Trends in Management of Simple Febrile Seizures at US Children’s Hospitals

Abstract

OBJECTIVE We sought to measure trends in evaluation and management of children with simple febrile seizures (SFSs) before and after the American Academy of Pediatrics updated guidelines published in 2011. METHODS In this retrospective, cross-sectional analysis, we used the Pediatric Health Information System database comprising 49 tertiary care pediatric hospitals in the United States from 2005 to 2019. We included children aged 6 to 60 months with an emergency department visit for first SFS identified using codes from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases 10th Revision. RESULTS We identified 142 121 children (median age 21 months, 42.4% female) with an emergency department visit for SFS. A total of 49 668 (35.0%) children presented before and 92 453 (65.1%) after the guideline. The rate of lumbar puncture for all ages declined from 11.6% (95% confidence interval [CI], 10.8% to 12.4%) in 2005 to 0.6% (95% CI, 0.5% to 0.8%) in 2019 (P < .001). Similar reductions were noted in rates of head computed tomography (10.6% to 1.6%; P < .001), complete blood cell count (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean costs ($1523 to $601; P < .001). Reductions in all outcomes began before, and continued after, the publication of the American Academy of Pediatrics guideline. There was no significant change in delayed diagnosis of bacterial meningitis (preperiod 2 of 49 668 [0.0040%; 95% CI, 0.00049% to 0.015%], postperiod 3 of 92 453 [0.0032%; 95% CI, 0.00066% to 0.0094%]; P = .99). CONCLUSIONS Diagnostic testing, hospital admission, and costs decreased over the study period, without a concomitant increase in delayed diagnosis of bacterial meningitis. These data suggest most children with SFSs can be safely managed without lumber puncture or other diagnostic testing.

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

“…The lower rates of neurodiagnostic testing in our study compared with the earlier prior studies may be due to the tertiary setting of most centers in our study, 8 methodologic differences such as limiting to simple febrile versus all febrile seizures, 7,9 or improved adherence to guideline recommendations over time. 11 The ABCs we calculated for the evaluation of simple febrile seizures demonstrate that adherence to the current guideline recommendations 4 to avoid routine neurodiagnostic testing or hospital admission for simple febrile seizures is an attainable goal. ABCs have been established for a variety of pediatric conditions and measures, including asthma, 28 bronchiolitis, 28,29 and readmissions.…”

“…The median rates for LP (4.0%), CT (3.1%), and admission (5.6%) were all higher than the rates we identified, though there was significant variation across hospitals. Raghavan et al 11 also utilized the PHIS database and reported significant reductions in rates of neurodiagnostic testing and admission at children's hospitals in the United States between 2005 and 2019. The lower rates of neurodiagnostic testing in our study compared with the earlier prior studies may be due to the tertiary setting of most centers in our study, 8 methodologic differences such as limiting to simple febrile versus all febrile seizures, 7,9 or improved adherence to guideline recommendations over time 11 …”

“…[7][8][9][10] Most of these studies were conducted exclusively in the emergency department (ED) setting [8][9][10] and the most recent study included data only through 2011. 10 A more recent study of children's hospitals in the United States demonstrated decreasing rates of testing and admission for simple febrile seizures over the last 15 years, 11 but current variation in testing and hospitalization across hospitals is unclear. Additionally, achievable benchmarks of care (ABCs) for the evaluation of simple febrile seizures are unavailable.…”

“…The median rates for LP (4.0%), CT (3.1%), and admission (5.6%) were all higher than the rates we identified, though there was significant variation across hospitals. Raghavan et al11 also utilized the PHIS database and reported significant reductions in rates ofF I G U R E 2 Abbreviations: ABC, achievable benchmark of care; ED, emergency department; EEG, electroencephalogram; IQR, interquartile range; LP, lumbar puncture. a Number of hospitals used to calculate the ABCs varied based on how many were required to include at least 10% of the cohort for each measure.…”

Lumbar puncture or not: when does febrile seizure require a neurodiagnostic evaluation?

“…4) This change accelerated after SFS guidelines was proposed by the American Academy of Pediatrics (AAP) in 2011, and has been consistently supported by other guidelines. 1,[4][5][6][7] The biggest difference from the previous AAP guidelines is that LP is no longer recommended in cases of infants aged 6-12 months. 1,4) In the absence of signs of a CNS infection, LP is an option for infants of this age with SFS whose vaccination history of Haemophilus influenza type b (Hib) or pneumococcus is uncertain or lacking.…”