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LP for Febrile Seizure – Less Is More?

December 9, 2021

Talking about race in EM

Thanks again for all the great questions so far! Be sure to include yours. Today’s article summary is below but first a quick announcement. We are planning a podcast with Cortlyn Brown, Kimberly Brown, Italo Brown, and Rosny Daniel, and you are asking the questions! Talking together as friends and colleagues is powerful. Nick Z., Eriny, and I will curate your questions and comments and present this podcast to you in early 2022. Submissions are anonymous. Let’s be curious, kind, and learn how we can better care for each other. ~Clay

Please drop your questions for this town hall into this Google Form.

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From 2005 to 2019 there was a statistically significant decline in the rate of LPs, head CTs, CBCs, hospital admissions, and mean costs of care for pediatric patients (6mo to 60mo) presenting to the ED for a first time simple febrile seizure (SFS). This occurred WITHOUT a concomitant rise in delayed diagnosis of bacterial meningitis.

Why does this matter?
Data from this analysis suggest that most children meeting the American Association of Pediatrics (AAP) criteria for SFS (and those without transfer, complex chronic conditions, co-diagnosis of head trauma, post traumatic seizure, hemiplegia, or bacterial meningitis) may be safely managed without LP or other invasive and often costly interventions. Are we doing less these days for SFS?

We should really seize this opportunity.
This was a retrospective cross-sectional analysis of 49 tertiary care pediatric hospitals across the country from 2005-2019. The authors identified 142,121 children with an ED visit for SFS. They tracked rates of LP, head CT, CBC, hospital admission, mean cost (adjusted), and delayed diagnosis of bacterial meningitis. They further examined these criteria before and after a 2011 AAP Guideline publication which recommended limiting LPs to non—low-risk patients. Overall, they saw a decline in rates of certain diagnostic testing well before the 2011 AAP guideline. A decline which continued after. More specifically, they found rates of LP declined from 11.6% in 2005 to 0.6% in 2019 (P < .001). Head CT (10.6% to 1.6%; P < .001), CBC (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean cost ($1,523 to $601; P < .001). There was no significant change in delayed diagnosis of bacterial meningitis (pre-period 0.0040% to post-period 0.0032%; P = .99). While this decline in testing continued after AAP guidelines, these authors posit that it was primarily driven be more widespread adoption of Haemophilus influenzae and conjugated pneumococcal vaccines, which decreased the prevalence of bacterial meningitis.

Overall, this is a well-powered study which provides a lot of reassurance for providers caring for patients in a vulnerable age group. I know I will be mentioning this study to the parents of children with SFS on my next Peds shift.

Trends in Management of Simple Febrile Seizures at US Children’s Hospitals. Pediatrics. 2021 Nov;148(5):e2021051517. doi: 10.1542/peds.2021-051517. Epub 2021 Oct 20.

What are your thoughts?