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Abstract & Commentary
Source: Trainor JL, et al. Children with first-time febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med 2001;8:781-787.
This retrospective, multicenter study from five community emergency departments (EDs) and two tertiary pediatric EDs sought to determine the rates of serious bacterial illness (SBI) in children ages 6-60 months presenting to the ED with first-time simple febrile seizures. A simple febrile seizure was defined as: triage temperature greater than 38.0°C, history of a single, generalized tonic-clonic seizure lasting less than 20 minutes, and a nonfocal neurologic exam. Exclusion criteria included prior seizure, anticonvulsant use, known neurologic disease, history or clinical suspicion of head trauma, no description on the chart of level of consciousness, and cases in which the patient’s highest recorded level of consciousness was unarousable or comatose. Primary outcomes measured included rates of meningitis, pneumonia, bacteremia, urinary tract infection (UTI), and bacterial enteritis.
Among the seven hospitals, 455 children were identified as meeting inclusion criteria. The mean age of the children was 21 months, and the mean temperature was 39.6°C. Blood cultures were drawn from 315 children, four (1.3%) of whom were bacteremic with Streptococcus pneumoniae. All four children, three of whom had been treated with antibiotics, had repeat blood cultures that were sterile. Urine cultures were obtained from 171 children, of which 5.9% grew pathogenic organisms. Two hundred-eight children had chest radiographs performed, 13% of which were interpreted as having focal consolidation consistent with pneumonia. One hundred thirty-five children had cerebrospinal fluid (CSF) cultures performed, none of which grew a bacterial pathogen. Additionally, all records of patients diagnosed with meningitis were reviewed, and none of these patients presented with simple febrile seizure.
The authors conclude that the incidences of bacteremia and UTI among children with first time, simple febrile seizures are very similar to those for their febrile counterparts without seizures. They refrain from making conclusions regarding the incidence of pneumonia as an SBI, as it is difficult to identify definitively the etiologic agent (bacterial, viral, etc.). They also state that their data, in conjunction with previous studies, support the belief of many that routine lumbar puncture (LP) using the age-based American Academy of Pediatrics (AAP) criteria is not necessary.
Comment by Jacob W. Ufberg, MD
This was a well-done study, but its retrospective design limits its impact. Not all children received all tests, leaving us wondering if all children with SBI were identified. Despite this flaw, the authors’ message is loud and clear. We should not be treating children who meet the above criteria any differently than we would treat a child with the same temperature who did not have a seizure.
The AAP states that LP should be "considered" in children younger than 18 months old and should be "strongly considered" in children younger than 12 months old. However, no patients among the 135 who received CSF cultures grew a bacterial pathogen. Additionally, no patients who were diagnosed with meningitis at the seven hospitals presented with a simple febrile seizure. A study by Green and colleagues retrospectively evaluated a large group of children with meningitis who presented with seizure. They found no case of bacterial meningitis that presented with a simple febrile seizure and lacked other clear indications for lumbar puncture (i.e., nuchal rigidity, multiple or prolonged seizures). While a sufficiently powered prospective study is unlikely to be performed due to the huge number of patients it would require, I believe that this paper and the Green et al study provide sufficient evidence to avoid routine lumbar puncture for any simple febrile seizure. However, a high level of suspicion must be maintained for any child with a history or physical exam that raises concern about meningitis, and certainly for any child without a completely normal level of consciousness.
1. Green, SM, et al. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics 1993;92:527-534.