AAP Updates Febrile Seizure Guidelines

A lumbar puncture should be performed in any child with a simple febrile seizure that is accompanied by signs of meningitis, according to new AAP guidelines.

New guidelines from the American Academy of Pediatrics (AAP) state that a lumbar puncture should be performed in any child with a simple febrile seizure that is accompanied by signs and symptoms of meningitis, which include such signs include neck stiffness, petechial rash, and Kernig and/or Brudzinski signs.

In a report published in Pediatrics, the AAP’s subcommittee on febrile seizures, the authors noted that although lumbar puncture is invasive, often painful, and can be costly, evidence suggests a benefit that outweighs harm when meningitis is suspected.

"Although parents may not wish to have their child undergo a lumbar puncture, healthcare providers should explain that if meningitis is not diagnosed and treated, it could be fatal," the authors wrote. The guideline was developed to provide evidence-based recommendations for health care professionals about the diagnosis and evaluation of a simple febrile seizure in infants and young children 6 through 60 months of age and to revise the practice guideline published by the AAP in 1996.

The guideline is intended for neurologically healthy infants and children who have had a simple febrile seizure and present for evaluation within 12 hours of the event. The authors specified that it is not aimed at patients who have had complex febrile seizures (prolonged, focal, and/or recurrent), and does not pertain to children with previous neurologic insults, known central nervous system abnormalities, or history of afebrile seizures.

The AAP defines febrile seizure as a seizure accompanied by fever (temperature 100.4°F or 38°C by any method), without central nervous system infection, that occurs in infants and children. Febrile seizures occur in 2% to 5% of all children and make up the most common convulsive event in children younger than 60 months.

Recommendations for the management of febrile seizures are:

  • A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms or in any child whose history or examination suggests the presence of meningitis or intracranial infection.
  • In 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 immunizations as recommended) or when immunization status cannot be determined because of an increased risk of bacterial meningitis.
  • A lumbar puncture is an option in the child who presents with a seizure and fever and is pretreated with antibiotics, because antibiotic treatment can mask the signs and symptoms of meningitis.
  • An electroencephalogram should not be performed in the evaluation of a neurologically healthy child with a simple febrile seizure.
  • The following tests should not be performed routinely for the sole purpose of identifying the cause of a simple febrile seizure: measurement of serum electrolytes, calcium, phosphorus, magnesium, or blood glucose or complete blood cell count.
  • Neuroimaging should not be performed in the routine evaluation of the child with a simple febrile seizure.

To access the Pediatrics guideline, click here.