LP for Complex Febrile Seizures
Dr. Molly McCormack
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)?
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.
Multicenter, retrospective study collecting data from 7 pediatric EDs in Paris, France from 2007 to 2011.
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.
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.
Will this study change my clinical practice? Possibly.