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

Febrile Seizures: A Systematic Review of Different Guidelines

BACKGROUND

Febrile seizures (FS) are the most common neurological disorder in pediatric age. FS affect 2% to 12% of children and result from a complex interplay of genetic and environmental factors. Effective management and unambiguous recommendations are crucial for allocating health care resources efficiently and ensuring cost-effectiveness in treating FS.

METHODS

This systematic review compares existing guidelines to provide insights into FS management. Seven guidelines published between 1991 and 2021, from Japan, United Kingdom, United States, Mexico, India, and Italy, were included. Data extraction covered definitions, diagnostic criteria, hospital admission criteria, diagnostic tests, management, and prophylaxis recommendations.

RESULTS

Hospital admission criteria varied but typically included age <18 months and complex FS. Neuroimaging and lumbar puncture recommendations varied, with most guidelines suggesting limited use. Pharmacologic prophylaxis was generally discouraged for simple FS but considered only for high-risk cases, due to the benign nature of FS and the potential side effects of antiseizure medications.

CONCLUSIONS

Guidelines on FS exhibit similarities and differences, highlighting the need for standardized management and improved parental education to enhance clinical outcomes and reduce economic and social costs associated with FS. Future research should focus on creating updated international guidelines and ensuring their practical implementation.

Characteristics and Risk Factors of Central Nervous System Infection in Children With Febrile Seizures

OBJECTIVE

The aim of the present study is to evaluate the necessity of performing lumbar puncture in patients experiencing febrile seizures, considering the epidemiology specific to Brazil.

METHODS

A retrospective cross-sectional study was performed from January 2017 to December 2021.

RESULTS

A total of 469 children with seizure and fever were analyzed. The identified event was the first in 65.9% (n = 309). A total of 54.2% (n = 254) of patients had a simple febrile seizure. Infectious focus, excluding previous central nervous system (CNS) infection, was identified in 35.6% (n = 167) patients. Meningitis was identified in 7.7% (n = 36) patients, all of them were viral. Patients with CNS infection had a higher frequency of symptoms such as nausea and vomiting, drowsiness, headache, and higher level of leukocytosis. A longer duration of fever was found to be more strongly associated with CNS infection.

CONCLUSIONS

When considering the use of lumbar puncture in febrile seizure, it is important to conduct a comprehensive evaluation that considers multiple factors, including clinical signs, symptoms, and the overall clinical context. Meningeal signs may be less prominent, and other symptoms such as lethargy, irritability, and vomiting may serve as more reliable indicators. Although clinical examination suggestive of meningitis remains an important factor, the recurrence of febrile seizures and a longer length of fever can provide additional insights and aid in decision-making regarding lumbar puncture.

Creating rare epilepsy cohorts using keyword search in electronic health records

OBJECTIVE

Administrative codes to identify people with rare epilepsies in electronic health records are limited. The current study evaluated the use of keyword search as an alternative method for rare epilepsy cohort creation using electronic health records data.

METHODS

Data included clinical notes from encounters with International Classification of Diseases, Ninth Revision (ICD-9) codes for seizures, epilepsy, and/or convulsions during 2010-2014, across six health care systems in New York City. We identified cases with rare epilepsies by searching clinical notes for keywords associated with 33 rare epilepsies. We validated cases via manual chart review. We compared the performance of keyword search to manual chart review using positive predictive value (PPV), sensitivity, and F-score. We selected an initial combination of keywords using the highest F-scores.

RESULTS

Data included clinical notes from 77 924 cases with ICD-9 codes for seizures, epilepsy, and/or convulsions. The all-keyword search method identified 6095 candidates, and manual chart review confirmed that 2068 (34%) had a rare epilepsy. The initial combination method identified 1862 cases with a rare epilepsy, and this method performed as follows: PPV median = .64 (interquartile range [IQR] = .50-.81, range = .20-1.00), sensitivity median = .93 (IQR = .76-1.00, range = .10-1.00), and F-score median = .71 (IQR = .63-.85, range = .18-1.00). Using this method, we identified four cohorts of rare epilepsies with over 100 individuals, including infantile spasms, Lennox-Gastaut syndrome, Rett syndrome, and tuberous sclerosis complex. We identified over 50 individuals with two rare epilepsies that do not have specific ICD-10 codes for cohort creation (epilepsy with myoclonic atonic seizures, Sturge-Weber syndrome).

SIGNIFICANCE

Keyword search is an effective method for cohort creation. These findings can improve identification and surveillance of individuals with rare epilepsies and promote their referral to specialty clinics, clinical research, and support groups.

The Success of Resident-Associated Lumbar Punctures at a Large, Single-Center Children's Hospital

OBJECTIVES

The frequency of lumbar punctures (LPs) has declined across US children's hospitals over the past decade, potentially decreasing procedural learning opportunities for pediatric resident trainees. Our study sought to determine whether the proportion of successful LPs performed by our pediatric residents has significantly changed over time.

METHODS

This study is a single-center retrospective study to evaluate our pediatric resident LP success. We evaluated our primary outcome, proportion of overall LP success over time, using linear regression. We similarly used linear regression for proportion of successful resident-associated LPs over time. We calculated the median number of LPs of all pediatric residents during the study period.

RESULTS

We analyzed 3143 LPs from April 2012 to December 2019. Both the overall number of LPs performed and the proportion of LPs that were successful have not significantly changed over an 8-year period ( P > 0.05, P > 0.05). Similarly, the number of our resident-associated LPs and the proportion of successful resident-associated LPs have not changed over the study period ( P > 0.05, P > 0.05). Our pediatric residents performed a median of 3 LPs (interquartile range: 2-4) in the pediatric emergency department (PED) over residency.

CONCLUSIONS

Despite national trends showing decreased LP rates at pediatric hospitals, we demonstrated stable proportions of LPs and success by our pediatric residents. Pediatric residents perform a relatively low number of LPs in the PED setting alone. Future research is needed to demonstrate whether these overall low numbers in the PED translate to procedural competency after residency graduation.

Management of children with febrile seizures: a Greek nationwide survey

The purpose of this study was to investigate knowledge, principles, and practices concerning the management of children with febrile seizures among pediatricians in Greece. A cross-sectional study was performed across Greece. Pediatricians completed an anonymous and voluntary 11-item questionnaire about their knowledge, attitudes, and practices with respect to the management of febrile seizures; the survey also collected demographic data. It was first administered in paper form in October 2017. This was followed by an online survey performed between June and August of 2018 and publicized by medical boards across Greece. Descriptive statistics and comparisons between groups were conducted with the significance level set at p ≤ 0.05. We recorded 457 responses. Pediatricians admitted to modifying their advice to the parents of children with febrile seizures by suggesting more "aggressive" fever management at low temperatures or systematically (63%), referral to a specialist after any episode of febrile seizures (63%), or hospitalization in a subsequent episode (67%), even though 72% admitted these practices were of no efficacy. Almost one in three pediatricians (28%) believed aggressive management of fever could delay the onset of febrile seizures; increasing age was associated with this perception. A minority (28%) would make parents aware of febrile seizures before a first episode regardless of family history; 38% would do so in the event of family history.

CONCLUSIONS

Several pediatricians in Greece use outdated and ineffective practices for the management of febrile seizures, despite the availability of updated evidence-based guidelines. Further training of practitioners is needed to bridge this gap.

WHAT IS KNOWN

•Aggressive management of fever at low temperatures with antipyretics, referral to a neurologist, and hospitalization are not supported by evidence or recent guidelines on childhood febrile seizures. •Febrile seizures are especially disturbing to uninformed parents, who may be inclined to pursue aggressive but ineffective treatments as a result.

WHAT IS NEW

•Pediatricians in Greece use non-evidence-based practices for the management of febrile seizures, even when they are aware that these practices are not effective. •Older age increases the likelihood that a pediatrician will pursue guideline non-compliant practices in Greece. At the same time, physicians with over 20 years of experience are more likely to inform parents in advance about febrile seizures.

Fever-Associated Seizures or Epilepsy: An Overview of Old and Recent Literature Acquisitions

In addition to central nervous system infections, seizures and fever may occur together in several neurological disorders. Formerly, based on the clinical features and prognostic evolution, the co-association of seizure and fever included classical febrile seizures (FS) divided into simple, complex, and prolonged FS (also called febrile status epilepticus). Later, this group of disorders has been progressively indicated, with a more inclusive term, as "fever-associated seizures or epilepsy" (FASE) that encompasses: (a) FS divided into simple, complex, and prolonged FS; (b) FS plus; (c) severe myoclonic epilepsy in infancy (Dravet syndrome); (d) genetic epilepsy with FS plus; and (e) febrile infection-related epilepsy syndrome (FIRES). Among the FASE disorders, simple FS, the most common and benign condition, is rarely associated with subsequent epileptic seizures. The correlation of FS with epilepsy and other neurological disorders is highly variable. The pathogenesis of FASE is unclear but immunological and genetic factors play a relevant role and the disorders belonging to the FASE group show to have an underlying common clinical, immunological, and genetic pathway. In this study, we have reviewed and analyzed the clinical data of each of the heterogeneous group of disorders belonging to FASE.

Trends in Management of Simple Febrile Seizures at US Children's Hospitals

OBJECTIVE

We sought to measure trends in evaluation and management of children with simple febrile seizures (SFSs) before and after the American Academy of Pediatrics updated guidelines published in 2011.

METHODS

In this retrospective, cross-sectional analysis, we used the Pediatric Health Information System database comprising 49 tertiary care pediatric hospitals in the United States from 2005 to 2019. We included children aged 6 to 60 months with an emergency department visit for first SFS identified using codes from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases 10th Revision.

RESULTS

We identified 142 121 children (median age 21 months, 42.4% female) with an emergency department visit for SFS. A total of 49 668 (35.0%) children presented before and 92 453 (65.1%) after the guideline. The rate of lumbar puncture for all ages declined from 11.6% (95% confidence interval [CI], 10.8% to 12.4%) in 2005 to 0.6% (95% CI, 0.5% to 0.8%) in 2019 (P < .001). Similar reductions were noted in rates of head computed tomography (10.6% to 1.6%; P < .001), complete blood cell count (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean costs ($1523 to $601; P < .001). Reductions in all outcomes began before, and continued after, the publication of the American Academy of Pediatrics guideline. There was no significant change in delayed diagnosis of bacterial meningitis (preperiod 2 of 49 668 [0.0040%; 95% CI, 0.00049% to 0.015%], postperiod 3 of 92 453 [0.0032%; 95% CI, 0.00066% to 0.0094%]; P = .99).

CONCLUSIONS

Diagnostic testing, hospital admission, and costs decreased over the study period, without a concomitant increase in delayed diagnosis of bacterial meningitis. These data suggest most children with SFSs can be safely managed without lumber puncture or other diagnostic testing.

Epidemiology of Pediatric Meningitis in South Korea From 2010 to 2018: A Population-based Retrospective Cohort Study

BACKGROUND

Studies evaluating the epidemiology of pediatric meningitis are limited in our region. This study aimed to describe recent trends in the incidence of pediatric meningitis.

METHODS

We estimated national trends in hospitalization rates for pediatric meningitis (<18 years) by analyzing data from the Health Insurance Review and Assessment database between 2010 and 2018. Meningitis cases were identified based on International Classification of Diseases, Tenth Revision (ICD-10) codes and hospitalization rates were calculated.

RESULTS

In this national population-based study, a total of 119,644 hospitalizations and 58 deaths due to pediatric meningitis were identified. The hospitalization rates of pediatric bacterial meningitis have declined by 50.0%, from 3.4 per 100,000 in 2010 to 1.7 per 100,000 in 2018. The mortality rates for bacterial and viral meningitis were 2.0% and 0.002%, respectively. Despite the decreased annual incidence of bacterial meningitis, its mortality rate did not change significantly during the study period. The only risk factor identified for mortality in bacterial meningitis patients among age group, sex, region of residence, and season was age below 1 year (P < 0.001). As children under 1 year have a high-mortality rate (4.2%), patients in this age group require close monitoring. The reasons behind indistinct seasonal patterns of bacterial meningitis warrant further investigation.

CONCLUSIONS

Childhood bacterial meningitis has shown a significant decline in incidence from 2010 to 2018. In contrast, viral meningitis has not shown a trend over time. Knowledge of these changes may aid clinicians in the decision-making process and management of meningitis patients.

Declines in the Number of Lumbar Punctures Performed at United States Children's Hospitals, 2009-2019

OBJECTIVE

To evaluate trends in lumbar puncture (LP) performance among US children's hospitals to assess how these trends may impact pediatric resident trainee exposure to LP.

STUDY DESIGN

We quantified LPs for emergency department (ED) and inpatient encounters at 29 US children's hospitals from 2009 to 2019. LP was defined by either a LP procedure code or cerebrospinal fluid culture billing code. Temporal trends and hospital variation in LP were assessed using logistic regression analysis.

RESULTS

A total of 215 030 LPs were performed during the study period (0.8% of all encounters). Twenty six thousand and five hundred twenty three and 16 696 LPs were performed in the 2009 and 2018 academic years, respectively (overall 37.1% reduction, per-year OR, 0.935; 95% CI, 0.922-0.948; P < .001), and the rate of LP decreased from 10.9 per 1000 hospital encounters to 6.0 per 1000 hospital encounters over the same period.

CONCLUSIONS

LP rates have declined across US children's hospitals over the past decade, potentially resulting in reduced clinical exposure for pediatric resident trainees. Improved procedural simulation during residency may augment the clinical experience.

Febrile Seizure Team-based Learning

Audience

This modified team-based learning (mTBL) is designed for junior and senior emergency medicine and pediatric residents.

Introduction/Background

Febrile seizures are the most common cause of seizures in children under 5 years old and are frequently evaluated in the emergency department.1,2 Febrile seizures can be frightening for parents to witness and often necessitate extensive parental reassurance and education by the emergency medicine (EM) provider. Most febrile seizures are brief, do not require a broad workup, and have a benign prognosis. With introduction of conjugate vaccines for Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae in the United States in 1987 and 2000 respectively, the incidence of bacterial meningitis is low, but still present.3-7 The most recent American Academy of Pediatrics practice guidelines no longer recommend routine lumbar puncture on children presenting with simple febrile seizures.2 A review of the current literature shows that bacterial meningitis in children after a complex febrile seizure is unexpected when the clinical examination is not suggestive of meningitis or encephalitis.5-8 The goal of this mTBL is for residents to feel comfortable counseling parents about their child currently in the emergency department and the future risk of recurrence. The second goal is for residents to identify which patients presenting with fever and a seizure do require workup beyond simply identifying the source of the fever.

Educational Objectives

By the end of this educational session, the learner will:List the characteristics of a simple febrile seizure.Discuss the management of a child with a simple vs. complex febrile seizure.Discuss the risk factors that correlate with an increased risk of a subsequent febrile seizure.Determine when a lumbar puncture should be considered in a febrile child with a seizure.Identify when to give anti-epileptics and construct an algorithm for their use.Discuss with parents, provide education and return precautions.

Educational Methods

This didactic session is a mTBL. The classic learner responsible content (LRC) has been omitted and a short PowerPoint presentation is given to start the session before the individual and group readiness assessment tests.

Research Methods

A post-TBL survey was given to each participant. A Likert scale was used to assess each participant's assessment for the learning session in the following categories: overall, context, quality, and speaker feedback. They were also given fields to enter ways in which they would improve their practice after this learning exercise and suggestions they had for improving the current educational opportunity.

Results

In the pilot session of this mTBL, 4 out of 11 participants (EM residents and pediatric emergency medicine [PEM] fellows) completed the post-TBL survey. Overall, this session was rated as "outstanding" (Likert 5/5) by 1 and "excellent" (Likert 4/5) by 3 for a weighted average of 4.25. All participants completing the survey found the activity "highly relevant," "very engaging," and wanted to repeat the activity in the future. Negative feedback consisted of wanting a video of a child having a seizure to be played and having a more interactive PowerPoint portion of the session like the interaction in the readiness assessment tests and group application exercise.

Discussion

Overall the content was effective as evidenced by the list of ways residents said they would improve their practice on the post-TBL survey. In the future, I would extend the session from 60 minutes to 90 minutes to allow for more time for the group application exercise and discussion of answers. I found this to be an enjoyable, highly interactive experience with high engagement of the residents during the session.

Topics

Simple febrile seizures, complex febrile seizures, seizure with fever, meningitis, lumbar puncture, status epilepticus.

Automated detection of sudden unexpected death in epilepsy risk factors in electronic medical records using natural language processing

OBJECTIVE

Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability.

METHODS

Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic-clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F-measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three "boilerplate" standard text phrases from away notes and repeated performance.

RESULTS

We observed high performance in home test data (F-measure range = 0.86-0.90), and low to high performance in away test data (F-measure range = 0.53-0.81). After removing three boilerplate phrases, away performance improved (F-measure range = 0.79-0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data.

SIGNIFICANCE

Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling.

Complex Febrile Seizures, Lumbar Puncture, and Central Nervous System Infections: A National Perspective

OBJECTIVES

The objective was to determine the national lumbar puncture (LP) practice patterns relative to the incidence of central nervous system (CNS) infections among children presenting to the emergency department (ED) with complex febrile seizures (CFS).

METHODS

This was a retrospective study of ED visits for CFS from 2007 to 2014 in patients aged 0 to 5 years using a national sample. Primary outcomes include the frequency of LP, incidence of CNS infections, and ED disposition.

RESULTS

Of 28,810 ED visits for CFS (44.4% female; mean age = 1.39 years), LP was performed in 7,445 (25.8%, 95% confidence interval [CI] 23.5%-28.2%). There was no significant difference in the proportion due to hospital teaching status or geographical region. The proportion decreased from 31.4% to 17.8% over the study period (Rao-Scott statistic = 5.85, p < 0.001). CNS infection was diagnosed in 80 (0.3%) encounters (95% CI = 41-112). The most commonly associated infections were otitis media (16.8%), upper respiratory infections (15.8%), and other viral infections (14.6%). A total of 14,696 encounters (51.0%, 95% CI = 47.9%-54.1%) resulted in a hospital admission.

CONCLUSIONS

Although rates have been declining, LP was performed in one-fourth of ED encounters for CFS over the 8-year study period. The incidence of CNS infections was very low, however, suggesting that this procedure could be avoided in many patients.

Assessment of physicians knowledge and attitudes in the management of febrile seizures

Objectives:

To assess the knowledge and attitudes of physicians in different specialties who are involved in the care of children with FS.

Methods:

We assessed knowledge and attitudes in the management of Febrile seizure (FS) among physicians working in different specialties in the Kingdom of Saudi Arabia using a questionnaire-based cross-sectional study conducted from September-December 2016.

Results:

Of the 300 physicians who responded to the questionnaire, 178 (59.3%) were males, 119 (39.7%) were consultants, 92 (30.7%) were specialists, and 89 (29.7%) were residents. The majority were general pediatric consultants. Our study showed that the consultants were more aware of the definition of simple FS in comparison to other groups of physicians, and the difference was statistically significant. However, there was no difference between pediatric neurologists and general pediatricians. There was a statistically significant difference among various specialties in the perceived need to perform routine lumbar puncture, neuroimaging, and serum electrolyte determination in the evaluation of children with FS. On the other hand, there was no difference in the perceived need to perform an electroencephalogram among physicians in different specialties.

Conclusion:

The study highlighted the wide variation in knowledge and attitudes of physicians in different specialties with different levels of experience toward the management of FS. The use of clinical practice guidelines will help minimize this diversity.

Utility of the Performance of Lumbar Puncture for Febrile Children With Status Epilepticus in the Bacterial Conjugate Vaccine Era

BACKGROUND

The necessity of lumbar puncture for the differentiation of central nervous system infection in children with febrile status epilepticus (FSE) remains controversial. The aim of the present study is to investigate the diagnostic necessity of lumbar puncture for children with FSE after the introduction of bacterial conjugate vaccines into the infant immunization program.

METHODS

Our retrospective cohort study was performed in children 6 to 60 months of age who were admitted to the pediatric ward at Kitakyushu General Hospital from January 1, 2011, to December 31, 2015, for seizures with fever. Of these patients, we compared the clinical characteristics between the patients initially diagnosed as having FSE and complex febrile seizures excluding FSE (non-FSE).

RESULTS

Of the eligible 333 children, 98 and 235 children were classified into FSE and non-FSE groups, respectively. The proportion of the children who underwent lumbar puncture in FSE group was significantly higher than that in non-FSE group (P < 0.0001). On the other hand, no significant difference in the proportion of the patients with abnormal cerebrospinal fluid findings was seen between the 2 groups. There was no patient with bacterial meningitis. The proportion of patients with encephalitis/encephalopathy in FSE group (n = 7, 7.1%) was significantly higher than that in non-FSE group (n = 0, P = 0.0003). However, only 1 of 6 patients with encephalitis/encephalopathy who underwent lumber puncture showed pleocytosis in cerebrospinal fluid.

CONCLUSIONS

Routine lumbar puncture for the differentiation of severe central nervous system infection cannot be recommended in children with FSE.

The Etiological Spectrum of Febrile Encephalopathy in Adult Patients: A Cross-Sectional Study from a Developing Country

The profile of febrile encephalopathy varies based on different demographic and geographical characteristics of the study population. This retrospective, cross-sectional study was conducted to evaluate the etiological spectrum of febrile encephalopathy in hospitalized adult patients. A total of 293 patients with the mean age of 49.7 ± 23 were evaluated of whom 77.1% presented with encephalopathy syndrome. The most common diagnosis in patients with clinical syndromes suggestive of central nervous system (CNS) infection was sepsis associated encephalopathy (SAE) (22.9%), followed by bacterial meningitis (14%) and neurotuberculosis (9.9%). The comparison between the elderly and young adults showed that, in the young adults, bacterial meningitis and neurotuberculosis, and in the elderly SAE, are among the most common causes of clinical syndromes suggestive of CNS infection including febrile encephalopathy in our region. Moreover, we illustrated an upward trend for the proportion of diagnosing CNS infections among those who underwent diagnostic LP, from 40.4% in 2011 to 70% in 2015, that could be indicative of an increasing threshold for performing LP at least in our center in recent years. Whether these changes have been associated with increasing the rate of diagnostic errors or not needs to be evaluated in future studies.

Need for Lumbar Puncture in Children Younger Than 12 Months Presenting With Simple Febrile Seizure

OBJECTIVES

Recently, conflicting results have been reported regarding the necessity of routine lumbar puncture in children less than 12 months of age with simple febrile seizure. The aims of this study were to evaluate the results of lumbar puncture in children younger than 60 months of age with febrile seizure and to reassess the need for lumbar puncture in children younger than 12 months with simple febrile seizure.

METHODS

A retrospective chart review was performed in patients younger than 60 months who presented with febrile seizure and underwent lumbar puncture from January 2005 to January 2015.

RESULTS

A total of 1249 patients presenting with febrile seizure were admitted. Of these, 816 met inclusion criteria for presenting with simple febrile seizure. Lumbar puncture was performed in 75 patients (9.2%; age, mean ± SD, 12.05 ± 9.13 months; male/female, 31/44), who were reviewed. Sixty-six (88.0%) of 75 patients were younger than 12 months. Five patients (6.7%) showed pleocytosis in cerebrospinal fluid, and 4 of them were younger than 1 year of age. Three patients (4.0%) had bacterial meningitis and were 4, 8, and 12 months. Streptococcus pneumoniae (2 patients) and Klebsiella pneumoniae (1 patient) were isolated in cerebrospinal fluid. Nobody had neurologic signs suggesting bacterial meningitis, and all of them completed scheduled immunizations and were up-to-date.

CONCLUSION

Lumbar puncture should be considered in every child younger than 12 months of age with a simple febrile seizure owing to lack of abnormal neurologic sign even if immunization is up-to-date.

New guidelines for management of febrile seizures in Japan

In 2015, the Japanese Society of Child Neurology released new guidelines for the management of febrile seizures, the first update of such guidelines since 1996. In 1988, the Conference on Febrile Convulsions in Japan published "Guidelines for the Treatment of Febrile Seizures." The Task Committee of the Conference proposed a revised version of the guidelines in 1996; that version released in 1996 was used for the next 19years in Japan for the clinical management of children with febrile seizures. Although the guidelines were very helpful for many clinicians, new guidelines were needed to reflect changes in public health and the dissemination of new medical evidence. The Japanese Society of Child Neurology formed a working group in 2012, and published the new guidelines in March 2015. The guidelines include emergency care, application of electroencephalography, neuroimaging, prophylactic diazepam, antipyretics, drugs needing special attention, and vaccines. While the new guidelines contain updated clinical recommendations, many unsolved questions remain. These questions should be clarified by future clinical research.

Diagnostic value of lumbar puncture among infants and children presenting with fever and convulsions

Introduction

Central nervous system (CNS) infections can be categorized according to the nature of the infectious pathogen into viral, bacterial, protozoan, or fungal. The diagnosis of diffuse CNS infections depends on examination of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP). The aim of this work was to determine the diagnostic value of CSF analysis in infants and children presenting with fever and convulsions.

Methods

Detailed clinical data of infants and children included in this study were collected with special reference to the course and duration of the illness, description of the convulsions, consciousness level, signs of increased intracranial pressure, and signs of meningeal irritation. Lumbar puncture and chemical and bacteriological analyses of the obtained cerebrospinal fluid were done for all of the children.

Results

The total number of children included in the study was 85, they had a median age 19 months, and 88% of them had generalized convulsions. CSF examination revealed that 20% had abnormal physical findings, while 23.5% had abnormal white blood cell count (WBC) (CSF Pleocytosis). CSF cultures were done in three cases with the highest White blood cells (WBCs), and streptococcus pneumoniae was present in all three cases.

Conclusion

This study found that CNS infections are not uncommon in infants and children presenting with fever and convulsions in our locality, and acute bacterial meningitis cannot be excluded. However, its presence in the absence of clinical symptoms and signs of meningeal irritation is a remote possibility, but it should always be considered.

Building a Natural Language Processing Tool to Identify Patients With High Clinical Suspicion for Kawasaki Disease from Emergency Department Notes

OBJECTIVE

Delayed diagnosis of Kawasaki disease (KD) may lead to serious cardiac complications. We sought to create and test the performance of a natural language processing (NLP) tool, the KD-NLP, in the identification of emergency department (ED) patients for whom the diagnosis of KD should be considered.

METHODS

We developed an NLP tool that recognizes the KD diagnostic criteria based on standard clinical terms and medical word usage using 22 pediatric ED notes augmented by Unified Medical Language System vocabulary. With high suspicion for KD defined as fever and three or more KD clinical signs, KD-NLP was applied to 253 ED notes from children ultimately diagnosed with either KD or another febrile illness. We evaluated KD-NLP performance against ED notes manually reviewed by clinicians and compared the results to a simple keyword search.

RESULTS

KD-NLP identified high-suspicion patients with a sensitivity of 93.6% and specificity of 77.5% compared to notes manually reviewed by clinicians. The tool outperformed a simple keyword search (sensitivity = 41.0%; specificity = 76.3%).

CONCLUSIONS

KD-NLP showed comparable performance to clinician manual chart review for identification of pediatric ED patients with a high suspicion for KD. This tool could be incorporated into the ED electronic health record system to alert providers to consider the diagnosis of KD. KD-NLP could serve as a model for decision support for other conditions in the ED.

Enteroviral Meningitis in Neonates and Children of Mashhad, Iran

Background

The highest incidence of meningitis occurs during the neonatal period and (then) infancy. Although Bacterial agents are the most dangerous cause of neonatal and childhood meningitis yet viruses especially, enteroviruses (EV), are by far the most common cause of meningitis in this age group.

Objectives

The aim of the current study was to evaluate the role of EVs in neonatal and childhood meningitis in the Mashhad city of Iran.

Materials and Methods

This was a descriptive study that was performed at Imam Reza hospital in a period of six months (March to September 2007), during which all of the cerebral spinal fluid (CSF) samples from the neonatal intensive care unit (NICU) and pediatrics ward were collected and real time-polymerase chain reaction (RT-PCR) for EVs was done on these samples. Clinical data were collected retrospectively from hospital files.

Results

We collected 58 CSF samples (35 neonates and 23 children) during six months. Pleocytosis of CSF was seen in 51.1% of the subjects (28% of neonates, and 66.6% of infants and children). Enteroviruses PCR was positive in 37.1% (13) of neonates and 34.7% (8) of children. Pleocytosis of CSF was seen in 23% and 75% of EV positive neonates and children, respectively. Polymorphonuclear (PMN) dominance (PMN > 50%) of CSF was seen in 50% and 33% of EV positive neonates and children, respectively. There were three cases of bacterial meningitis in our group; EV PCR result was positive for one of these subjects. Concomitant bacterial infection (meningitis and sepsis) was seen in 9.5% (two cases) of EV positive CSFs in our study. Almost half of the available neonates (four of nine) with pure enteroviral meningitis (EVM) were discharged (in good condition) with final diagnosis of culture negative sepsis (CNS) and mean length of hospital stay (MLOS) of 4.3 days. One (12.5%) of the neonates with EVM, who had a very low birth weight (< 1500 mg), was expired, and two (25%) cases were discharged with brain damage and final diagnosis of severe asphyxia. The MLOS for children with pure EVM was 1.6 days (one to four days); they didn't have any sign of brain damage or mortality. Qualitative c-reactive protein (CRP) of serum was negative in 72.7% and 37.5% of EV positive neonates and children, respectively. The mean white blood cell count and PMN percentage in the peripheral blood was 11416/mm³ and 60.8% for EV positive neonates, and 14500/mm³ and 77.1% for EV positive children, respectively. Hyponatremia, due to possible syndrome of inappropriate antidiuretic hormone (SIADH), was seen in 30% of neonates and 57% of children with EVM.

Conclusions

Enteroviruses were a common cause (> 30%) of meningitis in our study group. Concomitant bacterial infection is not rare in neonates and children with EVM. Many of the neonates (50%) and almost all of the children with EVM did not require prolonged hospitalization. Both normal CSF and PMN dominancy of CSF was common in neonates and children with EVM. Positive qualitative CRP of serum (up to two plus) was common especially in children with EVM. Non-symptomatic mild hyponatremia/SIADH was common in early life EVM.

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.

Emergency Department Evaluation and Management of Children With Simple Febrile Seizures

Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup. This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a medical record review of workup that was performed. The survey shows that laboratory workup is done routinely and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American Academy of Pediatrics' revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup.

An Introduction to Natural Language Processing: How You Can Get More From Those Electronic Notes You Are Generating

Electronically stored clinical documents may contain both structured data and unstructured data. The use of structured clinical data varies by facility, but clinicians are familiar with coded data such as International Classification of Diseases, Ninth Revision, Systematized Nomenclature of Medicine-Clinical Terms codes, and commonly other data including patient chief complaints or laboratory results. Most electronic health records have much more clinical information stored as unstructured data, for example, clinical narrative such as history of present illness, procedure notes, and clinical decision making are stored as unstructured data. Despite the importance of this information, electronic capture or retrieval of unstructured clinical data has been challenging. The field of natural language processing (NLP) is undergoing rapid development, and existing tools can be successfully used for quality improvement, research, healthcare coding, and even billing compliance. In this brief review, we provide examples of successful uses of NLP using emergency medicine physician visit notes for various projects and the challenges of retrieving specific data and finally present practical methods that can run on a standard personal computer as well as high-end state-of-the-art funded processes run by leading NLP informatics researchers.

Febrile seizures: emergency medicine perspective

PURPOSE OF REVIEW

The review describes current evidence on the evaluation of febrile seizures in the acute setting, the need for further outpatient assessment, and predictors regarding long-term outcomes of these patients.

RECENT FINDINGS

New evidence has been added in support of limited assessment and intervention: evidence on low utility of lumbar puncture, emergent neuroimaging, and follow-up electroencephalography, as well as low yield for antipyretic prophylaxis and intermittent use of antiepileptic drugs. Finally, there is growing evidence regarding the genetic basis of both febrile seizures and vaccine-related seizures/febrile seizures.

SUMMARY

Routine diagnostic testing for simple febrile seizures is being discouraged, and clear evidence-based guidelines regarding complex febrile seizures are lacking. Thus, clinical acumen remains the most important tool for identifying children with seizures who are candidates for a more elaborate diagnostic evaluation. Similarly, evidence and guidelines regarding candidates for an emergent out-of-hospital diazepam treatment are lacking.

Practice variability in the management of complex febrile seizures by pediatric emergency physicians and fellows

Objective:

Febrile seizures are the most common type of childhood seizure and are categorized as simple or complex. Complex febrile seizures (CFSs) are defined as events that are focal, prolonged (&gt; 15 minutes), or recurrent. The management of CFS is poorly defined. The objective of this study was to determine the degree of variability in the emergency department evaluation of children with CFSs.

Methods:

An online survey questionnaire was developed and sent to physicians identified via the listserv of the emergency medicine section of the American Academy of Pediatrics and the pediatric emergency medicine discussion list. The questionnaire consisted of five hypothetical case vignettes describing children under 5 years of age presenting with a CFS. Following review of the first four vignettes, participants were asked if they would (1) obtain blood and urine for evaluation; (2) perform a lumbar puncture; (3) perform neurologic imaging while the child was in the emergency department; (4) admit the child to the hospital; or (5) discharge with follow-up as an outpatient, with either the primary care provider or a neurologist. The final vignette determined if antiepileptic medication would be prescribed by the physician on discharge.

Results:

Of the 353 physicians who participated, 293 (83%) were pediatric emergency medicine attending physicians and 60 (17%) were pediatric emergency medicine fellows. Overall, 54% of participants indicated that they would obtain blood for evaluation, 62% would obtain urine, 34% would perform a lumbar puncture, and 36% would perform neurologic imaging. The overall hypothetical admission rate for the case vignettes was 42%.

Conclusions:

This study indicates that extensive variability exists in the emergency department approach to patients with CFS. Our findings suggest that optimal management for CFS remains unclear and support the potential benefit of future prospective studies on this subject.

Febrile seizures

Febrile seizure (FS) is the most common seizure disorder of childhood, and occurs in an age-related manner. FS are classified into simple and complex. FS has a multifactorial inheritance, suggesting that both genetic and environmental factors are causative. Various animal models have elucidated the pathophysiological mechanisms of FS. Risk factors for a first FS are a family history of the disorder and a developmental delay. Risk factors for recurrent FS are a family history, age below 18 months at seizure onset, maximum temperature, and duration of fever. Risk factors for subsequent development of epilepsy are neurodevelopmental abnormality and complex FS. Clinicians evaluating children after a simple FS should concentrate on identifying the cause of the child's fever. Meningitis should be considered in the differential diagnosis for any febrile child. A simple FS does not usually require further evaluation such as ordering electroencephalography, neuroimaging, or other studies. Treatment is acute rescue therapy for prolonged FS. Antipyretics are not proven to reduce the recurrence risk for FS. Some evidence shows that both intermittent therapy with oral/rectal diazepam and continuous prophylaxis with oral phenobarbital or valproate are effective in reducing the risk of recurrence, but there is no evidence that these medications reduce the risk of subsequent epilepsy. Vaccine-induced FS is a rare event that does not lead to deleterious outcomes, but could affect patient and physician attitudes toward the safety of vaccination.

Febrile seizures

Febrile seizures are the most common form of childhood seizures, affecting 2% to 5% of children. They are considered benign and self-limiting; however, a febrile seizure is a terrifying event for most parents, and is one of the most common causes of trips to the emergency room. A febrile seizure is "an event in infancy or childhood, usually occurring between 3 months and 5 years of age, associated with fever but without evidence of intracranial infection or defined cause." This definition excludes seizures with fever in children who have had a prior afebrile seizure. In 2011, The American Academy of Pediatrics (AAP) published a clinical practice guideline defining a febrile seizure as "a seizure accompanied by fever (temperature ≥ 100.4°F or 38°C by any method), without central nervous system infection, that occurs in infants and children 6 through 60 months of age." Febrile seizures are further classified as simple or complex. This article reviews the evaluation, management, and prognosis of simple and complex seizures, including febrile status epilepticus.

Comparison of underlying factors behind parental refusal or consent for lumbar puncture

BACKGROUND

Although lumbar puncture (LP) is a safe procedure in experienced hands, some parents fear having it performed on their children and refuse consent. The factors associated with this refusal are unclear, and any differences with consenting parents might provide clues as to how to address them. Therefore, we compared the underlying factors between the parents who refuse and those who consent to this procedure, as well as their children's outcomes.

METHODS

A prospective study of the two groups of parents was conducted by a face-to-face structured interview. Parents' demographic factors, knowledge, perceptions, beliefs and attitudes, as well as their children's outcomes, were compared. The odds ratio (OR) with 95% confidence intervals was calculated for significant associations.

RESULTS

Consent was declined by 24 out of 55 families (44%). Alternative options were offered more often to those refusing consent (OR=5.7). Significantly more parents who refused consent also refused bladder catheterization (OR=18), knowing someone with complications following LP (OR=8.7), felt that it was not needed (OR=7.9) or that it induced complications (OR=12.5). A significantly higher proportion of the consenting parents were aware that meningitis might cause convulsions (OR=4.6), deafness or blindness (OR=2.9).

CONCLUSION

The differences in the understanding, perceptions, beliefs and fears between the parents who refused consent and those who agreed, can provide clues to the developing of appropriate strategies when requesting consent for LP.

Fever in the pediatric patient

Fever is the most common reason that children and infants are brought to emergency departments. Emergency physicians face the challenge of quickly distinguishing benign from life-threatening conditions. The management of fever in children is guided by the patient's age, immunization status, and immune status as well as the results of a careful physical examination and appropriate laboratory tests and radiographic views. In this article, the evaluation and treatment of children with fevers of known and unknown origin are described. Causes of common and dangerous conditions that include fever in their manifestation are also discussed.

Pediatric seizures

Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies.

Clinical factors associated with invasive testing and imaging in patients with complex febrile seizures

BACKGROUND

Complex febrile seizures (CFSs) are a common diagnosis in the pediatric emergency department (PED). Although multiple studies have shown a low likelihood of intracranial infections and abnormal neuroimaging findings among those who present with CFS, the absence of a consensus recommendation and the diversity of CFS presentations (ie, multiple seizures, prolonged seizure, focal seizure) often drive physicians to do a more extensive workup than needed. Few studies examine the factors that influence providers to pursue invasive testing and emergent neuroimaging.

OBJECTIVE

The objective of this study was to determine the clinical factors associated with a more extensive workup in a cohort of patients who present to the PED with CFSs.

METHODS

Patient visits to a tertiary care PED with an International Classification of Diseases, Ninth Revision, diagnosis of CFS were reviewed from April 2009 to November 2011. Patients included were 6 months to 6 years of age. Complex febrile seizures were defined as febrile seizures lasting 15 minutes or longer, more than 1 seizure in 24 hours, and/or a focal seizure. Charts were reviewed for demographics, clinical parameters (duration of fever, history of febrile seizure, focality of seizure, antibiotic use before PED, and immunization status), PED management (antiepileptic drugs given in the PED or by Emergency Medical Services, empiric antibiotics given in the PED, laboratory testing, lumbar puncture, or computed tomography [CT] scan), and results (cultures, laboratories, or imaging). A logistic regression model was created to determine which clinical parameters were associated with diagnostic testing.

RESULTS

One hundred ninety patients were diagnosed with CFS and met study criteria. Clinical management in the PED included a lumbar puncture in 37%, blood cultures in 88%, urine cultures in 47%, and a head CT scan in 28%. There were no positive cerebral spinal fluid or blood cultures in this cohort. Of the 90 patients, 4 (4.4%) with urine cultures had a urinary tract infection. Of the 53 patients who had head CT imaging, there were no significant findings that guided therapy. The only factor associated with having a lumbar puncture performed was whether empiric antibiotics were used (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.28-6.8). History of a febrile seizure was associated with lower odds of a lumbar puncture (OR, 0.29; 95% CI, 0.12-0.69). In addition, higher age category was also associated with lower odds of a lumbar puncture (OR, 0.53; 95% CI, 0.31-0.91). Those who received an antiepileptic drug had a higher odds of getting a head CT (OR, 3.5; 95% CI, 1.5-8.6). Furthermore, patients presenting with a focal seizure also had higher odds of getting a head CT (OR, 4.89; 95% CI, 1.41-16.9).

CONCLUSIONS

Despite the low utility of associated findings, there are important clinical parameters that are associated with obtaining a lumbar puncture or a head CT as part of the diagnostic workup. National practice parameters to guide evaluation for CFSs in the acute setting are warranted to reduce the amount of invasive testing and imaging.

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.

Recent Research on Febrile Seizures: A Review

Febrile seizures are common and mostly benign. They are the most common cause of seizures in children less than five years of age. There are two categories of febrile seizures, simple and complex. Both the International League against Epilepsy and the National Institute of Health has published definitions on the classification of febrile seizures. Simple febrile seizures are mostly benign, but a prolonged (complex) febrile seizure can have long term consequences. Most children who have a febrile seizure have normal health and development after the event, but there is recent evidence that suggests a small subset of children that present with seizures and fever may have recurrent seizure or develop epilepsy. This review will give an overview of the definition of febrile seizures, epidemiology, evaluation, treatment, outcomes and recent research.

Update on the management of simple febrile seizures: emphasis on minimal intervention

PURPOSE OF REVIEW

We summarize recent clinical reviews and updated American Academy of Pediatrics (AAP) clinical guidelines for the management of children with simple febrile seizures.

RECENT FINDINGS

There has been a dramatic reduction in the incidence of bacterial meningitis and of occult bacteremia since the advent of Haemophilus influenzae type b and Streptococcus pneumoniae immunization. This has made routine laboratory evaluation for these bacterial infections unnecessary in a fully immunized, well appearing child who presents with a simple febrile seizure. At the same time there is increasing evidence that the neurotropic human herpes viruses 6 and 7 (HHV-6, HHV-7) comprise a significant proportion of viral infections associated with febrile seizures, and may be the primary cause of the seizure in many instances. Recent evidence-based guidelines emphasize the lack of a need for routine laboratory and neurodiagnostic evaluation, and for prophylactic antipyretics and anticonvulsants, in the majority of children with simple febrile seizures.

SUMMARY

If a child who is fully immunized according to the recommended schedule presents with a simple febrile seizure, minimal intervention should be the norm. Routine blood tests and routine lumbar punctures are usually unnecessary, and the risks of neurodiagnostic procedures (imaging or EEG), prophylactic antipyretics and anticonvulsants far outweigh their potential benefits.

What is quality improvement and why should child neurologists care?

In this article, the authors discuss the 6 domains of care identified by the Institute of Medicine report, Crossing the Chasm, with examples and questions that are especially relevant to physicians caring for children who have neurologic disorders and their families.

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.

Integrating spatial epidemiology into a decision model for evaluation of facial palsy in children

OBJECTIVE

To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors.

DESIGN

Retrospective cohort study.

SETTING

Children's Hospital Boston emergency department, 1995-2007.

PATIENTS

Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease.

MAIN OUTCOME MEASURES

Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy.

RESULTS

Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases.

CONCLUSIONS

Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.

Neurodiagnostic evaluation of the child with a simple febrile seizure

OBJECTIVE

To formulate evidence-based recommendations for health care professionals about the diagnosis and evaluation of a simple febrile seizure in infants and young children 6 through 60 months of age and to revise the practice guideline published by the American Academy of Pediatrics (AAP) in 1996.

METHODS

This review included search and analysis of the medical literature published since the last version of the guideline. Physicians with expertise and experience in the fields of neurology and epilepsy, pediatrics, epidemiology, and research methodologies constituted a subcommittee of the AAP Steering Committee on Quality Improvement and Management. The steering committee and other groups within the AAP and organizations outside the AAP reviewed the guideline. The subcommittee member who reviewed the literature for the 1996 AAP practice guidelines searched for articles published since the last guideline through 2009, supplemented by articles submitted by other committee members. Results from the literature search were provided to the subcommittee members for review. Interventions of direct interest included lumbar puncture, electroencephalography, blood studies, and neuroimaging. Multiple issues were raised and discussed iteratively until consensus was reached about recommendations. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed by the committee member most experienced in informatics and epidemiology and graded according to AAP policy.

CONCLUSIONS

Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child's fever. Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern. For any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended), or when immunization status cannot be determined, because of an increased risk of bacterial meningitis. A lumbar puncture is an option for children who are pretreated with antibiotics. In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography, blood studies, or neuroimaging.

Predictors of meningitis in children presenting with first febrile seizures

No data exist on the prevalence of meningitis in a first episode of seizures with fever in the Indian population. We investigated the prevalence of bacterial meningitis in children aged 6-18 months presenting with a first episode of seizures with fever, and we assessed clinical predictors of bacterial meningitis in these patients. We analyzed clinical and investigative profiles of 497 children, aged 6-18 months, admitted to pediatric casualty wards with a diagnosis of first febrile seizures. Lumbar puncture was performed in 199 (40.04%) infants. The prevalence of meningitis was 2.4% in children with first febrile seizures, 0.86% in simple febrile seizures, and 4.81% in complex febrile seizures. Duration of seizures more than 30 minutes, the presence of postictal drowsiness, and neurologic deficits were predictive of meningitis, with neurologic deficits as the most reliable. These predictors should be assessed in larger prospective studies.

Yield of lumbar puncture among children who present with their first complex febrile seizure

OBJECTIVE

To assess the rate of acute bacterial meningitis (ABM) among children who present with their first complex febrile seizure (CFS).

DESIGN AND METHODS

This study was a retrospective, cohort review of patients aged 6 to 60 months who were evaluated in a pediatric emergency department (ED) between 1995 and 2008 for their first CFS. Cases were identified by using a computerized text search followed by a manual chart review. Exclusion criteria included prior history of nonfebrile seizures, an immunocompromised state, an underlying illness associated with seizures or altered mental status, or trauma. Data extracted included age, gender, seizure features, the number of previous simple febrile seizures, temperature, a family history of seizures, findings on physical examination, laboratory and imaging study results, and ED diagnosis and disposition.

RESULTS

We identified 526 patients. The median age was 17 months (interquartile range: 13-24), and 44% were female. Ninety patients (17%) had a previous history of simple febrile seizures. Of the patients, 340 (64%) had a lumbar puncture (LP). The patients' median white blood cell count during a CFS was 1 cell per microL (interquartile range: 1-2), and 14 patients had CSF pleocytosis (2.7% [95% confidence interval [CI]: 1.5-4.5]). Three patients had ABM (0.9% [95% CI: 0.2-2.8]). Two had Streptococcus pneumoniae in a culture of their cerebrospinal fluid. Among these 2 patients, 1 was nonresponsive during presentation, and the other had a bulging fontanel and apnea. The third child appeared well; however, her blood culture grew S pneumoniae and failed the LP test. None of the patients for whom an LP was not attempted subsequently returned to the hospital with a diagnosis of ABM (0% [95% CI: 0, 0.9]).

CONCLUSION

Few patients who experienced a CFS had ABM in the absence of other signs or symptoms.

Quality initiatives in the emergency department

PURPOSE OF REVIEW

To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate.

SUMMARY

There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.