Suspected diagnosis “febrile seizures”: What renders the need for further diagnostics unnecessary?

Author Prof. J. Spranger, University Department of Pediatrics Mainz

In cases of “febrile seizures” any inflammatory conditions must be ruled out, especially all types of meningitis. Most children presenting with febrile seizures for the first time are admitted to a clinic for lumbar puncture, EEG, laboratory diagnostics and diagnostic imaging. In 2011, the American Academy of Pediatrics issued a guideline on when and under what circumstances these procedures can be forgone.
To examine the extent to which this guideline was followed and, if so, whether meningitis went untreated in many of these cases, the incident-related data of nearly 150,000 children who presented with their first febrile seizures between 2005 and 2019, as recorded in the United States Pediatric Health Insurance System (PHIS), was analysed [1].

First, it became apparent that the trend towards abandoning outpatient diagnostics, which had started in 2005, continued. Throughout the specified timeframe, five meningitis cases were overlooked, i.e. recognised and treated too late (misdiagnosis rate 0.0033%). This figure was contrasted with the reduction in medical costs brought about by outpatient treatment. They fell from $1,523 per patient in 2005 to $605 per patient in 2019.

Comment: The febrile seizure guideline of the American Academy of Pediatrics [2] considers an immediate lumbar puncture to be indispensable in cases of neurological abnormalities in infants such as neck stiffness, signs of intracranial pressure, Kernig’s or Brudzinski’s signs. With somewhat less emphasis, it is also recommended in cases where the infants are not known to have received a pneumococcal and Hib vaccination and where they are currently treated with antibiotics. In general, the guideline renders a blood test (electrolytes, glucose levels, blood count), EEG, cranial X-ray, CT, MR unnecessary in cases of simple febrile seizures.

[1] Rhagavan VR, Porter JJ, Neuman MI, Lyons TW. Trends in Management of Simple Febrile Seizures at US Children’s Hospitals. Pediatrics 2021; 148: Pediatrics (5): e2021051517.
[2] AM Acad Pediat Clinical Practice Guideline – Febrile Seizures. Guideline for the Neurodiagnostic Evaluation of the Child with a Simple Febrile Seizure. Pediatrics 2011;127:389–394.