To the Editor. One of the areas of controversy in the practice of pediatric emergency medicine is the evaluation of the infant who presents with its first febrile seizure. I applaud the American Academy of Pediatrics (AAP) Provisional Committee on Quality Improvement's attempt to clarify the issues regarding the treatment of these infants. I must, however, question both the recommendations and the methods by which they were developed.Whenever a committee of the AAP presents practice parameters, recommendations must reflect the practice patterns of the medical community and the state of the art scientific evidence available to substantiate the recommendation. The Committee recommends “after the first seizure with fever in infants younger than 12 months, performance of a lumbar puncture must be strongly considered.” Neither the prevailing practice patterns of pediatric emergency physicians nor the most recent literature were considered. The makeup of the Committee as listed in the abstract lists general pediatricians and consultants in the field of neurology and epilepsy as the developers of this practice parameter. Absent from the Subcommittee on Febrile Seizures was any representation from the Section on Pediatric Emergency Medicine. The references used to support this recommendation cannot be considered contemporary. The most recent article quoted in references substantiating this recommendation is 13 years old.Pediatric emergency physicians manage fevers with seizures as a daily part of their clinical practice.1 If the child is previously healthy, has not been treated previously with an antibiotic, and has a simple febrile seizure, he/she is managed as any child with an acute fever. Simple febrile seizures are a normal variant. This question of lumbar puncture for the first febrile seizure was recently addressed in the pediatric emergency medicine literature.1A case study was presented, a simple febrile seizure in a previously healthy 8-month-old infant who was not currently on antibiotics and at the time of examination in the emergency department was alert, smiling, and had a normal white blood cell count. The pediatric emergency discussants indicated that lumbar puncture for such a case scenario would not be indicated. Studies have addressed the issue both retrospectively and prospectively.23 A recent review by Green et al2 found that all children who presented with fever, seizures, and meningitis either appeared extremely ill, had meningeal signs, or had febrile seizures with complex features. The authors conclude that lumbar puncture for simple febrile seizures was not indicated unless the child had an indication independent of the seizure for requiring the study.2Indications for lumbar puncture in a febrile child age 6 months to 5 years old include presence of meningeal signs and toxicity consistent with the diagnosis of meningitis. Lumbar puncture should be strongly considered in this age group for children who present with seizure activity at the time of arrival in the emergency department, or with findings on physical examination such as rash, cyanosis, hypotension, respiratory distress, or abnormal neurologic examination.4Children with complex febrile seizures should strongly be considered for performance of a lumbar puncture.3 The recommendation algorithm would be better served highlighting theseindications rather than their basis of particular age subgroups.Such practice parameter recommendations become significant medical legal literature. The Academy would have been better served if the recommendations regarding the evaluation of the child with a first simple febrile seizure reflected both current practice patterns in pediatric emergency departments and current contemporary pediatric literature.In Reply. The American Academy of Pediatrics (AAP) Subcommittee on Febrile Seizures thanks Dr Nozicka, Medical Director of Pediatric Services at the Columbia Hospital and State Medical Center, for his thoughtful comments. The Subcommittee members recognize that the most controversial area of the practice parameter on febrile seizures is the recommendation regarding lumbar punctures.It should be noted that these recommendations were developed only after an extensive review of the literature and consultation with 11 experts in the field, various AAP sections and committees including the Committee on Pediatric Emergency Medicine and Section on Emergency Medicine, the American Academy of Pediatrics' Board of Directors as well as committees from the American College of Emergency Physicians, Child Neurology Society, the American Academy of Family Physicians, the American Academy of Neurology, the American Neurologic Association, and the Epilepsy Foundation of America. As might be anticipated, there was a range of reactions to the practice parameter. Most reviewers were supportive of the recommendations but two groups had differing opinions. One society considered our recommendation “a lumbar puncture in children less than 12 months of age with first febrile seizure should be strongly considered” as too weak and wanted us to “strongly recommend” routine lumbar puncture in all children less than 18 months with a first febrile seizure. In contrast, another society thought that a lumbar puncture should not be recommended unless the child had definite signs of meningitis. It is the nature of this type of exercise that there will be differences of opinion. However, it should be stressed that our recommendations were based on a careful analytic review of the literature. Unfortunately, the technical report, which describes and analyzes each article we reviewed, was not published in its entirety in Pediatrics due to space considerations. The full technical report is available through the American Academy of Pediatrics' Division of Publications.As reported in the literature, between 1% and 5% of children with first febrile seizures may have abnormal cerebrospinal examinations. In some children (particularly the very young), the only presenting clinical sign is a seizure and fever. Therefore, young children are at high risk for undiagnosed meningitis. In Dr Nozicka's letter, young age at the time of the first febrile seizure is not considered high risk, but we do not feel that this view is supportable either based on the literature or on clinical experience.As noted in the technical report, clearly the clinical evaluation of young febrile children requires skills that vary between examiners. As such, the Subcommittee deliberately chose a conservative approach with an emphasis on the value of the lumbar puncture in diagnosing meningitis. Practice parameters are meant solely to give guidance and not to eliminate clinical judgment. Although this practice parameter states that a lumbar puncture should be “strongly considered” in certain situations, we are not suggesting it be mandated. If the pediatrician feels confident in his examination of the child, is comfortable that he/she will have adequate follow-up of the patient over the next 24 hours, and it is in her/his judgment that a lumbar puncture is not indicated, this practice parameter would not presume to change that approach. Alternatively, in situations that are not optimal, ie, a young child with a first febrile seizure seen in an emergency department by physicians who may be less experienced and where follow-up is likely to be less than ideal, it would appear that a lumbar puncture would be the appropriate diagnostic approach.
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