. Subgroups: with clinical signs of meningitis (209) and without (630).

Of all the patients with complex febrile seizures, 260 had an LP performed on initial visit.  If they did not have an LP performed follow up was attempted. Charts were reviewed for the second hospital visit,  parents were called to determine the child’s outcome, and a national meningitis database was reviewed for all children in the study.

Results

Of the 839 patients who presented for complex febrile seizures, 260 (31%) had lumbar punctures done in the ED. The outcomes of bacterial meningitis and HSV-ME were seen with 5 cases (0.7%) of bacterial meningitis in this study. All with meningitis had an LP performed on the initial visit. No subsequent negative outcomes were identified for those patients who did not receive an LP and were sent home. Among the 630 visits of children with a clinical exam that was not suggestive of meningitis or encephalitis, there were no cases of bacterial meningitis and no HSV. The outcomes of 15% of patients were left unconfirmed, as their parents could not be reached. However, these children were not found in the national database and therefore imply a low likelihood that meningitis was missed.

Bomb!

In children with complex febrile seizures, routine LP is not needed as bacterial meningitis and HSV-ME are unexpected and unlikely events when the clinical examination is not concerning.

Discussion

Will this study change my clinical practice?  Possibly.

This study helped me see the following:

  1. If a child is well appearing without meningeal signs, consider holding on performing the LP.  Have a discussion with the parents regarding the utility of performing an LP if there is low suspicion.
  2. The type of complex febrile seizure may influence the likelihood of performing a LP in ED.
  3. Until the AAP guidelines are updated and clearly define when LP is needed in complex febrile seizure, most may still need a LP to exclude bacterial meningitis or HSV-ME.
  4. Since LP is generally well tolerated and easy to perform in children, it’s better to have many negative LPs in order to not miss one bacterial meningitis.

Molly McCormack is a PGY3 EM resident at UIC