LP Is Not Needed for Young Children with First Simple Febrile Seizure
It is time for the American Academy of Pediatrics to revise its recommendations for LP.
Although first simple febrile seizure (FSFS) usually is not the sole manifestation of bacterial meningitis, the American Academy of Pediatrics (AAP) practice parameter for the diagnostic evaluation of FSFS in children recommends that lumbar puncture (LP) be "strongly considered" for patients younger than 12 months and "considered" for those aged 12 to 18 months (Pediatrics 1996; 97:769). Investigators challenged this recommendation in the era of Haemophilus influenzae type B and pneumococcal conjugate vaccines.
The investigators retrospectively reviewed charts of well-appearing children aged 6 to 18 months who presented within 12 hours after FSFS to a single emergency department in Boston between 1995 and 2006. The primary outcome was the rate of bacterial meningitis. Secondary outcomes were compliance with the AAP practice parameter and temporal trends in the performance of LP. Of 704 patients, 27% were younger than 12 months. Overall, 8% of patients were hospitalized, and 10% had received at least one dose of antibiotics before their ED visit. LP was attempted in 271 cases (38%), and cerebrospinal fluid (CSF) was obtained in 260. Ten cases (3.8%) had CSF pleocytosis (median white cell count, 1 cell/mm3). No CSF culture was positive for a pathogen, and no patients with CSF pleocytosis had positive blood cultures. None of the 704 patients returned to the hospital with bacterial meningitis. During the study period, LP was performed in 70% of patients younger than 12 months and in 25% of those aged 12 to 18 months, with rates decreasing over time in both age groups. The authors recommend changing the wording of the AAP practice parameter to simply state that "meningitis should be considered in the differential diagnosis for any febrile child, and LP should be performed if there are clinical signs or symptoms of concern."
Most children with apparent FSFS who turn out to have meningitis also present with altered mental status and other clinical signs of meningitis. Given the low probability of bacterial meningitis in the current era of conjugate vaccines, there is no reason to assume that a febrile child aged 6 to 18 months with FSFS has an appreciable risk for meningitis; therefore, LP is not indicated. These data support a revision of the AAP practice parameter.
Jill M. Baren, MD, MBE, FACEP, FAAP
Published in Journal Watch Emergency Medicine February 27, 2009
Citation(s): Kimia AA et al. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics 2009 Jan; 123:6.