Febrile seizure: measuring adherence to AAP guidelines among community ED physicians

Investigating Associations Between Nonadherence to Guideline-Recommended Treatment of Pediatric Seizures and Adverse Outcomes: A Canadian Feasibility Study

BACKGROUND

Emerging evidence suggests that nonadherence to treatment guidelines for seizures may affect patient outcomes. We examined the feasibility of conducting a larger investigation to test this hypothesis in the pediatric population.

METHODS

We retrospectively reviewed charts of patients aged ≤18 years who presented with seizure to the emergency departments of two Ontario hospitals in 2019 to 2021. Patients were grouped by seizure duration (<5 minutes [n = 37], ≥5 minutes [n = 41]). We examined nonadherence to guideline-recommended treatment, adverse outcomes (hospitalization, length of stay, respiratory complications), and missing values for key variables.

RESULTS

Of 78 patients, 34 (44%) did not receive guideline-recommended treatment. Nonadherence was similar in the two groups (<5 minutes: 46%; ≥5 minutes: 41%). Common deviations included administering an antiseizure medication (ASM) for seizures of less than five minutes (46%), a delay (>10 minutes) between the first and second ASM doses (50%), and use of a benzodiazepine for the third dose (45%). Hospitalizations were common in both seizure duration groups (∼90%), whereas respiratory complications were relatively rare. Time of seizure onset was missing in 51% of charts, and none contained the time of first contact with emergency services when patients were transported by ambulance.

CONCLUSION

We found evidence of substantial nonadherence to guideline-recommended treatment of pediatric seizures. Medical records do not contain sufficient information to comprehensively investigate this issue. A multicenter prospective study is the most feasible option to examine the association between nonadherence to guideline-recommended treatment and patient outcomes.

The non-clinical burden of febrile seizures: a systematic review

Febrile seizures (FS) can be frightening for parents, even though they are usually harmless. Various questionnaires have been used to assess parental reactions and awareness about FS, revealing insufficient knowledge. Studies have shown that educational interventions significantly reduce parental concerns, improve knowledge, and promote better first-aid measures. Providing clear information and emotional support to parents is important to reduce their concerns and improve FS management. Healthcare providers should give comprehensive information about FS, including the risk of recurrence, and provide clear instructions on their management. The economic impact of FS includes direct and indirect costs. Studies have shown a decrease of hospitalizations and associated costs due to improved clinical adherence to guidelines, which also reduces the inappropriate use of healthcare resources. This systematic review provides a comprehensive overview of the existing literature on parental anxiety and education about FS, as well as their economic impact, aiming at identifying areas for improvement in the management of FS and providing valuable insights for healthcare providers and policymakers to better address the non-clinical burden of this condition.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures

BACKGROUND

Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.

OBJECTIVES

(1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.

OUTCOME MEASURES

Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.

RESULTS

We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.

CONCLUSIONS

Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Epidemiology and Resource Utilization of Simple Febrile Seizure-associated Hospitalizations in the United States, 2003-2012

BACKGROUND

Simple febrile seizure (SFS) affects 2% to 4% of children under 6 years of age. The purpose of this study is to examine the epidemiologic patterns and resource utilization of SFS-associated hospitalizations in children aged younger than 6 years of age in the United States.

MATERIALS AND METHODS

This study is a serial, retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Databases for the years 2003, 2006, 2009, and 2012. SFS-associated hospitalizations were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 780.31. We calculated the proportion of hospitalizations in pediatric patients under 6 years of age due to SFS and all other nonbirth causes, the rate of SFS-associated hospitalizations per 100,000 population, the mean length of stay and inflation-adjusted hospital costs of SFS-associated hospitalizations, as well as patient demographics and hospital characteristics.

RESULTS

From 2003 to 2012, the weighted proportion of hospitalizations due to SFS declined from 0.83% to 0.41% (P<0.01) and the annual rate of SFS-associated hospitalizations per 100,000 population decreased from 48.0 to 18.7 (P<0.01). However, use of computed tomography, electroencephalogram, and lumbar puncture in SFS-associated hospitalizations decreased significantly (all P<0.001), but the utilization rate of magnetic resonance imaging remained stable (P=0.53). The mean length of stay for SFS-associated hospitalizations decreased from 2.03 days in 2003 to 1.74 days in 2012, and the mean hospital costs (exclusive of professional payment) decreased from $3830 in 2003 to $3223 in 2012 (both P<0.001).

CONCLUSIONS

SFS-associated hospitalizations and resource utilization in children under 6 years of age have decreased markedly in the United States, probably due to improved clinical adherence to the practice parameters set forth by the American Academy of Pediatrics for managing patients with SFS.

Advocacy for children with epilepsy: Leveraging the WHA resolution. Advocacy Task Force, Commission of Pediatrics, International League Against Epilepsy

In May 2015 the World Health Assembly (WHA) approved the Resolution on the Global Burden of Epilepsy. This report addresses how the Resolution can be leveraged to improve the care of children with epilepsy worldwide. Children with epilepsy have unique needs and face unique challenges from stigma at all levels of society. Children lack a voice to lobby for their own needs, including their right to have access to education. Effective leadership and governance should be enhanced through the support of stakeholders empowered to counsel, advise, and lobby for appropriate care. National health care plans should integrate primary and specialist care, and they need to be adapted to local specificities. Antiepileptic medicines should be widely accessible in appropriate, sustained, and affordable ways. Public awareness initiatives are needed to improve the inclusion of affected children in society and to reduce stigma. Cost-effective interventions are also needed to address preventable causes of epilepsy. Without greater investment in research, evidence-based interventions cannot be implemented. Through all of this, civil society must be engaged to ensure that the multivariate dimensions from the clinic to the community are addressed to fulfil the needs of children with epilepsy.

The assessment of risk factors for febrile seizures in children

OBJECTIVE

The aim of the paper was to assess the risk factors of febrile seizures in children.

METHODS

The paper presents an analysis of a group of 176 children aged 6 months to 5 years who were admitted to A&E because of febrile seizures.

RESULTS

The analysed group of 176 children comprised 61.96% boys and 38.07% girls, and the average age equalled 23 months. Family history was significant in 9.66% of patients. A statistically significant difference was noticed between insignificant family history and the incidence of febrile seizures. In all the studied groups of children the factor that determined the incidence of febrile seizures was a sudden increase in the body temperature with an infection of the upper respiratory tract of several day's duration as another cause. Febrile seizure incident was most frequently associated with a sudden increase in the body temperature in 53.40% children. A statistically significant difference was observed between persisting fever and an increase thereof during the day. Yet another factor predisposing for febrile seizures incidence was an infection of the upper respiratory system that could be observed in 32.95% patients. The mean body temperature when the seizures occurred was 38.9°C.

CONCLUSIONS

A sudden increase in the body temperature within the first day of pyrexia predisposes for the incidence of febrile seizures and it was proved that it depends on how long fever persists during the day. The other factor triggering the seizures was an infection of the upper respiratory tract of several days' duration.

Assessing the prevalence distribution of abnormal laboratory tests in patients with simple febrile seizure

INTRODUCTION

Febrile seizure is an important issue in pediatric practice. Even some pediatricians do not have a proper approach to febrile seizure, making the sick child undergo complex laboratory tests or invasive procedures or even long-term treatment with anticonvulsant drugs. In spite of multiple studies, many controversies have still remained about the significance of febrile seizure. The goal of this study is to assess the prevalence distribution of routinely requested laboratory tests results in simple febrile seizure.

MATERIALS AND METHODS

In a descriptive study, 549 patients with simple febrile seizure were studied. The routine lab tests including complete blood count, electrolyte, urine analysis, and cerebrospinal fluid (CSF) analysis had already been performed for all patients and the results had been recorded in their medical data. These results were collected and statistically analyzed through SPSS software.

RESULTS

About 58.7% of our cases were male. Most of the cases were 12-24 months old and the mean body temperature of them was 38.2°C. 99.3% of blood sugar tests, 98% of blood calcium tests, 100% and 99.5% of sodium, and potassium tests, respectively, 100% of blood creatinine, 96.9% of blood urea nitrogen, and 99.1% of urine analysis tests were normal. CSF analysis was done in only 49 cases and the results were normal in all of them.

CONCLUSION

The percentage of abnormal laboratory test results was not statistically significant in febrile seizure and shows that performing all these tests in all patients with simple febrile seizure as routine is not necessary.

Predicting factors and prevalence of meningitis in patients with first seizure and fever aged 6 to 18 months

OBJECTIVE

To evaluate predicting factors and prevalence of meningitis in patients with first seizure and fever aged 6-18 months old.

METHODS

This cross-sectional study was performed on 800 patients aged 6-18 months old who had first attack of seizure with fever between March 2005 and March 2012 in the pediatric ward of Ghaem Hospital, Mashhad, Iran.

RESULTS

Among 800 patients, lumbar puncture (LP) was performed in 453 (56.6%) patients, of whom 80 cases had meningitis (17.6% of LP patients). Postictal drowsiness (p=0.003), neurologic deficit (p=0.000), and body temperature >/=38.5&#730;C (p=0.035) were among the clinical signs, which were statistically significant predicting factors for meningitis. Laboratory tests including white blood count (WBC) >/=15000 mm3 (p=0.004), and hemoglobin (Hb) <10.5 gr/dl (p=0.020) also had statistical significance in predicting meningitis.

CONCLUSION

Postictal drowsiness, neurological deficit, body temperature >/=38.5&#730;C, WBC >/=15000 mm3, and Hb <10.5 gr/dl were clinical and laboratory factors predictive of meningitis in cases with first attack of seizure and fever.

Clinical factors associated with invasive testing and imaging in patients with complex febrile seizures

BACKGROUND

Complex febrile seizures (CFSs) are a common diagnosis in the pediatric emergency department (PED). Although multiple studies have shown a low likelihood of intracranial infections and abnormal neuroimaging findings among those who present with CFS, the absence of a consensus recommendation and the diversity of CFS presentations (ie, multiple seizures, prolonged seizure, focal seizure) often drive physicians to do a more extensive workup than needed. Few studies examine the factors that influence providers to pursue invasive testing and emergent neuroimaging.

OBJECTIVE

The objective of this study was to determine the clinical factors associated with a more extensive workup in a cohort of patients who present to the PED with CFSs.

METHODS

Patient visits to a tertiary care PED with an International Classification of Diseases, Ninth Revision, diagnosis of CFS were reviewed from April 2009 to November 2011. Patients included were 6 months to 6 years of age. Complex febrile seizures were defined as febrile seizures lasting 15 minutes or longer, more than 1 seizure in 24 hours, and/or a focal seizure. Charts were reviewed for demographics, clinical parameters (duration of fever, history of febrile seizure, focality of seizure, antibiotic use before PED, and immunization status), PED management (antiepileptic drugs given in the PED or by Emergency Medical Services, empiric antibiotics given in the PED, laboratory testing, lumbar puncture, or computed tomography [CT] scan), and results (cultures, laboratories, or imaging). A logistic regression model was created to determine which clinical parameters were associated with diagnostic testing.

RESULTS

One hundred ninety patients were diagnosed with CFS and met study criteria. Clinical management in the PED included a lumbar puncture in 37%, blood cultures in 88%, urine cultures in 47%, and a head CT scan in 28%. There were no positive cerebral spinal fluid or blood cultures in this cohort. Of the 90 patients, 4 (4.4%) with urine cultures had a urinary tract infection. Of the 53 patients who had head CT imaging, there were no significant findings that guided therapy. The only factor associated with having a lumbar puncture performed was whether empiric antibiotics were used (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.28-6.8). History of a febrile seizure was associated with lower odds of a lumbar puncture (OR, 0.29; 95% CI, 0.12-0.69). In addition, higher age category was also associated with lower odds of a lumbar puncture (OR, 0.53; 95% CI, 0.31-0.91). Those who received an antiepileptic drug had a higher odds of getting a head CT (OR, 3.5; 95% CI, 1.5-8.6). Furthermore, patients presenting with a focal seizure also had higher odds of getting a head CT (OR, 4.89; 95% CI, 1.41-16.9).

CONCLUSIONS

Despite the low utility of associated findings, there are important clinical parameters that are associated with obtaining a lumbar puncture or a head CT as part of the diagnostic workup. National practice parameters to guide evaluation for CFSs in the acute setting are warranted to reduce the amount of invasive testing and imaging.

Magnesium use in asthma pharmacotherapy: a Pediatric Emergency Research Canada study

OBJECTIVES

To examine the use of intravenous magnesium in Canadian pediatric emergency departments (EDs) in children requiring hospitalization for acute asthma and association of administration of frequent albuterol/ipratropium and timely corticosteroids with hospitalization.

METHODS

Retrospective medical record review at 6 EDs of otherwise healthy children 2 to 17 years of age with acute asthma. Data were extracted on history, disease severity, and timing of ED stabilization treatments with inhaled albuterol, ipratropium, corticosteroids, and magnesium. Primary outcome was the proportion of hospitalized children given magnesium in the ED. Secondary outcome was the ED use of "intensive therapy" in hospitalized children, defined as 3 albuterol inhalations with ipratropium and corticosteroids within 1 hour of triage.

RESULTS

A total of 19 (12.3%) of 154 hospitalized children received magnesium (95% confidence interval 7.1, 17.5) versus 2 of 962 discharged patients. Children given magnesium were more likely to have been previously admitted to ICU (odds ratio [OR] 11.2), hospitalized within the past year (OR 3.8), received corticosteroids before arrival (OR 4.0), presented with severe exacerbation (OR 6.1), and to have been treated at 1 particular center (OR 14.9). Forty-two (53%) of 90 hospitalized children were not given "intensive therapy." Children receiving "intensive therapy" were more likely to present with severe disease to EDs by using asthma guidelines (ORs 8.9, 3.0). Differences in the frequencies of all stabilization treatments were significant across centers.

CONCLUSIONS

Magnesium is used infrequently in Canadian pediatric EDs in acute asthma requiring hospitalization. Many of these children also do not receive frequent albuterol and ipratropium, or early corticosteroids. Significant variability in the use of these interventions was detected.

Role of head computed tomography in the evaluation of children admitted to the paediatric intensive care unit with new-onset seizure

OBJECTIVE

The role of neuroimaging in children presenting with new-onset seizure is poorly defined. This study evaluates the incidence of abnormal CT findings in children admitted to the paediatric intensive care unit (PICU) with new-onset seizure and examines potential clinical variables associated with abnormal head CT findings.

METHODS

A retrospective analysis of 89 previously asymptomatic children admitted to Sydney Children's Hospital (Sydney, Australia) PICU between November 2005 and September 2009 with new-onset seizure was undertaken. Demographic data, clinical details and head CT findings were abstracted from medical records. The clinical significance and the impact of CT findings on acute management decisions was analysed. Clinical variables associated with abnormal clinically significant CT results were examined.

RESULTS

A total of 71/89 patients underwent head CT. Of the children who underwent head CT (n= 71), clinically significant CT results were found in 19.7% of patients and head CT findings resulted in a change in acute management in 7% of patients. Children without fever were more than twice as likely to have a positive CT scan (P= 0.049); however, a substantial proportion (6/45) of febrile children also had abnormal scans. Focal seizures were not predictive of abnormal CT results. There was a significant relationship between abnormal CT and multiple seizures (P < 0.02), and age less than 24 months (P < 0.049).

CONCLUSION

In this highly selected group head CT findings are frequently abnormal and might change acute management. Children admitted to the PICU with first presentation of seizure who have multiple seizures and/or are aged <2 years should have immediate CT or MRI scanning.

Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with complex febrile seizures

OBJECTIVE

To estimate the rates of bacterial meningitis and herpes simplex virus (HSV) encephalitis in children presenting with complex febrile seizures.

METHODS

Health records from 2002 to 2006 of all children 6 months to 6 years with a discharge diagnosis from the Hospital for Sick Children (Toronto, ON) of febrile convulsion, meningitis, or encephalitis were reviewed. Rates of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures were calculated.

RESULTS

There were 390 encounters of complex febrile seizures in 366 children. Of these encounters, 75 (19%) were transferred from an outlying hospital. A history of febrile convulsions was noted in 140 (36%). Lumbar puncture was performed in 146 (37%) patients. Six patients (all but one transferred) were diagnosed with bacterial meningitis (all due to Streptococcus pneumoniae). One transferred patient was diagnosed with HSV encephalitis. In patients initially presenting to our emergency department the rates of bacterial meningitis and HSV encephalitis were 0.3% (95% confidence interval, 0.0-1.8) and 0.0% (95% confidence interval, 0.0-1.2), respectively.

CONCLUSIONS

Given the low rate of bacterial meningitis and HSV encephalitis in children presenting with complex febrile seizures, routine lumbar puncture in these patients may be unnecessary.

Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age

OBJECTIVES

American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children.

METHODS

A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006.

RESULTS

First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis.

CONCLUSIONS

The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.

Methods of investigation and management of infections causing febrile seizures

The management of febrile seizures is reviewed, with emphasis on methods of investigation and treatment of associated infections. Records of 100 consecutive febrile seizure patient-visits were examined retrospectively at an East Carolina University-affiliated hospital. Causes of fever and infection, viral and bacterial studies, antipyretic, antibiotic, and antiviral treatments, and indications for lumbar puncture were analyzed. Febrile seizures were first episodes in 64, simple in 76, and complex in 23 (prolonged, at 30-60 minutes, in 4). The mean age was 20 months. Viral studies in 26 patients were positive in 9 (35%). Bacterial cultures in 100 were positive in 5%, none from CSF. Antibiotics were prescribed in 65%, and antipyretics in 89%. Lumbar puncture was performed in 14 patients; 11 had complex seizures, and 3 simple. Of simple seizure patients, none was aged <12 months, and only 1 was aged <18 months at time of lumbar puncture. Clinical manifestations and complex seizures are the principal indications for lumbar puncture, and not patient age. Viral infection is the most common cause of fever, and bacterial infection is infrequent. Early viral diagnosis should lessen the emphasis on bacterial cultures, and lead to reduced use of empiric antibiotics.

Quality of care for common pediatric respiratory illnesses in United States emergency departments: analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

OBJECTIVE

The goal was to measure US emergency department performance in the pediatric care of asthma, bronchiolitis, and croup, by using systematically developed quality indicators.

METHODS

Data on visits to emergency departments by children 1 to 19 years of age with moderate/severe asthma, 3 months to 2 years of age with bronchiolitis, and 3 months to 3 years of age with croup from the 2005 National Hospital Ambulatory Medical Care Survey, with a nationally representative sample of US patients, were analyzed. We used national rates of use of corticosteroids, antibiotics, and radiographs as our main outcome measures.

RESULTS

Physicians prescribed corticosteroids in 69% of the estimated 405,000 annual visits for moderate/severe asthma and in 31% of the estimated 317,000 annual croup visits. Children with bronchiolitis received antibiotics in 53% of the estimated 228,000 annual visits. Physicians obtained radiographs in 72% of bronchiolitis visits and 32% of croup visits.

CONCLUSIONS

Physicians treating children with asthma, bronchiolitis, and croup in US emergency departments are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

Seizure visits in US emergency departments: epidemiology and potential disparities in care

INTRODUCTION

While epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for "seizure" involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management.

METHODS

Seizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression.

RESULTS

Seizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000-1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0-10.0), and children aged 1-5 years (7.4; 95% CI: 6.4-8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7-3.9], males (OR: 1.4; 95% CI: 1.3-1.5) and Blacks (OR: 1.4; 95% CI: 1.3-1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4-0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4-0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2-0.6) or Medicaid (OR: 0.5; 95% CI: 0.4-0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4-0.8).

CONCLUSION

Seizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.