Lumbar puncture following febrile convulsion

Change in Prevalence of Meningitis among Children with Febrile Seizure after the Pentavalent Vaccination

Introduction

One of the most significant current discussions in pediatrics is whether lumbar puncture (LP) should be performed in children with febrile seizure (FS) as in the past.

Objectives

We compared the prevalence of meningitis among FS children before and after the pentavalent vaccine to determine the importance of the LP in these children.

Methods

We performed a retrospective cross-sectional study on the prevalence and etiology of bacterial meningitis (BM) in 1314 children with FS before and after pentavalent vaccination.

Results

We found that complex FS was more prevalent in patients aged under 12 months compared to other patients. The peak incidence of aseptic meningitis and BM was in the age group of 12- to 18- and 18- to 36-month-old, respectively (P value <0.001 and <0.05, respectively). Children with complex FS had a significantly higher rate of BM and a lower rate of seizure recurrence than those with simple FS (P value <0.05). There was a significant relationship between getting the pentavalent vaccine and reducing the prevalence of BM and Hib-induced BM, but no SP-induced BM (P value <0.05 and 0.05 and 0.104, respectively).

Conclusion

This study offers some insights into the effectiveness of the pentavalent vaccine. In addition, the low prevalence of BM in vaccinated FS cases does not support strong recommendations for LP in FS children.

Mothers' Views About Lumbar Puncture for Their Children in a Maternity and Children's Hospital in Najran, Saudi Arabia

BACKGROUND

Refusal rates for offered pediatric lumbar puncture (LP) are high in many parts of the world, potentially hindering diagnosis and treatment for thousands of children. There is relatively little research about why such rates are so high. Understanding the formation and development of mothers' opinions about LP could help identify barriers to accessing this modality to improve diagnostic and treatment outcomes in children with neurological and systemic diseases.

METHODS

We surveyed mothers of hospitalized children in the Maternity and Children's Hospital in Najran in November and December 2018. We queried their familiarity with LP and their decision to accept or refuse LP when it was offered. The team recorded demographic data on survey respondents, as well as their stated reasons for their LP decisions, and used chi-square tests to evaluate the correlation between patient or parent characteristics and the decision to accept or refuse LP.

RESULTS

A total of 202 mothers responded to the survey, with a mean age of 30.7 (± 6.9); nearly all women were stay-at-home mothers (93.1%). Most (61.4%) lived in urban settings. Four in 10 respondents (40.6%) were not familiar with LP. A sizable minority of 89 mothers (44.0%) refused LP for their children when offered, most commonly citing fear of paralysis (39.3%) as the reason for refusal. Those who accepted LP were more likely to do so following physician advice than for any other reason (p <0.001).

CONCLUSION

Lumbar puncture refusal rates may be even higher than previously reported, and there is a pressing need to educate women on the diagnostic and therapeutic benefits of LP for their children. Maternal education from physicians may help improve acceptance rates for the procedure.

Basics of modern epilepsy classification and terminology

BACKGROUND

The terminology and classification of seizures and epilepsy has undergone multiple revisions in the last several decades, which can lead to confusion and miscommunication amongst physicians and researchers. In 2017, the International League Against Epilepsy (ILAE) revised the classification of both seizures and epilepsy types in an effort to use less ambiguous terminology. Over time, definitions for status epilepticus, febrile seizures, and neonatal seizures have also evolved, as has the delineation of various epilepsy syndromes by age.

METHODS

Review of the literature for old and new terminology and various epilepsy syndromes was accomplished using the PubMed database system.

RESULTS

In the following article, we review old terminology for classifying seizures and epilepsy as compared to the new (2017) ILAE guidelines. We discuss neonatal seizures, status epilepticus, febrile seizures, autoimmune epilepsy and various epilepsy syndromes by age of onset.

CONCLUSION

Adopting a classification system that uses plain language allows for more effective and efficient communication between individuals and across specialties. Definitions of various syndromes and seizure types have evolved over time and are reviewed.

Risk of Bacterial Meningitis in Children 6 to 11 Months of Age With a First Simple Febrile Seizure: A Retrospective, Cross-sectional, Observational Study

OBJECTIVES

National and international guidelines are very heterogeneous about the necessity to perform a lumbar puncture (LP) in children under 12 months of age with a first simple febrile seizure. We estimated the risk of bacterial meningitis in children aged 6 to 11 months with a first simple febrile seizure.

METHODS

This multicenter retrospective study was conducted in seven pediatric emergency departments (EDs) in the region of Paris, France. Visits of patients aged 6 to 11 months for a first simple febrile seizure from January 2007 to December 2011 were analyzed. Bacterial meningitis was sequentially sought for by 1) analyzing bacteriologic data at the time of the visit, 2) looking for data from a second visit to the hospital after the index visit, and 3) phone calling the child's parents to determine the symptom evolution after the index visit. Infants lost to this follow-up were searched for in a national bacterial meningitis database.

RESULTS

From a total of 1,183,487 visits in the seven pediatric EDs, 116,503 were for children 6 to 11 months of age. From these, 205 visits were for a first simple febrile seizure. An LP was performed in 61 patients (29.8%). The outcome bacterial meningitis was ascertainable for 168 (82%) visits. No bacterial meningitis was found among these patients (95% confidence interval = 0% to 2.2%). None of the 37 infants lost to our follow-up were registered in the national database as having bacterial meningitis.

CONCLUSIONS

Among children between 6 and 11 months of age with a first simple febrile seizure, the risk of bacterial meningitis is extremely low. These results should encourage national and international societies to either develop or endorse guidelines limiting routine LP in these infants and contribute to widely homogenized management practices.

Frequency of Meningitis in Children Presenting with Febrile Seizures at Ali-Asghar Children's Hospital

OBJECTIVE

Febrile seizures (FS) are the most common type of childhood seizures, affecting 2-5% of children. As the seizure may be the sole presentation of bacterial meningitis in febrile infants, it is mandatory to exclude underlying meningitis in children presenting with fever and seizure. To determine the frequency of meningitis in children with FS and related risk factors, the present study was conducted at Ali-Asghar Children's Hospital.

MATERIALS & METHODS

The records of children aged from 1-month-6 years of age with fever and seizure admitted to the hospital from October 2000-2010 were studied. The charts of patients who had undergone a lumbar puncture were studied and cases of meningitis were selected. The related data was collected and analyzed with SPSS version 16.

RESULTS

A total of 681 patients with FS were known from which 422 (62%) lumbar punctures (LP) were done. Meningitis (bacterial or aseptic) was identified in 19 cases (4.5%, 95% CI 2.9-6.9 by Wilson- Score internal) and bacterial meningitis in 7 (1.65%, 95% CI 0.8-3.3). None of the patients with bacterial meningitis had meningeal irritation signs. Complex FS, first attack of FS, and impaired consciousness were more common in patients with meningitis when compared to non- meningitis patients.

CONCLUSION

Meningitis is more common in patients less than 18 months presenting with FS; however, complex features of seizures, first attack of FS, or impaired consciousness seem significant risk factors for meningitis in these children and an LP should be considered in this situation.

[Complex febrile seizures: study of the associated pathology and practical use of complementary tests]

INTRODUCTION

Although one third of febrile seizures are complex, a consensus has still not been reached on how to manage them, as is the case with simple febrile seizures. The objective of this study is to estimate the usefulness of complementary examinations and the risk of associated serious intracranial pathology.

PATIENTS AND METHODS

A retrospective review was conducted from 2003 until 2011 on patients from 6 months to 6 years presenting with a complex febrile seizure admitted to a tertiary care hospital, excluding the cases with previous neurological disease. Epidemiological and clinic variables were collected, as well as complementary tests and complications.

RESULTS

We found 65 patients (31 females and 34 males), of whom 44 had repeated seizures in the first 24 hours, with 15 having focal seizures. The vast majority (90%) of the recurrences occurred before 15 hours. The mean age was 20.7 months and temperature was 39.1 ± 0.12°C. None of the patients had severe intracranial pathology. The electroencephalogram gave no helpful information for the diagnosis. Neuroimaging was normal in all studied cases.

CONCLUSIONS

The incidence of complications in complex febrile seizure in our series did not justify the systematic admission or the systematic study with complementary tests when the neurological examination was normal. The routine electroencephalogram does not appear to be justified.

Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis

Background

Of major concern in any febrile child presenting with a seizure is the possibility of bacterial meningitis (BM). We did a systematic review to estimate the risk of BM among various subgroups of young children with a first seizure in the context of fever, and to assess the utility of routine lumbar puncture (LP) in children with an apparent first FS.

Methods/Principal Findings

MEDLINE, INIST, and the COCHRANE Library databases were searched from inception to December 2011 for published studies, supplemented by manual searches of bibliographies of potentially relevant articles and review articles. Studies reporting the prevalence of BM in young children presenting to emergency care with a first: i) “seizure and fever”, ii) apparent simple FS, and iii) apparent complex FS were included. Fourteen studies met the inclusion criteria. In children with a first “seizure and fever”, the pooled prevalence of BM was 2.6% (95% CI 0.9–5.1); the diagnosis of BM might be suspected from clinical examination in 95% of children >6 months. In children with an apparent simple FS, the average prevalence of BM was 0.2% (range 0 to 1%). The pooled prevalence of BM among children with an apparent complex FS was 0.6% (95% CI 0.2–1.4). The utility of routine LP for diagnosis of CNS infections requiring immediate treatment in children with an apparent first FS was low: the number of patients needed to test to identify one case of such infections was 1109 in children with an apparent first simple FS, and 180 in those with an apparent first complex FS.

Conclusion

The values provided from this study provide a basis for an evidence-based approach to the management of different subgroups of children presenting to emergency care with a first seizure in the context of fever.

Febrile and other occasional seizures

Seizures with fever that result from encephalitis or meningitis usually occur late in the course of febrile illness, and are focal and prolonged. Febrile seizures are by far the most common affecting 5% of the population, followed by posttraumatic seizures and those observed in the setting of a toxic, infectious, or metabolic encephalopathy. This chapter reviews the clinical presentation of the three most common forms, due to fever, trauma, and intoxication. Febrile seizures carry no cognitive or mortality risk. Recurrence risk is increased by young age, namely before 1 year of age. Febrile seizures that persist after the age of 6 years are usually part of the syndrome of Generalized epilepsy febrile seizures plus. These febrile seizures have a strong link with epilepsy since non-febrile seizures may occur later in the same patient and in other members of the same family with an autosomal dominant transmission. Complex febrile seizures, i.e., with focal or prolonged manifestations or followed by focal defect, are related to later mesial temporal epilepsy with hippocampal sclerosis; risk factors are seizure duration and brain malformation. Prophylactic treatment is usually not required in febrile seizures. Early onset of complex seizures is the main indication for AED prophylaxis. Early posttraumatic seizures, i.e., within the first week, are often focal and indicate brain trauma: contusion, hematoma, 24 hours amnesia, and depressed skull fracture are major factors of posttraumatic epilepsy. Prophylaxis with antiepileptic drugs is not effective. Various psychotropic drugs, including antiepileptics, may cause seizures.

The low rate of bacterial meningitis in children, ages 6 to 18 months, with simple febrile seizures

OBJECTIVES

This evidence-based review examines the risk of bacterial meningitis as diagnosed by lumbar puncture (LP) in children presenting to the emergency department (ED) with a simple febrile seizure. The study population consists of fully immunized children between ages 6 and 18 months of age with an unremarkable history and normal physical examination.

METHODS

MEDLINE, EMBASE, and Cochrane Library databases were searched for studies that enrolled children who presented with simple febrile seizure to the ED and had LP performed to rule out meningitis. The primary outcome measure was the risk of bacterial meningitis based on findings of the LP. The secondary outcome was the rate of cerebrospinal fluid (CSF) pleocytosis in children who were pretreated with antibiotics.

RESULTS

Two studies enrolling a total of 150 children met the inclusion and exclusion criteria. The overall rate of meningitis was 0% (95% confidence interval [CI] = 0.0% to 3.0%). The rate of CSF pleocytosis in children who were pretreated with antibiotics was 2.5% (95% CI = 0.0% to 14.0%).

CONCLUSIONS

The sample size of the studies included in this review is too small to draw any definitive conclusion. However, their findings suggest that that the risk of bacterial meningitis in children presenting with simple febrile seizure is very low.

Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with complex febrile seizures

OBJECTIVE

To estimate the rates of bacterial meningitis and herpes simplex virus (HSV) encephalitis in children presenting with complex febrile seizures.

METHODS

Health records from 2002 to 2006 of all children 6 months to 6 years with a discharge diagnosis from the Hospital for Sick Children (Toronto, ON) of febrile convulsion, meningitis, or encephalitis were reviewed. Rates of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures were calculated.

RESULTS

There were 390 encounters of complex febrile seizures in 366 children. Of these encounters, 75 (19%) were transferred from an outlying hospital. A history of febrile convulsions was noted in 140 (36%). Lumbar puncture was performed in 146 (37%) patients. Six patients (all but one transferred) were diagnosed with bacterial meningitis (all due to Streptococcus pneumoniae). One transferred patient was diagnosed with HSV encephalitis. In patients initially presenting to our emergency department the rates of bacterial meningitis and HSV encephalitis were 0.3% (95% confidence interval, 0.0-1.8) and 0.0% (95% confidence interval, 0.0-1.2), respectively.

CONCLUSIONS

Given the low rate of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures, routine lumbar puncture in these patients may be unnecessary.

Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age

OBJECTIVES

American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children.

METHODS

A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006.

RESULTS

First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis.

CONCLUSIONS

The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.

Methods of investigation and management of infections causing febrile seizures

The management of febrile seizures is reviewed, with emphasis on methods of investigation and treatment of associated infections. Records of 100 consecutive febrile seizure patient-visits were examined retrospectively at an East Carolina University-affiliated hospital. Causes of fever and infection, viral and bacterial studies, antipyretic, antibiotic, and antiviral treatments, and indications for lumbar puncture were analyzed. Febrile seizures were first episodes in 64, simple in 76, and complex in 23 (prolonged, at 30-60 minutes, in 4). The mean age was 20 months. Viral studies in 26 patients were positive in 9 (35%). Bacterial cultures in 100 were positive in 5%, none from CSF. Antibiotics were prescribed in 65%, and antipyretics in 89%. Lumbar puncture was performed in 14 patients; 11 had complex seizures, and 3 simple. Of simple seizure patients, none was aged <12 months, and only 1 was aged <18 months at time of lumbar puncture. Clinical manifestations and complex seizures are the principal indications for lumbar puncture, and not patient age. Viral infection is the most common cause of fever, and bacterial infection is infrequent. Early viral diagnosis should lessen the emphasis on bacterial cultures, and lead to reduced use of empiric antibiotics.

Pneumococcal meningitis presenting with a simple febrile seizure and negative blood-culture result

A 12-month-old girl with occult bacterial meningitis presented with a simple febrile seizure. On examination, the patient was alert, interactive, and smiling responsively without meningeal signs, focal neurologic findings, or signs of extreme illness. Her parents were reluctant to allow a lumbar puncture, and the patient was admitted for observation without lumbar puncture. Her fever resolved, and she was playful, had good oral intake, and was discharged 24 hours after admission. Her initial blood-culture result remained negative. Within 24 hours of discharge, the patient had a focal febrile seizure, came back to the hospital, and was found to have meningitis with a penicillin-susceptible, nonvaccine Streptococcus pneumoniae strain 12F.

Febrile seizures

Febrile seizures are the most frequent of seizure disorders in childhood. Febrile seizures are most common in children between 6 months and 3 years of age, with a peak incidence at about 18 months. Approximately 30% to 40% of children who experience a febrile seizure will have a recurrence. The majority of febrile seizures occur within 24 hours of the onset of the fever. Febrile seizures can be simple or complex. Diagnostic studies are usually not necessary. Febrile seizures usually are self-limited, and intervention to stop the seizure often is unnecessary. When possible, the cause of the fever should be treated. Continuous preventative anticonvulsant therapy is not recommended for children with either simple or complex febrile seizures. The use of intermittent anticonvulsant therapy is not routinely indicated. Parental educational and counseling is important. The prognosis is excellent.

Meningitis is a common cause of convulsive status epilepticus with fever

AIMS

In children with convulsive status epilepticus (CSE) with fever, to determine the likelihood of acute bacterial meningitis (ABM), the proportion that are treated with antibiotics, and the proportion that have diagnostic CSF sampling.

METHODS

Patients with an incident episode of CSE with fever were identified as part of an ongoing prospective population based study of CSE in childhood.

RESULTS

There were 49 incident cases of CSE in the first six months. Ascertainment was 96%. Twenty four had CSE with fever, 16 had early parenteral antibiotics, nine had diagnostic CSF sampling, and four had ABM. The population risk of ABM in CSE with fever was significantly higher than that of short seizures with fever (17% v 1.2%).

CONCLUSIONS

The classical symptoms and signs of ABM may be absent in CSE with fever. A high index of suspicion for ABM in the child with CSE with fever is paramount. The most appropriate management is suggested to be early parenteral antibiotics and a lumbar puncture when there are no contraindications.

Indicators of acute bacterial meningitis in children at a rural Kenyan district hospital

OBJECTIVE

Acute bacterial meningitis remains an important cause of death and neurologic sequelae in African children. The clinical features of meningitis are often nonspecific and in this setting may overlap with those of malaria. Early diagnosis and appropriate antibiotic treatment are perhaps the most important steps in management, but published data suggest that fewer than half of the cases of childhood meningitis are identified at first assessment in hospitals in this region. The objective of this study was to identify clinical indicators of acute bacterial meningitis by examining components of the World Health Organization Integrated Management of Childhood Illness (IMCI) referral criteria for meningitis (lethargy, unconsciousness, inability to feed, stiff neck, or seizures) and other symptoms and signs.

METHODS

Kilifi District Hospital, serving approximately 200,000 people in a rural, malaria-endemic area of the Kenyan coast, was studied. A Kenya Medical Research Institute research center is located at the hospital. All pediatric admissions aged > or =60 days between June 2001 and July 2002 were eligible.

RESULTS

A total of 91 (2.0%) of 4582 admissions had meningitis, including 77 (4.0%) of 1929 of those who met the IMCI referral criteria for meningitis at admission (sensitivity: 85%; specificity: 59%). Independent indicators of the presence of meningitis were a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range. One or more of these indicators was present in 895 (19%) of admissions, 72 (8.0%) of whom had meningitis (sensitivity: 79%; specificity: 80%). Independent indicators of the absence of meningitis were the absence of a history of fever, a history of diarrhea, and a positive malaria slide. The area under the receiver operating characteristic curve for a set of simple screening rules based on the positive indicators identified was 0.88 (95% confidence interval: 0.85-0.92).

CONCLUSIONS

The presence of > or =1 of a bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, and seizures outside the febrile convulsions age range is a clear indication for lumbar puncture and/or presumptive treatment. However, careful observation and reassessment may be the only practical way to identify one fifth of meningitis cases in this setting.

Febrile seizures: an update

This review focuses on the latest knowledge and understanding of febrile seizures and outlines the more important issues in the management of children who present with an apparent "febrile seizure". It is not the remit of this paper to discuss the detailed management of febrile seizures. Throughout this review, the words "partial" and "focal" will be used interchangeably and the term "febrile seizure" (FS) will be used, reflecting the proposed changes in the terminology of seizures and epilepsies.1