Clinical Practice Guideline—Febrile Seizures:Guideline for the Neurodiagnostic Evaluation of theChild With a Simple Febrile Seizure
abstractOBJECTIVE: To formulate evidence-based recommendations for healthcare professionals about the diagnosis and evaluation of a simplefebrile seizure in infants and young children 6 through 60 months ofage and to revise the practice guideline published by the AmericanAcademy of Pediatrics (AAP) in 1996.
METHODS: This review included search and analysis of the medicalliterature published since the last version of the guideline. Physicianswith expertise and experience in the fields of neurology and epilepsy,pediatrics, epidemiology, and research methodologies constituted asubcommittee of the AAP Steering Committee on Quality Improvementand Management. The steering committee and other groups within theAAP and organizations outside the AAP reviewed the guideline. Thesubcommittee member who reviewed the literature for the 1996 AAPpractice guidelines searched for articles published since the lastguideline through 2009, supplemented by articles submitted by othercommitteemembers. Results from the literature searchwere providedto the subcommittee members for review. Interventions of direct inter-est included lumbar puncture, electroencephalography, blood studies,and neuroimaging. Multiple issues were raised and discussed itera-tively until consensus was reached about recommendations. Thestrength of evidence supporting each recommendation and thestrength of the recommendation were assessed by the committeemember most experienced in informatics and epidemiology andgraded according to AAP policy.
CONCLUSIONS: Clinicians evaluating infants or young children after asimple febrile seizure should direct their attention toward identifyingthe cause of the child’s fever. Meningitis should be considered in thedifferential diagnosis for any febrile child, and lumbar puncture shouldbe performed if there are clinical signs or symptoms of concern. Forany infant between 6 and 12months of age who presents with a seizureand fever, a lumbar puncture is an option when the child is considereddeficient in Haemophilus influenzae type b (Hib) or Streptococcuspneumoniae immunizations (ie, has not received scheduled immuniza-tions as recommended), or when immunization status cannot be de-termined, because of an increased risk of bacterial meningitis. A lum-bar puncture is an option for children who are pretreated withantibiotics. In general, a simple febrile seizure does not usually requirefurther evaluation, specifically electroencephalography, blood studies,or neuroimaging. Pediatrics 2011;127:389–394
SUBCOMMITTEE ON FEBRILE SEIZURES
KEY WORDseizure
ABBREVIATIONSAAP—American Academy of PediatricsHib—Haemophilus influenzae type bEEG—electroencephalogramCT—computed tomography
The recommendations in this report do not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.
This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-3318
doi:10.1542/peds.2010-3318
All clinical practice guidelines from the American Academy ofPediatrics automatically expire 5 years after publication unlessreaffirmed, revised, or retired at or before that time.
DEFINITION OF THE PROBLEMThis practice guideline provides recom-mendations for the neurodiagnosticevaluation of neurologically healthy in-fants and children 6 through 60 monthsof age who have had a simple febrile sei-zureandpresent for evaluationwithin 12hours of the event. It replaces the 1996practice parameter.1 This practiceguideline is not intended for patientswho have had complex febrile seizures(prolonged, focal, and/or recurrent),and it does not pertain to children withprevious neurologic insults, known cen-tral nervous system abnormalities, orhistory of afebrile seizures.
TARGET AUDIENCE AND PRACTICESETTING
This practice guideline is intended foruse by pediatricians, family physicians,child neurologists, neurologists, emer-gency physicians, nurse practitioners,and other health care providers whoevaluate children for febrile seizures.
BACKGROUND
A febrile seizure is a seizure accompa-nied by fever (temperature� 100.4°F or38°C2 by any method), without centralnervous system infection, that occurs ininfants and children 6 through 60months of age. Febrile seizures occur in2% to 5% of all children and, as such,make up the most common convulsiveevent in children younger than 60months. In 1976, Nelson and Ellenberg,3
using data from the National Collabora-tive Perinatal Project, further defined fe-brile seizures as being either simple orcomplex. Simple febrile seizures weredefined as primary generalized seizuresthat lasted for less than 15 minutes anddid not recur within 24 hours. Complexfebrile seizures were defined as focal,prolonged (�15minutes), and/or recur-rent within 24 hours. Children who hadsimple febrile seizures had no evidenceof increased mortality, hemiplegia, ormental retardation. During follow-upevaluation, the risk of epilepsy after a
simple febrile seizure was shown to beonly slightly higher than that of the gen-eral population, whereas the chief riskassociated with simple febrile seizureswas recurrence in one-third of the chil-dren. The authors concluded that simplefebrile seizures are benign events withexcellent prognoses, a conclusion reaf-firmed in the 1980 consensus statementfrom the National Institutes of Health.3,4
The expected outcomes of this practiceguideline include the following:
1. Optimize clinician understanding ofthe scientific basis for the neurodi-agnostic evaluation of children withsimple febrile seizures.
2. Aid the clinician in decision-makingby using a structured framework.
3. Optimize evaluation of the child whohas had a simple febrile seizure bydetecting underlying diseases, min-imizing morbidity, and reassuringanxious parents and children.
4. Reduce the costs of physician andemergency department visits, hospi-talizations, and unnecessary testing.
5. Educate the clinician to understandthat a simple febrile seizure usuallydoes not require further evaluation,specifically electroencephalography,blood studies, or neuroimaging.
METHODOLOGY
To update the clinical practice guidelineon the neurodiagnostic evaluation ofchildren with simple febrile seizures,1
the American Academy of Pediatrics(AAP) reconvened the Subcommittee onFebrile Seizures. The committee waschaired by a child neurologist and con-sisted of a neuroepidemiologist, 3 addi-tional child neurologists, and a practic-ing pediatrician. All panel membersreviewed and signed the AAP voluntarydisclosure and conflict-of-interest form.No conflictswere reported. Participationin the guideline process was voluntaryandnotpaid. Theguidelinewas reviewedbymembersof theAAPSteeringCommit-
teeonQuality Improvement andManage-ment;membersof theAAPSectiononAd-ministration and Practice Management,Section on Developmental and Behav-ioral Pediatrics, Section on Epidemiol-ogy, Section on Infectious Diseases, Sec-tion on Neurology, Section on NeurologicSurgery, SectiononPediatric EmergencyMedicine, Committee on Pediatric Emer-gency Medicine, Committee on Practiceand AmbulatoryMedicine, Committee onChild Health Financing, Committee on In-fectiousDiseases, CommitteeonMedicalLiability and Risk Management, Councilon ChildrenWith Disabilities, and Councilon Community Pediatrics; and membersof outside organizations including theChild Neurology Society, the AmericanAcademyof Neurology, the AmericanCol-lege of Emergency Physicians, andmem-bers of the Pediatric Committee of theEmergency Nurses Association.
A comprehensive review of the evidence-based literature published from 1996 toFebruary 2009 was conducted to dis-cover articles that addressed the diag-nosis and evaluation of children withsimple febrile seizures. Preference wasgiven to population-based studies, butgiven the scarcity of such studies, datafrom hospital-based studies, groups ofyoung children with febrile illness, andcomparable groups were reviewed.Decisions were made on the basis of asystematic grading of the quality of evi-dence and strength of recommendations.
In the original practice parameter,1 203medical journal articles were reviewedand abstracted. An additional 372 arti-cles were reviewed and abstracted forthis update. Emphasis was placed on ar-ticles that differentiated simple febrileseizures fromother typesof seizures. Ta-bles were constructed from the 70 arti-cles that best fit these criteria.
The evidence-based approach to guide-line development requires that the evi-dence in support of a recommendationbe identified, appraised, and summa-rized and that an explicit link between
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evidence and recommendations be de-fined. Evidence-based recommendationsreflect the quality of evidence and thebalanceof benefit andharmthat is antic-ipated when the recommendation is fol-lowed. The AAP policy statement “Classi-fying Recommendations for ClinicalPractice Guidelines”5 was followed indesignating levels of recommendations(see Fig 1).
KEY ACTION STATEMENTS
Action Statement 1
Action Statement 1a
A lumbar puncture should be per-formed in any child who presentswith a seizure and a fever and hasmeningeal signs and symptoms(eg, neck stiffness, Kernig and/orBrudzinski signs) or in any childwhose history or examination sug-gests the presence of meningitis orintracranial infection.
● Aggregate evidence level: B (over-whelming evidence from observa-tional studies).
● Benefits: Meningeal signs and symp-toms strongly suggest meningitis,which, if bacterial in etiology, willlikely be fatal if left untreated.
● Harms/risks/costs: Lumbar punc-ture is an invasive and often painfulprocedure and can be costly.
● Benefits/harms assessment: Pre-ponderance of benefit over harm.
● Value judgments: Observational dataand clinical principles were used inmaking this judgment.
● Role of patient preferences: Althoughparents may not wish to have theirchild undergo a lumbar puncture,health care providers should explainthat ifmeningitis is not diagnosedandtreated, it could be fatal.
● Exclusions: None.
● Intentional vagueness: None.
● Policy level: Strongrecommendation.
Action Statement 1b
In any infant between 6 and 12months of age who presents with aseizure and fever, a lumbar punctureis an option when the child is consid-ered deficient in Haemophilus influ-enzae type b (Hib) or Streptococcuspneumoniae immunizations (ie, hasnot received scheduled immuniza-tions as recommended) or when im-munization status cannot be deter-mined because of an increased riskof bacterial meningitis.
● Aggregate evidence level: D (expertopinion, case reports).
● Benefits: Meningeal signs and symp-toms strongly suggest meningitis,which, if bacterial in etiology, will
likely be fatal or cause significantlong-term disability if left untreated.
● Harms/risks/costs: Lumbar punc-ture is an invasive and often painfulprocedure and can be costly.
● Benefits/harms assessment: Pre-ponderance of benefit over harm.
● Value judgments: Data on the in-cidence of bacterial meningitisfrom before and after the existenceof immunizations against Hib andS pneumoniae were used in makingthis recommendation.
● Role of patient preferences: Althoughparents may not wish their child toundergo a lumbar puncture, healthcare providers should explain that inthe absence of complete immuniza-tions, their childmay be at risk of hav-ing fatal bacterial meningitis.
● Exclusions: This recommendationapplies only to children 6 to 12months of age. The subcommitteefelt that clinicians would recognizesymptoms of meningitis in childrenolder than 12 months.
● Intentional vagueness: None.
● Policy level: Option.
Action Statement 1c
A lumbar puncture is an option inthe child who presents with a sei-zure and fever and is pretreatedwith antibiotics, because antibi-otic treatment can mask the signsand symptoms of meningitis.
● Aggregate evidence level: D (rea-soning from clinical experience,case series).
● Benefits: Antibiotics may mask men-ingeal signs and symptoms but maybe insufficient to eradicate meningi-tis; a diagnosis of meningitis, if bacte-rial in etiology, will likely be fatal if leftuntreated.
● Harms/risks/costs: Lumbar punc-ture is an invasive and often painfulprocedure and can be costly.
FIGURE 1Integrating evidence quality appraisal with an assessment of the anticipated balance between bene-fits and harms if a policy is carried out leads to designation of a policy as a strong recommendation,recommendation, option, or no recommendation. RCT indicates randomized controlled trial; Rec,recommendation.
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● Benefits/harms assessment: Pre-ponderance of benefit over harm.
● Value judgments: Clinical experienceand case series were used in makingthis judgment while recognizing thatextensive data from studies arelacking.
● Role of patient preferences: Althoughparents may not wish to have theirchild undergo a lumbar puncture,medical providers should explain thatin the presence of pretreatment withantibiotics, the signs and symptomsof meningitis may be masked. Menin-gitis, if untreated, can be fatal.
● Exclusions: None.
● Intentional vagueness: Data are in-sufficient to define the specific treat-ment duration necessary to masksigns and symptoms. The committeedetermined that the decision to per-form a lumbar puncture will dependon the type and duration of antibiot-ics administered before the seizureand should be left to the individualclinician.
● Policy level: Option.
The committee recognizes the diversityof past and present opinions regardingthe need for lumbar punctures in chil-dren younger than12monthswitha sim-ple febrile seizure. Since the publicationof the previous practice parameter,1
however, there has beenwidespread im-munization in the United States for 2 ofthe most common causes of bacterialmeningitis in this age range: Hib and Spneumoniae. Although compliance withall scheduled immunizations as recom-mended does not completely eliminatethe possibility of bacterial meningitisfrom the differential diagnosis, currentdata no longer support routine lumbarpuncture in well-appearing, fully immu-nizedchildrenwhopresentwithasimplefebrile seizure.6–8 Moreover, althoughapproximately 25% of young childrenwithmeningitis have seizures as the pre-senting sign of the disease, some are ei-
ther obtunded or comatose when evalu-ated by a physician for the seizure, andthe remainder most often have obviousclinical signs of meningitis (focal sei-zures, recurrent seizures, petechialrash, or nuchal rigidity).9–11 Once a deci-sionhasbeenmade toperforma lumbarpuncture, then blood culture and serumglucose testing should be performedconcurrently to increase the sensitivityfor detecting bacteria and to determineif there is hypoglycorrhachia character-istic of bacterialmeningitis, respectively.
Recent studies that evaluated the out-come of children with simple febrile sei-zures have included populations with ahigh prevalence of immunization.7,8 Datafor unimmunized or partially immunizedchildren are lacking. Therefore, lumbarpuncture is an option for young childrenwho are considered deficient in immuni-zations or those in whom immunizationstatus cannot be determined. There arealso no definitive data on the outcome ofchildren who present with a simple fe-brile seizurewhilealreadyonantibiotics.The authors were unable to find a defini-tion of “pretreated” in the literature, sothey consulted with the AAP Committeeon Infectious Diseases. Although there isno formal definition, pretreatment canbeconsidered to includesystemicantibi-otic therapybyany routegivenwithin thedays before the seizure. Whether pre-treatment will affect the presentationand course of bacterial meningitis can-not be predicted but will depend, in part,on the antibiotic administered, the dose,the route of administration, the drug’scerebrospinal fluid penetration, and theorganism causing the meningitis. Lum-bar puncture is an option in any childpretreatedwith antibiotics before a sim-ple febrile seizure.
Action Statement 2
An electroencephalogram (EEG)should not be performed in the eval-uation of a neurologically healthychild with a simple febrile seizure.
● Aggregate evidence level: B (over-whelming evidence from observa-tional studies).
● Benefits: One study showed a pos-sible association with paroxysmalEEGs and a higher rate of afebrileseizures.12
● Harms/risks/costs: EEGs are costlyand may increase parental anxiety.
● Benefits/harmsassessment: Prepon-derance of harm over benefit.
● Value judgments: Observational datawere used for this judgment.
● Role of patient preferences: Althoughan EEG might have limited prognosticutility in this situation, parents shouldbe educated that the study will not al-ter outcome.
● Exclusions: None.
● Intentional vagueness: None.
● Policy level: Strongrecommendation.
There is no evidence that EEG readingsperformed either at the time of presen-tation after a simple febrile seizure orwithin the following month are predic-tive of either recurrence of febrile sei-zures or the development of afebrileseizures/epilepsy within the next 2years.13,14 There is a single study thatfound that a paroxysmal EEGwas associ-ated with a higher rate of afebrile sei-zures.12 There is no evidence that inter-ventions based on this test would alteroutcome.
Action Statement 3
The following tests should not be per-formed routinely for the sole pur-pose of identifying the cause of a sim-ple febrile seizure: measurement ofserum electrolytes, calcium, phos-phorus, magnesium, or blood glu-cose or complete blood cell count.
● Aggregate evidence level: B (over-whelming evidence from observa-tional studies).
● Benefits: A complete blood cell countmay identify children at risk for bacte-
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remia; however, the incidence of bac-teremia in febrile children youngerthan 24 months is the same with orwithout febrile seizures.
● Harms/risks/costs: Laboratory testsmay be invasive and costly and pro-vide no real benefit.
● Benefits/harmsassessment: Prepon-derance of harm over benefit.
● Value judgments: Observational datawere used for this judgment.
● Role of patient preferences: Althoughparents may want blood tests per-formed to explain the seizure, theyshould be reassured that blood testsshould be directed toward identifyingthe source of their child’s fever.
● Exclusions: None.
● Intentional vagueness: None.
● Policy level: Strongrecommendation.
There is no evidence to suggest that rou-tine blood studies are of benefit in theevaluation of the child with a simple fe-brile seizure.15–18 Although some chil-dren with febrile seizures have abnor-mal serum electrolyte values, theircondition should be identifiable by ob-taining appropriate histories and per-forming careful physical examinations. Itshouldbenoted that asagroup, childrenwith febrile seizures have relatively lowserum sodium concentrations. As such,physicians and caregivers should avoidoverhydration with hypotonic fluids.18
Complete blood cell counts may be use-ful as a means of identifying young chil-dren at risk of bacteremia. It should benoted, however, that the incidence ofbacteremia in children younger than 24months with or without febrile seizuresis the same. When fever is present, thedecision regarding the need for labora-tory testing should be directed towardidentifying the source of the fever rather
than as part of the routine evaluation ofthe seizure itself.
Action Statement 4
Neuroimaging should not be per-formed in the routine evaluation ofthe child with a simple febrileseizure.
● Aggregate evidence level: B (over-whelming evidence from observa-tional studies).
● Benefits: Neuroimaging might pro-vide earlier detection of fixed struc-tural lesions, such as dysplasia, orvery rarely, abscess or tumor.
● Harms/risks/costs: Neuroimagingtests are costly, computed tomogra-phy (CT) exposes children to radia-tion, and MRI may require sedation.
● Benefits/harmsassessment: Prepon-derance of harm over benefit.
● Value judgments: Observational datawere used for this judgment.
● Role of patient preferences: Althoughparents may want neuroimaging per-formed to explain the seizure, theyshould be reassured that the testscarry risks andwill not alter outcomefor their child.
● Exclusions: None.
● Intentional vagueness: None.
● Policy level: Strongrecommendation.
The literature does not support the useof skull films in evaluation of the childwith a febrile seizure.15,19 No data havebeen published that either support ornegate the need for CT or MRI in theevaluation of children with simple fe-brile seizures. Data, however, show thatCT scanning is associated with radia-tion exposure that may escalate futurecancer risk. MRI is associated withrisks from required sedation and highcost.20,21 Extrapolation of data from the
literature on the use of CT in neurologi-cally healthy children who have general-ized epilepsy has shown that clinicallyimportant intracranial structural abnor-malities in this patient population areuncommon.22,23
CONCLUSIONS
Clinicians evaluating infants or youngchildren after a simple febrile seizureshould direct their attention towardidentifying the cause of the child’s fe-ver. Meningitis should be consideredin the differential diagnosis for any fe-brile child, and lumbar punctureshould be performed if the child is ill-appearing or if there are clinical signsor symptoms of concern. A lumbarpuncture is an option in a child 6 to 12months of age who is deficient in Hiband S pneumoniae immunizations orfor whom immunization status is un-known. A lumbar puncture is an optionin children who have been pretreatedwith antibiotics. In general, a simplefebrile seizure does not usually re-quire further evaluation, specificallyEEGs, blood studies, or neuroimaging.
SUBCOMMITTEE ON FEBRILESEIZURES, 2002–2010Patricia K. Duffner, MD (neurology, noconflicts)Peter H. Berman, MD (neurology, no conflicts)Robert J. Baumann, MD (neuroepidemiology,no conflicts)Paul Graham Fisher, MD (neurology, noconflicts)John L. Green, MD (general pediatrics, noconflicts)Sanford Schneider, MD (neurology, noconflicts)
STAFFCaryn Davidson, MA
OVERSIGHT BY THE STEERINGCOMMITTEE ON QUALITYIMPROVEMENT AND MANAGEMENT,2009–2011
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Subcommittee on Febrile Seizuresa Simple Febrile Seizure
Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With
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