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by members of the AAP Grand Rounds editorial team.

Revised AAP Guidelines for Evaluation

of Simple Febrile Seizure
by J. Gordon Millichap, MD, FAAP, Chicago, IL
Dr Millichap has disclosed no financial relationship relevant to this commentary. This commentary does not contain
a discussion of an unapproved/investigative use of a commercial product/device.

Source: American Academy of Pediatrics. Subcommittee on

Febrile Seizures. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure.
Pediatrics. 2011;127(2):389-394; doi:10.1542/peds.2010-3318

n American Academy of Pediatrics (AAP) subcommittee

on febrile seizures recently revised their practice guidelines for the diagnosis and evaluation of a simple febrile
seizure in children 6 months through 60 months of age. These
guidelines replace the 1996 AAP practice parameter.1 A simple
febrile seizure is a generalized seizure accompanied by fever
(temperature >100.4F or 38C) lasting less than 15 minutes and
not recurring within 24 hours. Evidence-based recommendations
proposed for the management of a child with a febrile seizure are
as follows:
Identify the cause of fever.
Consider meningitis in the differential diagnosis.
Perform a lumbar puncture (LP) if the child is ill-appearing
or there are clinical signs or symptoms of concern.
LP is an option in any infant 6 to 12 months of age who
presents with a seizure and fever and who has not been adequately vaccinated against Haemophilus influenzae type b
or Streptococcus pneumoniae, or when immunization status
cannot be determined.
LP is an option for children pretreated with antibiotics.
Further evaluation is not generally required, specifically EEG,
blood studies, or neuroimaging. The decision regarding the
need for laboratory tests should be directed toward identifying the source of the fever.
To lessen the risk of hyponatremia, overhydration with hyponatremic fluids should be avoided.2
The committee notes that these recommendations do not
indicate an exclusive course of treatment; variations according to
individual circumstances may be appropriate. The guidelines do
not apply to children with complex febrile seizures.

72

The 1996 AAP diagnostic guidelines1 recommended that LP

should be strongly considered for children younger than 12
months old, considered for those aged 12 to 18 months, and be
guided by clinical suspicion of meningitis in older children. In
the revised guideline, previous recommendations for LP based on
age are replaced by symptoms of concern or an ill-appearing
child. The main reason for this change in recommendation is the
decrease in rates of bacterial meningitis because of widespread
immunization against H influenza type b and invasive strains of
S pneumoniae.
While emphasizing indications for LP and discouraging routine laboratory testing, the authors of the guidelines give minimal
attention to the relative paucity of bacterial as compared to viral
infections associated with simple febrile seizures or to their identification. Rates of bacterial illness in children with simple febrile
seizures are low, and are similar to rates for febrile children without seizures.3 In one study of 455 children with first-time febrile
seizures treated in the emergency departments of Chicago-area
hospitals, blood cultures were positive in only 1.3%, and cerebrospinal fluid cultures were negative in all 135 patients tested.3
In another report of 100 consecutive children treated for febrile
seizures in a university-affiliated hospital, bacterial cultures were
performed on 64 patients with simple febrile seizures, of which
only 3 (5%) were positive.4 Despite this low rate of bacterial disease, antibiotics were prescribed empirically in 65% of patients.
Viral cultures were positive in 35% of the 26 patients in whom
they were obtained. In a total of 77 patients with simple febrile
seizures, only 3.9% underwent an LP, compared with 48% of those
with complex seizures. Complex seizure was the chief indication
for LP in this febrile seizure patient cohort; age was not a determining factor, and no child had meningitis.
The frequency of viral infection in the etiology of febrile seizures is well established, but rapid viral testing is not yet readily
available. Early viral diagnosis might lessen the indication for LP
and bacterial cultures and reduce empiric antibiotics use.5 Guidelines for the evaluation of a child with a simple febrile seizure will
continue to evolve, and indications for LP and other diagnostic
tests will be determined by advances in the rapid diagnosis of the
source of fever and the mechanism of the febrile seizure.6
References

1. American Academy of Pediatrics. Provisional Committee on Quality Improvement and

Subcommittee on Febrile Seizures. Pediatrics. 1996;97:769-772
2. Thoman JE, et al. Pediatr Neurol. 2004;31:342-344
3. Trainor JL, et al. Acad Emerg Med. 2001;8:781-787
4. Millichap JJ, et al. Pediatr Neurol. 2008;39:381-386
5. Millichap JJ, et al. J Infect Dis. 2008;198:1093-1094
6. Millichap JG, et al. Pediatr Neurol. 2006;35:165-172

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