Compliance with American Academy of Pediatrics consensus statement recommendations regarding lumbar puncture for infants 6-18 months of age with a first simple febrile seizure was investigated by a retrospective review of 704 infants evaluated in the pediatric emergency medicine division at Children’s Hospital Boston, MA, Oct 1995-Oct 2006. Immunization was up to date in 80% of 563 patients with recorded data. Lumbar puncture was performed for 271 (38%) of the children. CSF samples were available for 131 (70%) of 188 children 6-12 months of age and 129 (25%) of 516 children 12-18 months of age. Rates of lumbar puncture decreased significantly after 12 months of age and over time in both age groups (P<0.001). The proportion of patients, 6-12 months of age, with LP decreased from 100% (5 of 5) in 1995 to 22% (2 of 9) in 2006; in infants 12 to 18 months of age, the proportion with LP decreased from 71% (17 of 24) in 1995 to 5% (1 of 20) in 2006. No pathogen was discovered in CSF cultures. CSF white cell count was elevated in 10 patients, and a contaminant was identified in 10 cultures (3.8%). None of the 10 patients with CSF pleocytosis had bacteria isolated from blood cultures. No patient was diagnosed as having bacterial meningitis. Of 68 patients (10%) who had received antibiotics before the ED visit, 36 (53%) underwent LP, and 1 had CSF pleocytosis (9 WBCs/mm3, with 80% monocytes/lymphocytes). No pretreated child received a course of antibiotics as recommended for meningitis. The AAP consensus recommendation that clinicians strongly consider or consider LP for very young children with first simple febrile seizure has limited utility. The recommendations should be reconsidered and LP performed if there are clinical signs or symptoms of concern of meningitis. There is currently no evidence that a first simple febrile seizure represents any increase in risk for meningitis, compared with children in the same age group with fever but without febrile seizure. [1]

COMMENT. The AAP practice parameter emphasizes age as the main criterion for considering LP in young patients with first simple febrile seizure [2]. In contrast, pediatric emergency medicine physicians consider symptoms of meningitis, independent of the seizure and fever, are required before LP is performed [3, 4]. A representative of the AAP committee responded that practice guidelines should not eliminate clinical judgment and are not mandatory [4].

A recent 2008 report of patients with febrile seizures (FS) treated in a 1-year period, 2005-06, at an East Carolina University-affiliated hospital found that FS were first episodes in 64%, simple in 77%, and complex in 23%. At 100 consecutive FS patient visits, LP was performed in 14%; 11 had complex FS and 3 were simple FS (no SFS patient was aged <12 months and only 1 was aged <18 months). Of 49 patients with FSFS, only 3 (6%) underwent LP, and age (13 months) was an indication in 1. In a total of 77 patients with SFS, 3.9% underwent LP, compared with 48% of those with complex FS [5]. All were negative for evidence of bacterial or viral meningitis. Age was not a prominent criterion for LP. Complex FS was the main criterion for LP. Other factors significantly more prevalent in patients with LP compared to those without were an abnormal neurological examination, and signs of infection prompting blood culture and empiric antibiotic treatment. In the year 2006, the proportion of patients aged 6-18 months with first SFS who received LP was 3.5% (1 of 28) in the East Carolina and 10% (3 of 29) in the Boston studies. The decision to perform LP based on clinical indications and the physician’s judgment is supported by the findings and recommendations of both groups.