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Shake & BakeShake & BakeEvaluation and Management of First Time Evaluation and Management of First Time

Pediatric SeizuresPediatric Seizures

Tricia Falgiani, MDTricia Falgiani, MDAssistant Professor Assistant Professor

Department of Emergency MedicineDepartment of Emergency MedicineDivision of Pediatric Emergency MedicineDivision of Pediatric Emergency Medicine

ObjectivesObjectives

At the end of this session, the At the end of this session, the participant will be able to:participant will be able to:– Discuss indications for laboratory and Discuss indications for laboratory and

radiographic studies in a child with first radiographic studies in a child with first time afebrile seizure. time afebrile seizure.

– Discuss indications for testing and Discuss indications for testing and treatment of a child with a febrile seizuretreatment of a child with a febrile seizure

– Discuss the differences in evaluation and Discuss the differences in evaluation and treatment of the very young infant with treatment of the very young infant with first time seizures. first time seizures.

First Time SeizuresFirst Time SeizuresWho cares?Who cares?

Seizures are the most common Seizures are the most common pediatric neurologic disorderpediatric neurologic disorder

4 – 6 % of children will have at 4 – 6 % of children will have at least one seizure in the first 16 least one seizure in the first 16 years of lifeyears of life

The greatest incidence occurs in The greatest incidence occurs in those under 3 years of agethose under 3 years of age

Seizure DefinitionSeizure Definition

““A transient, involuntary alteration of A transient, involuntary alteration of consciousness, behavior, motor consciousness, behavior, motor activity, sensation, or autonomic activity, sensation, or autonomic function caused by an excessive rate function caused by an excessive rate and hypersynchrony of discharges and hypersynchrony of discharges from a group of cerebral neurons”from a group of cerebral neurons”

Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53 Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53 (2006)(2006)

Pediatric SeizuresPediatric SeizuresDifferential DiagnosisDifferential Diagnosis

Disorders with altered Disorders with altered consciousnessconsciousness– Apnea and syncopeApnea and syncope– Breath-holding spellsBreath-holding spells– Cardiac dysrhythmiasCardiac dysrhythmias– Atypical migrainesAtypical migraines

Gastroesophageal refluxGastroesophageal reflux

Pediatric SeizuresPediatric SeizuresDifferential DiagnosisDifferential Diagnosis

Paroxysmal movement disordersParoxysmal movement disorders– Acute dystoniaAcute dystonia– Benign myoclonusBenign myoclonus– PseudoseizuresPseudoseizures– Shuddering attacksShuddering attacks– Spasmus nutansSpasmus nutans– TicsTics

Sleep disordersSleep disorders Psychological disordersPsychological disorders

SeizuresSeizuresTreatmentTreatment--Acute StabilizationAcute Stabilization

Establish ABCsEstablish ABCs

Consider IV glucose, naloxone, or pyridoxineConsider IV glucose, naloxone, or pyridoxine

First dose of benzodiazepineFirst dose of benzodiazepine

Phenytoin or Fosphenytoin (20 mg/kg IV)Phenytoin or Fosphenytoin (20 mg/kg IV)

Phenobarbital (20mg/kg IV)Phenobarbital (20mg/kg IV) reassess, consider intubationreassess, consider intubation

Continuous Infusion of BarbiturateContinuous Infusion of Barbiturate intubate nowintubate now

General anesthesiaGeneral anesthesia

Nonfebrile SeizuresNonfebrile Seizures

Practice ParameterPractice Parameter Based on recommendations Based on recommendations

publishedpublished in Neurology in 2000in Neurology in 2000 Comprehensive review of 66 articles Comprehensive review of 66 articles Children 1 month – 21 yearsChildren 1 month – 21 years 1st time seizures not explained by 1st time seizures not explained by

immediate, obvious, provoking causeimmediate, obvious, provoking cause Seizure lasting < 30 minutesSeizure lasting < 30 minutes

Nonfebrile SeizuresNonfebrile SeizuresLaboratory evaluationLaboratory evaluation

EvidenceEvidence Eisner, et alEisner, et al

– 30 children (0-18) and 133 adults30 children (0-18) and 133 adults– CBC, BMP, Ca, Mg doneCBC, BMP, Ca, Mg done– 1 case of unsuspected hyperglycemia1 case of unsuspected hyperglycemia

Turnbull, et alTurnbull, et al– 136 new onset seizures136 new onset seizures– No clinically significant lab abnormalities in No clinically significant lab abnormalities in

the 16 children in the study (12-19 years old)the 16 children in the study (12-19 years old)


Evidence, cont.Evidence, cont. Larger retrospective studies (Nypaver et Larger retrospective studies (Nypaver et

al and Smith et al)al and Smith et al)– 507 children total- febrile and nonfebrile 507 children total- febrile and nonfebrile

seizuresseizures– Lab did not contribute to diagnosis or Lab did not contribute to diagnosis or

managementmanagement FarrarFarrar

– 47 infants < 6 months of age47 infants < 6 months of age– 70% with hyponatremia70% with hyponatremia


RecommendationsRecommendations Laboratory tests should be ordered Laboratory tests should be ordered

based on individual clinical based on individual clinical circumstances that include suggestive circumstances that include suggestive historic or clinical findings historic or clinical findings (think hard about electrolytes in children (think hard about electrolytes in children

under 6 months of age)under 6 months of age) Toxicology screening should be Toxicology screening should be

considered if there is any question of considered if there is any question of exposure or substance abuse exposure or substance abuse

Nonfebrile SeizuresNonfebrile SeizuresLumbar PunctureLumbar Puncture

EvidenceEvidence– Rider et alRider et al

57 CSF samples in children with nonfebrile 57 CSF samples in children with nonfebrile seizures (2-24 months old)seizures (2-24 months old)

12.3% with >5 leukocytes/mm312.3% with >5 leukocytes/mm3 None with meningitisNone with meningitis

RecommendationRecommendation– Lumbar Puncture is of limited value and Lumbar Puncture is of limited value and

should only be used if there is clinical should only be used if there is clinical concern for meningitis or encephalitis concern for meningitis or encephalitis

Nonfebrile SeizuresNonfebrile SeizuresEEGEEG

EvidenceEvidence– Multiple studiesMultiple studies

EEGs are the best predictors of recurrence in EEGs are the best predictors of recurrence in children who are neurologically normalchildren who are neurologically normal

Helps determine seizure type, epilepsy Helps determine seizure type, epilepsy syndrome and risk of recurrencesyndrome and risk of recurrence

Optimal timing is not clearOptimal timing is not clear

RecommendationRecommendation– The EEG is recommended as part of the The EEG is recommended as part of the

evaluation of the child with first time evaluation of the child with first time nonprovoked seizures (nonprovoked seizures (StandardStandard))

Nonfebrile SeizuresNonfebrile SeizuresNeuroimagingNeuroimaging

EvidenceEvidence Multiple studiesMultiple studies

– Abnormalities found in up to 1/3, but most did not Abnormalities found in up to 1/3, but most did not influence management decisionsinfluence management decisions

– 2% clinically significant findings2% clinically significant findingsMost of those done because of focality of seizure or Most of those done because of focality of seizure or

specific clinical findingsspecific clinical findings

– EmergentEmergent imaging is to detect a serious condition imaging is to detect a serious condition that may require immediate interventionthat may require immediate intervention

– Non-urgentNon-urgent imaging detects abnormalities that imaging detects abnormalities that may affect prognosis, and thus have an impact on may affect prognosis, and thus have an impact on long term managementlong term management

Nonfebrile SeizuresNonfebrile SeizuresImagingImaging

Sharma et alSharma et al– 500 nonfebrile first time seizures500 nonfebrile first time seizures– Mean age 46 months (0 – 21 years)Mean age 46 months (0 – 21 years)– 95% were imaged 95% were imaged

91% CT, 4% MRI 91% CT, 4% MRI

– 83% normal83% normal– 9% clinically insignificant abnormalities9% clinically insignificant abnormalities– 8% (38 pts) clinically significant8% (38 pts) clinically significant

Only 6 patients defined as “low risk” Only 6 patients defined as “low risk”

Nonfebrile SeizuresNonfebrile SeizuresImagingImaging

RecommendationsRecommendations– If neuroimaging is obtained, MRI is preferred If neuroimaging is obtained, MRI is preferred

modality (modality (guidelineguideline))– Emergent imagingEmergent imaging should be performed in a child should be performed in a child

who exhibits a post-ictal focal deficit not quickly who exhibits a post-ictal focal deficit not quickly resolving , or who does not return to baseline resolving , or who does not return to baseline within several hours (within several hours (optionoption))

– Non-urgent imagingNon-urgent imaging with MRI should be considered with MRI should be considered in any child with a significant cognitive or motor in any child with a significant cognitive or motor impairment of unknown etiology, unexplained impairment of unknown etiology, unexplained abnormalities on neurological exam, a seizure of abnormalities on neurological exam, a seizure of partial (focal) onset, an EEG that does not partial (focal) onset, an EEG that does not represent a benign partial epilepsy of childhood or represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under primary generalized epilepsy, or in children under 1 year of age. (1 year of age. (optionoption))

Nonfebrile SeizuresNonfebrile SeizuresTreatmentTreatment

Practice ParameterPractice Parameter– Defined first seizure to include Defined first seizure to include

multiple seizures in a 24 hour periodmultiple seizures in a 24 hour period– Excluded seizures with a known Excluded seizures with a known

precipitating causeprecipitating cause– Asked several key questionsAsked several key questions


ConclusionConclusion– Majority of children will have few or no Majority of children will have few or no

recurrencesrecurrences– Treatment with anti-epileptic drug (AED) after Treatment with anti-epileptic drug (AED) after

first seizure does not improve prognosis for first seizure does not improve prognosis for long-term remissionlong-term remission

– Treatment does reduce risk of recurrenceTreatment does reduce risk of recurrence– AED therapy does have potential serious AED therapy does have potential serious

pharmacologic and psychosocial side effectspharmacologic and psychosocial side effects– There is no evidence whether treatment after There is no evidence whether treatment after

a first afebrile seizure alters risk of sudden a first afebrile seizure alters risk of sudden unexplained death in epilepsy patientsunexplained death in epilepsy patients


Recommendations:Recommendations:– Treatment with AED is Treatment with AED is notnot indicated indicated

for the prevention of the for the prevention of the development of epilepsydevelopment of epilepsy

– Treatment with AED Treatment with AED may be may be consideredconsidered in circumstances where in circumstances where benefits of reducing the risk of benefits of reducing the risk of second seizure outweigh the risks of second seizure outweigh the risks of side effectsside effects

Nonfebrile SeizuresNonfebrile SeizuresDischargeDischarge

Patient may go home if returns to Patient may go home if returns to baseline baseline – Must be able to follow up with primaryMust be able to follow up with primary– Should have EEG doneShould have EEG done– Neurology follow-upNeurology follow-up– What to tell family:What to tell family:

Sudden death or significant injury is extremely Sudden death or significant injury is extremely uncommonuncommon

General safety precautionsGeneral safety precautions Follow-up EEG recommendedFollow-up EEG recommended

Febrile SeizuresFebrile Seizures

DefinitionDefinition– Any seizure occurring in an infant or young Any seizure occurring in an infant or young

child (6 months – 5 years of age) in child (6 months – 5 years of age) in conjunction with a fever or history of conjunction with a fever or history of recent fever without evidence of previous recent fever without evidence of previous seizure or underlying causeseizure or underlying cause

– Simple febrile seizures last less than 15 Simple febrile seizures last less than 15 minutes, are generalized, and occur only minutes, are generalized, and occur only once in a 24 hour periodonce in a 24 hour period


EpidemiologyEpidemiology– 2-5% of children2-5% of children– No racial, geographic or ethnic No racial, geographic or ethnic

differencesdifferences– 25 – 40% have family history of febrile 25 – 40% have family history of febrile

seizures in first degree relativesseizures in first degree relatives– Etiology is most commonly viralEtiology is most commonly viral– Rate of SBI is same as in children with Rate of SBI is same as in children with

fever and no seizurefever and no seizure


Risk of recurrenceRisk of recurrence– Higher if: Higher if:

first seizure occurs first seizure occurs << 15 months of age 15 months of age history of epilepsy or febrile seizure in first degree history of epilepsy or febrile seizure in first degree

relative relative many episodes of fever many episodes of fever initial seizure is complexinitial seizure is complex

– 10% recurrence if no risk factors10% recurrence if no risk factors– 25-50% recurrence if 1-2 risk factors25-50% recurrence if 1-2 risk factors– 50-100% if 50-100% if >>3 risk factors3 risk factors– Risk also higher if lower fever when seizure occurs Risk also higher if lower fever when seizure occurs

or shorter duration of fever when seizure occursor shorter duration of fever when seizure occurs

Knudsen and Berg et alKnudsen and Berg et al


Risk of complex febrile seizuresRisk of complex febrile seizures– Increased if:Increased if:

<12 months old at onset <12 months old at onset family history of febrile seizures family history of febrile seizures lower rectal temp during initial seizure (<40 C)lower rectal temp during initial seizure (<40 C)

– Offringa et alOffringa et al Risk of developing epilepsyRisk of developing epilepsy

– 1 simple febrile seizure- slightly higher 1 simple febrile seizure- slightly higher than general population (1%)than general population (1%)

– <12 months at onset- 2-4% risk<12 months at onset- 2-4% risk– Complex seizures – 30 – 50 times risk of Complex seizures – 30 – 50 times risk of

general pop.general pop.

Febrile SeizuresFebrile SeizuresEvaluation and Evaluation and managementmanagement

StabilizeStabilize– ABCsABCs– Benzodiazepines first lineBenzodiazepines first line– Phenytoin or phenobarbital secondPhenytoin or phenobarbital second

Good history and physical examGood history and physical exam Routine labs NOT indicatedRoutine labs NOT indicated

– Maybe bedside glucoseMaybe bedside glucose


LP studiesLP studies– GreenGreen

503 patients with meningitis (2 mon – 15 503 patients with meningitis (2 mon – 15 yrs)yrs)

No cases presented as isolated seizureNo cases presented as isolated seizure

– Al-EissaAl-Eissa 200 children with fever and seizure200 children with fever and seizure 51% had LP51% had LP 1.5% had bacterial meningitis- all had 1.5% had bacterial meningitis- all had

complex sz. And most had altered complex sz. And most had altered sensoriumsensorium


LP studiesLP studies– Lorber and SunderlindLorber and Sunderlind

15/452 with meningitis- all looked ill or had 15/452 with meningitis- all looked ill or had classic signs of meningitisclassic signs of meningitis

– Joffe et alJoffe et al 11/241 had bacterial meningitis11/241 had bacterial meningitis All had either:All had either:

– Visit to physician within prior 48 hoursVisit to physician within prior 48 hours– Seizure in EDSeizure in ED– Focal seizure ORFocal seizure OR– Suspicious finding on examSuspicious finding on exam


Lumbar Puncture?????Lumbar Puncture?????– 2011 AAP recommendations2011 AAP recommendations

Any child with meningeal signs or hx/PE Any child with meningeal signs or hx/PE suggestive of meningitis (level B)suggestive of meningitis (level B)

Any infant 6-12 mo if deficient in Any infant 6-12 mo if deficient in immunizations (Hib, prevnar) (level D)immunizations (Hib, prevnar) (level D)

Any child that has been treated with antibiotics Any child that has been treated with antibiotics (level D)(level D)

– HOWEVER- no documented cases of occult HOWEVER- no documented cases of occult bacterial meningitis in patients presenting bacterial meningitis in patients presenting with simple febrile seizures alonewith simple febrile seizures alone

Febrile SeizuresFebrile SeizuresWho to tap…Who to tap…

Strongly consider if less than 18 months old Strongly consider if less than 18 months old with:with:– History of irritability, poor feeding or lethargyHistory of irritability, poor feeding or lethargy– Abnormal appearance or mental status on initial Abnormal appearance or mental status on initial

exam after post-ictal periodexam after post-ictal period– Physical signs of meningitisPhysical signs of meningitis– Any complex featuresAny complex features– Slow post-ictal clearing of mentationSlow post-ictal clearing of mentation– Pretreatment with antibioticsPretreatment with antibiotics

Warden et al, ”Evaluation and Management of Febrile Seizures in Warden et al, ”Evaluation and Management of Febrile Seizures in the Out-of-Hospital and Emergency Department Settings”, Ann the Out-of-Hospital and Emergency Department Settings”, Ann Emerg Med. 2003Emerg Med. 2003

Febrile SeizuresFebrile SeizuresWho to scan…Who to scan…

Routine neuroimaging NOT Routine neuroimaging NOT recommendedrecommended

Consider urgent imaging if:Consider urgent imaging if:– Unable to clinically exclude increased Unable to clinically exclude increased

intracranial pressure on examintracranial pressure on exam– Status epilepticus or complex featuresStatus epilepticus or complex features– Evidence of traumaEvidence of trauma– Presence of a CSF shuntPresence of a CSF shunt

Febrile SeizuresFebrile SeizuresEEG and LabsEEG and Labs

2011 AAP Recommendations2011 AAP Recommendations– EEG should not be preformed in EEG should not be preformed in

neurologically normal child with neurologically normal child with simple febrile seizuresimple febrile seizure

– Serum electrolytes, ca, phos, mg, Serum electrolytes, ca, phos, mg, cbc, or blood glucose should NOT be cbc, or blood glucose should NOT be performed for the sole purpose of performed for the sole purpose of identifying the cause of a simple identifying the cause of a simple febrile seizurefebrile seizure

Febrile SeizuresFebrile SeizuresDispositionDisposition

Simple febrile seizuresSimple febrile seizures– Home if adequate follow-upHome if adequate follow-up– Anticipatory guidance about the benign Anticipatory guidance about the benign

nature of febrile seizures, recurrence risks nature of febrile seizures, recurrence risks and return precautionsand return precautions

Complex febrile seizuresComplex febrile seizures– May need admission for monitoring and May need admission for monitoring and

further evaluationfurther evaluation– If discharge, arrange follow-up with PCP or If discharge, arrange follow-up with PCP or

neurologist, or bothneurologist, or both

Febrile SeizuresFebrile SeizuresPProphylaxisrophylaxis

Phenobarbital no longer used Phenobarbital no longer used routinelyroutinely

Antipyretics not effective in Antipyretics not effective in preventing recurrencepreventing recurrence

Rectal diazepam on stand-by for Rectal diazepam on stand-by for repeat offendersrepeat offenders

Neonatal SeizuresNeonatal Seizures

Often harder to Often harder to differentiatedifferentiate

Jittery baby vs. Jittery baby vs. seizureseizure

Over 2/3 will Over 2/3 will have significant have significant underlying underlying pathologypathology

May look wellMay look well

Neonatal SeizuresNeonatal SeizuresCausesCauses

– 50 - 60% secondary to hypoxic-50 - 60% secondary to hypoxic-ischemic insultischemic insult

– 15% secondary to intracranial, 15% secondary to intracranial, subdural or subarachnoid bleedsubdural or subarachnoid bleed

– 10% due to inborn errors of 10% due to inborn errors of metabolism, infection, metabolic metabolism, infection, metabolic disease or toxinsdisease or toxins

– Pyridoxine deficiencyPyridoxine deficiency– Benign familial neonatal convulsionsBenign familial neonatal convulsions– Benign idiopathic neonatal convulsionsBenign idiopathic neonatal convulsions

Neonatal SeizuresNeonatal SeizuresTypesTypes

SubtleSubtle TonicTonic ClonicClonic MyoclonicMyoclonic

Neonatal SeizuresNeonatal SeizuresEvaluationEvaluation

Detailed birth historyDetailed birth history ImagingImaging

– All should be imaged (US, CT, or MRI)All should be imaged (US, CT, or MRI) LabsLabs

– Electrolytes, glucose, Ca, Mg, phosElectrolytes, glucose, Ca, Mg, phos– Toxicology screenToxicology screen– UA with micro and cultureUA with micro and culture– CBC and Blood cultureCBC and Blood culture– CSF studiesCSF studies

ExtrasExtras– Consider blood for amino acids, lactate, ammonia, Consider blood for amino acids, lactate, ammonia,

pyruvate and urine for organic acids pyruvate and urine for organic acids

Neonatal SeizuresNeonatal SeizuresTreatmentTreatment

ABC’sABC’s Correct electrolyte abnormalitiesCorrect electrolyte abnormalities AntibioticsAntibiotics BenzodiazepinesBenzodiazepines Phenobarbital before phenytoinPhenobarbital before phenytoin Consider pyridoxineConsider pyridoxine Consider acyclovirConsider acyclovir

ADMITADMIT

Questions?Questions?

ReferencesReferences

Friedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N Am Friedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N Am 2006;53:257-277.2006;53:257-277.

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Neurology 2000;55:616-623.nonfebrile seizure in children. Neurology 2000;55:616-623.

Eisner RF, Turnbull TL, Howes DS, Gold IW. Efficacy of a ‘Standard’ Seizure Eisner RF, Turnbull TL, Howes DS, Gold IW. Efficacy of a ‘Standard’ Seizure Workup in the Emergency Department. Ann Emerg Med 1986; 15:69-75.Workup in the Emergency Department. Ann Emerg Med 1986; 15:69-75.

Turnbull TL, Vanden Hoek TL, Howes DS, Eisner RF. Utility of laboratory Turnbull TL, Vanden Hoek TL, Howes DS, Eisner RF. Utility of laboratory studies in th emergency departemnt patient with new onset seizure. Ann studies in th emergency departemnt patient with new onset seizure. Ann Emerg Med 1990;19:373-377.Emerg Med 1990;19:373-377.

Nypaver mm, Reynolds SL, Tanz RR, Davis T. Emergency department Nypaver mm, Reynolds SL, Tanz RR, Davis T. Emergency department laboratory evaluation of children with seizures: dogma or dilemma? Pediatr laboratory evaluation of children with seizures: dogma or dilemma? Pediatr Emerg care 1992;8:13-16.Emerg care 1992;8:13-16.

Farrar HC, Chande VT, FitzpatrickDF, ShemmaSJ. Hypontaremia as the cause Farrar HC, Chande VT, FitzpatrickDF, ShemmaSJ. Hypontaremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors. Ann Emerg Med 1995;26:42-48.clinical predictors. Ann Emerg Med 1995;26:42-48.

Rider LG, Thapa PB, Del Beccaro MA, et al. Cerebrospinal fluid analysisin Rider LG, Thapa PB, Del Beccaro MA, et al. Cerebrospinal fluid analysisin children with seizures. Pediatr Emerg Care 1995;11:226-229.children with seizures. Pediatr Emerg Care 1995;11:226-229.

Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics neuroimaging in children with new-onset afebrile seizures. Pediatrics 2003;111:1-6.2003;111:1-6.

Hirtz D, Birg A, Bettis Det al. Practice parameter: treatmentof the child with a Hirtz D, Birg A, Bettis Det al. Practice parameter: treatmentof the child with a first unprovoked Seizure, Neurology 2003;60:166-75.first unprovoked Seizure, Neurology 2003;60:166-75.

ReferencesReferences

Warden CR, Zibulewsky J, Mace S, et al. Evaluation and management of Warden CR, Zibulewsky J, Mace S, et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215-222.settings. Ann Emerg Med 2003;41:215-222.

Knudsen FU. Recurrence risk after first febrile seizure and effect of short Knudsen FU. Recurrence risk after first febrile seizure and effect of short term diazepam prophylaxis. Arch Dis Child 1985;60:1045-1049.term diazepam prophylaxis. Arch Dis Child 1985;60:1045-1049.

Berg AT, Shinnar S, Hauser WA, et al. Predictors of recurrent febrile Berg AT, Shinnar S, Hauser WA, et al. Predictors of recurrent febrile seizures; a metaanalytic review. J Pediatr 1990;116:329-327.seizures; a metaanalytic review. J Pediatr 1990;116:329-327.

Offringa M, Bossuyt PM, LubsenJ, et al. Risk factors for seizure Offringa M, Bossuyt PM, LubsenJ, et al. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of recurrence in children with febrile seizures: a pooled analysis of individual patient data from five studies. J Pediatr 1994;124:574-584.individual patient data from five studies. J Pediatr 1994;124:574-584.

Green SM, Rothrock SG, Clem KJ, et al. Can seizures be the sole Green SM, Rothrock SG, Clem KJ, et al. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics 1993;92:527-manifestation of meningitis in febrile children? Pediatrics 1993;92:527-534.534.

Al-Eissa YA. Lumbar puncture in the clinical evaluation of children with Al-Eissa YA. Lumbar puncture in the clinical evaluation of children with seizures ssociated with fever. Pediatr Emerg Care 1995;11:347-350.seizures ssociated with fever. Pediatr Emerg Care 1995;11:347-350.

Lorber J, Sunderlind R. Lumbar puncture in children with convulsions Lorber J, Sunderlind R. Lumbar puncture in children with convulsions associated with fever. Lancet 1980;1:785-786.associated with fever. Lancet 1980;1:785-786.

Joffe A, McCormick M, DeAngelis C. Which children with febrile eizures Joffe A, McCormick M, DeAngelis C. Which children with febrile eizures need lumbar puncture? A decision analysis approach. Am J Dis Child need lumbar puncture? A decision analysis approach. Am J Dis Child 1983;137:1153-1156.1983;137:1153-1156.

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