ObjectiveFebrile convulsion is the most common benign convulsive disorder in children. Meningitis is one of the most important causes of fever and convulsions, diagnosed by lumbar puncture (LP), a painful and invasive procedure much debated  regarding its necessity. This study evaluates the frequency of abnormal LP findings in a group of patients, to determine whether or not unnecessary LP can be prevented without missing patients with serious problems such as meningitis.Materials& MethodsThe study was a descriptive, cross sectional study, conducted on 200 children suffering from fever and convulsions. Medical files of patients were taken from the hospital records and relevant data were collected to complete the appropriate forms.ResultsOf 200 patients included in the study, 116 (58%) children were male, and 84 (42%) were female. 47 cases (23.5%) underwent LP, of whom just one (0.5%) had abnormal LP and meningitis.ConclusionRegarding Considering the low prevalence of meningitis in children with convulsion and fever, we conclude that by means of precise clinical examination and monitoring, it is possible to prevent unnecessary LP in these patients.Key Words:Fever and convulsion, Lumbar puncture, Meningitis

Alizadeh MD, M.

Edraki MD, MR.

Salehi Omrani MD, MR.

English

Journals Portal, Shahid Beheshti University of Medical Sciences

41Iran J Child Neurology  Feb. 2007IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THEFEBRILE CHILD WITH CONVULSION?MR. Salehi Omrani  MD¹,MR. Edraki MD2,M. Alizadeh MD3Abstract:ObjectiveFebrile convulsion is the most common benign convulsive disorderin children. Meningitis is one of the most important causes of feverand convulsions, diagnosed by lumbar puncture (LP), a painful andinvasive procedure much debated regarding its necessity. This studyevaluates the frequency of abnormal LP findings in a group of patients,to determine whether or not unnecessary LP can be prevented withoutmissing patients with serious problems such as meningitis.Materials& MethodsThe study was a descriptive, cross sectional study, conducted on 200children suffering from fever and convulsions. Medical files of patientswere taken from the hospital records and relevant data were collectedto complete the appropriate forms.ResultsOf 200 patients included in the study, 116 (58%) children were male,and 84 (42%) were female. 47 cases (23.5%) underwent LP, of whomjust one (0.5%) had abnormal LP and meningitis.ConclusionRegarding Considering the low prevalence of meningitis in childrenwith convulsion and fever, we conclude that by means of preciseclinical examination and monitoring, it is possible to preventunnecessary LP in these patients.Key Words: Fever and convulsion, Lumbar puncture, Meningitis.1. Pediatric neurologist, BabolUniversity of Medical Sciences2. Pediatric resident,   BabolUniversity of  Medical Sciences3. Pediatrician, Babol University of Medical SciencesCorresponding author:MR. Salehi  OmranTel: + 98 111 3240655Fax: + 98 111 3240356E-mail:salehiomran@yahoo.comRESEARCH ARTICLEIntroductionManagement of convulsion accompanied with fever is a controversial issue.During the first years of life, 3 to 4 percent of infants are affected by fever withconvulsion (1). Literature shows that children who have had one or more episodesof fever and convulsion as compared to children, who have not, are more likelyto be affected by epilepsy (2); also febrile convulsion can lead to status epilepticuswhich has many complications. Hence pediatricians are almost daily faced withsuch patients and the related problems, such as diagnosis, treatment, prevention,type of drug, duration of therapy and outcomes, and the effects on child's mentalabilities. It follows that quite naturally the exact diagnosis and etiology of thecondition is of high importance (3).Bacterial meningitis is a convulsive disease, themisdiagnosis of which leads to serious untreatable braindisabilities or death. Febrile convulsion (FC) is the mostcommon convulsive disorder in children aged between6 months to 5 years, in the absence of any CNS infections,meningitis, encephalitis, severe electrolyte imbalance,heat stroke and acute neurological injuries (4).To rule out these disorders and confirm FC, diverseclinical evaluations and paraclinical tests are necessary(4). While LP is an important procedure used todifferentiate between them, it is an invasive, painful andsometimes dangerous test which could be probablyavoided in unnecessary situations.Materials & MethodsThis was a cross sectional, descriptive study conductedon febrile children hospitalized for convulsion with feverin the Amir-cola children hospital between July andDecember 2003. Data was collected from records ofchildren hospitalized for fever and convulsion in theemergency ward. Two hundred files were selected andthe data required for each child was entered in specificquestionnaires. Studied parameters were: age, sex, andbody temperature; type of convulsion, duration ofconvulsion, time of convulsion in the current febrileepisode, history of FC in the child, history of FC in thefamily, using drugs, mental status and analysis of CSFfluid were also obtained. All statistical analyses weredone using SPSS statistical software. In our study, atemperature as of 37.8 C (rectal) was considered as fever. Simple FC was defined as a convulsion of less than 15minutes, without focal symptoms, just one occurrenceper 24 hours, otherwise complex FC was implied. Familialhistory of convulsion in the first and second relativeswas taken into consideration.According to the recommendations of American Academyof Pediatrics (AAP) on doing LP in patients with febrileconvulsion, the procedure was done for our patients (5).This recommendation is shown in table 1.ResultsOf the 200 patients, 47 cases (23.5%) had undergone LPaccording to AAP recommendations; among these, 26(55.31%) were boys and 21 (44.68%) were girls. Overall164 children (82%) had simple FC and 36 (18%) hadcomplex FC. The findings have been presented in table2.42 Iran J Child Neurology  Feb. 2007IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?Iran J Child Neurology  Feb. 2007 43None of the 164 patients with simple febrile convulsionshad meningitis; one child of 36 with complex febrileconvulsions showed abnormal findings in LP analysis.Among the children studied, in 63.02% , convulsionslasting less then 5 minutes were seen; 5 to 15 minuteconvulsions were seen in 27.63% and 7.53% of them hadconvulsions of more them 15 minutes. History of familialconvulsion was positive in 36.68% of children with FC.Among the children, 33.16% had previously convulsions.20 cases of complex F.C. had over 2 episodes or more in24 hours and one child had both risk factors.Table 3: Frequency of children who underwent L.P, according to their ages and sex*This girl had abnormal CSF.Figure: Frequency of fever in patients (centigrade via rectal route )IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?DiscussionOf the 200 febrile children, hospitalized for convulsion,23.5 percent underwent LPs, and of these just one hadshowed abnormal LP and meningitis. Considering thelow frequency of abnormal LP in patients with convulsionand fever, it is concluded that there is a high frequencyof unnecessary LP in these patients.In 1996, the American Academy of Pediatrics (4), andin 1991, some pediatricians of the British society ofchildren, (5) developed guidelines for performing an LPfor the neurological evaluation of 6 mo-5 yr old childrenwith FC; those guidelines recommended LP in all childrenaged below 12 months, and monitoring of 12 to 18 monthold children for hidden symptoms of meningitis.According to the recommendations, LP in children morethan 18 months old in absence of clinical suspicions wasconsidered unnecessary (6).LP needs to be done more carefully; the procedure isinvasive and not much favored by parents or children.Various related studies assessing complaints and clinicalexaminations, found doing LP as a routine wasunnecessary (7), while some thought it to be necessaryfor prevention of the complications of meningitis (1).Undoubtedly as compared to twenty years ago, there hasbeen a reduced tendency to do the procedure in manycountries.According to one study in England, in 1970, 96% ofchildren with the first FC had undergone LP, whereasthis rate decreased to 67% in 1980 and to 16% in 1990(8).Recent evidence shows that considering meningitis inchildren with convulsion and fever in the absence ofother symptoms is now questionable; two other pointsin these new findings, are first, the prevalence of bacterialmeningitis as a cause of convulsion plus fever is rarewith an overall incidence of 0.8% and second, in the lastfew years, there has been a drop in the prevalence ofmeningitis, and a consequent decline by to 0.23% in1990. More studies by experts reveal that the incidenceof meningitis, in the absence of other related symptomsis rare, as in one study only 4 of 30 patients withmeningitis showed no other symptoms whereas in 3 othercases, the absence or presence of symptoms was notevaluated.   In this study of the 7 patients who underwentLP, 3 cases were normal and LP was repeated for themwhen the patient's condition worsened. The resultsconfirmed pneumococcal meningitis in one andmeningococcal meningitis in the other two. One of themdied due to delayed administration of antibiotics. Althoughthe age of two patients was undefined but 4 of them wereover 1 year old while and one patient was below thatage (9). In one study, patients with meningococcalmeningitis, at the time of hospitalization, had up to 8%normal CSF results; of course most of these children hadmeningitis symptoms and septicemia (such as skin rash)(10). Rutten and his colleagues in their two year studyof children with convulsion and fever, just 4 children,out of 328 who underwent LP, had meningitis and oneof them had bacterial meningitis. Of these children, twohad primary normal LPs which 48 hours later werediagnosed as meningococcal meningitis (11).In another study conducted by Green et al examined 20-year records of 503 cases of meningitis in children aged2 mo-5yrs, of two hospitals. Of these, 115 cases (23%)had meningitis plus convulsion. From this group, 105children had consciousness levels of obtundation orcoma. The 10 remaining children in spite of acceptablelevels of consciousness, showed indications for lumbarpuncture, such as nuchal rigidity, long time focalconvulsion, frequent convulsions, skin rash and forcefulevidence implied meningitis (6, 9), suggesting indicationsof LP in 6 year-old febrile convulsive children who areadmitted with convulsion, skin rash, cyanosis,hypertension, respiratory distress, and abnormalneurological findings on examination; here the singlesymptom suspected for meningitis was convulsions.Other studies have also reported prevalence of meningitisin less than 1% of patients with convulsion plus fever(12-14). Again a study in Chicago revealed the rates ofserious bacterial illness in first simple febrile seizurewere low and consistent with febrile children withoutseizures (15).According to results shown in table 3, there is partialadvantage in favor of doing LP in patients with complexF.C rather than simple ones. In our study, there was justa sickly 3.5 year old girl with abnormal LP who had alsopresented with other symptoms of meningitis, includingmeningeal irritation and frequent prolonged convulsions.ConclusionTo conclude, considering the complications such as thepossibility of dangerous outcomes of LP in children, if44 Iran J Child Neurology  Feb. 2007IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?45Iran J Child Neurology  Feb. 2007the child does not have any signs indicating meningitis(such as neck rigidity, Kerning's sign, Brudzinski's sign,decrease in consciousness level, headache, irritability,nausea, vomiting), physicians could prevent unnecessaryLPs from being performed by monitoring the patientsregular examination in the early stages, except whenother signs of meningitis are seen. Further studies toconfirm these results are strongly recommended; theprecise criteria for carrying out an LP must be clarified,so that any potential case of meningitis may not bemissed.AcknowledgmentWe greatly appreciate respected staff of library andmedical record department of the Amir-kola childrenhospital for their friendly collaboration.References1. Shinnar S,Pellock JM, Berg AT, et al . Short - term outcomes   of children with febrile convulsion. Epilepsia  2001; 42:47.2. Lennox-Buchthal MA. Febrile convulsion. A reappraisal.    Electroncephalogr 1993;(suppl 32)75-83.3. Mayateal J, Shinnar S, Moshe SL. Low morbidity of status  epilepticues in children. Pediatrics  1989; 83: 313-331.4. Berg AT, Shinnar S. Complex febrile seizures. epilepsia 1996;    37:126-33.5. Freemen jm. Less testing is needed in the emergency room   after a first febrile seizure.Pediatrics 2003;111:194-196.6. Joint working, group of the research unit of the royal college   of physicians and British pediatric association, guideline for    management of convulsion with fever. B.M.J.  1991; 30-3:    637-6.7. Hampers LC, Trainor JL, Listernick R. Setting based in the    management of febrile seizure. Acad Emerg Med  2000;     7(1):21- 7.8. Comfield PR. Prevention of recurrent febrile seizure. J Pediatr    1995;126:929-930.9. Green L, Rothrock S, Slem KJ, et al .Can seizures be the sole    manifestation of meningitis in children with febrile seizures.    pediatric emergency  1999; 15: 120-125.10. Kanagaye JT,Soleimanzadeh P,Bradly JS. Lumbar Puncture     in pediatric bacterial meningitis. Pediatrics 2001;108:1169-      1174.11. Ruher N, Smales DR .Role of routine investigations in children     presenting with their first febrile convulsion. Arch D S child     1999; 52: 188.12. Larber JS, Jaunderland R. Lumbar puncture in children with    convulsion associated with fever lancet 1980; 1: 785-6.13. Mc Intyre P.B, Gray S.V, Vance J.C.Unspected bacterial     infections in febrile convulsion, Med J  1999;152: 183-6.14. Rossi L, Brunelli G, Dujioni N, et al. Lumbar puncture and    febrile convulsion  Health pediatric  1986: 141: 19-24.15. Trainor JL, Hampters LC, kruq LN. Children with first time,      simple febrile seizures are at low risk of serious baterial    illness. Acad emergency med   2001; 8(8): 781-7.IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?

IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?

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IS LUMBAR PUNCTURE ALWAYS NECESSARY IN THE FEBRILE CHILD WITH CONVULSION?

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