Among 309 children with a first seizure and fever seen in 2 ERs in Rotterdam, The Netherlands, 23 (7%) had meningitis. The clinical findings in the patients with meningitis were compared with a control group of 69 children with seizures and fever and no meningitis. The signs of meningitis in 21 cases identified were: petechiae, nuchal rigidity, coma, persistent drowsiness, ongoing convulsions, and paresis or paralysis. Two children who proved to have meningitis had none of these signs. The median age at presentation with the first seizure associated with fever was 18 months (range: 3-52 months); 171 (65%) underwent lumbar puncture. Meningitis could be excluded on clinical grounds at reevaluation in all 138 children (45%) who did not undergo lumbar puncture. Children whose seizures showed no complex features and whose febrile illness revealed no suspicious features did not have meningitis. If all children with positive indicators were considered eligible for lumbar puncture, no meningitis cases would have been missed, and 75 of the 309 children (24%) would have been spared the puncture. The authors conclude that meningitis can be ruled out clinically in children presenting with seizures and fever and routine investigation of cerebrospinal fluid is unnecessary. [1]

COMMENT. In a questionnaire study to determine the methods of management of febrile seizures by pediatricians and family practitioners in the State of Illinois, spinal taps were employed by 70% of respondents in the workup of an acute febrile seizure [2]. This frequency of spinal taps was higher than that routinely ordered by private pediatric practitioners for children with first febrile seizures in the United States [3]. It was lower than the estimate for children admitted to medical centers [4]. Routine taps have been recommended in all children with an initial febrile convulsion [5]. Lorber J and Sunderland R have argued against routine lumbar punctures in children with seizures and fever, but recommend examination by a senior staff member if symptoms and signs of meningitis are absent. [6]

The indications for lumbar puncture should be determined not only by the patient’s clinical manifestations, but also the physician’s experience and clinical acumen and the opportunity for close patient observation. A selective approach avoids many unnecessary lumbar punctures a false sense of security and engendered by a normal premature tap. A second seizure with fever is no less likely to herald a bacterial meningitis than a first seizure, and the common emphasis on routine taps for first seizures with fever may be misleading.

Another source of confusion is the determination of complex features of febrile seizures. Berg AT et al. have found disagreement among pediatric neurologists regarding the assessment of focality of the seizure [7]. The reasons for disagreement included variation in interpretation of lateral eye deviation, staring episodes and motor asymmetries of the convulsion.