570623

research-article2015

CPJXXX10.1177/0009922815570623Clinical PediatricsCarapetian et al

Article

Emergency Department Evaluation and

Management of Children With Simple
Febrile Seizures

Clinical Pediatrics
2015, Vol. 54(10) 992998
The Author(s) 2015
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0009922815570623
cpj.sagepub.com

Stephanie Carapetian, MD, MS1, Joseph Hageman, MD2,3,

Evelyn Lyons, RN, MPH4, Daniel Leonard, MS5, Kathryn Janies, BA6,
Kent Kelley, MD3, and Susan Fuchs, MD7,8

Abstract
Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to
practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup.
This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a
medical record review of workup that was performed. The survey shows that laboratory workup is done routinely
and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates
documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American
Academy of Pediatrics revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to
the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve
management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup.
Keywords
simple febrile seizure, lumbar puncture, quality improvement

Introduction
Febrile seizures are the most common convulsive event
in childhood, occurring in 2% to 5% of children 6 to 60
months of age,1 with simple febrile seizures (SFS)
occurring about 65% to 91% of the time.2 A SFS, as
defined by the American Academy of Pediatrics
Subcommittee on Febrile Seizures, is a primary generalized tonicclonic convulsive event, which resolves
spontaneously, lasting less than 10 to 15 minutes, without recurrence in a 24-hour period. It is accompanied by
fever (temperature >38C) in a neurologically healthy
child aged 6 to 60 months.2,3
As a quality improvement measure in May 1996, the
American Academy of Pediatrics published a practice
guideline regarding the appropriate neurodiagnostic
evaluation of patients with a first simple febrile seizure
specifically lumbar puncture, electroencephalography,
blood studies, and neuroimaging.4 In February 2011, this
guideline was revised, directing the clinicians attention
to identifying the fever source and away from routine
laboratory evaluation (lumbar puncture, blood studies,
and urine analysis), neuroimaging, and electroencephalography.2,3 If there is a high suspicion for intracranial
infection, a lumbar puncture should be performed.3,4 In

the case of an infant 6 to 12 months of age presenting

with seizure and fever, without evidence of intracranial
infection, the revised guideline states that the clinician
has the option of performing a lumbar puncture even
if the patient has vaccination deficiencies or an indeterminate immunization status or at any age, or if there was
antibiotic pretreatment.3 The original guideline stated
that in the previous cases, a lumbar puncture should be
1

Seattle Childrens Hospital, University of Washington, Seattle, WA,

USA
2
Comer Childrens Hospital, University of Chicago, Chicago, IL, USA
3
NorthShore University HealthSystem, Evanston Hospital, Evanston,
IL, USA
4
Illinois Department of Public Health, Springfield, IL, USA
5
Loyola University, Chicago, IL, USA
6
The American Academy of Pediatrics, Elk Grove Villiage, IL, USA
7
Northwestern University Division of Pediatric Emergency Medicine,
Chicago, IL, USA
8
Ann & Robert H. Lurie Childrens Hospital of Chicago, Chicago, IL,
USA
Corresponding Author:
Stephanie Carapetian, Division of Pediatric Neurology, Seattle
Childrens Hospital, University of Washington, 4800 Sand Point Way
NW, Neurology B-5552, Seattle, WA 98105, USA.
Email: scarapet@uw.edu

993

Carapetian et al
strongly considered.4 The 2011 revision was made
after multiple retrospective studies demonstrated that
the original guidelines were not being followed.5 The
reasons cited for this were that children with SFS are at
low risk for a serious bacterial illness,6 including bacterial meningitis,7 and the incidence of bacterial meningitis presenting solely as fever and seizure is between 0%
and 0.6%.8
Quality improvement collaboratives (QIC) are frequently used to improve health care by disseminating
new and useful knowledge that can be applied directly
to patient care.9 This, in turn, improves patient outcomes
secondary to increased use of effective treatment and
decreases in wasteful care.10 As a quality initiative, in
1984, the federal government approved legislation to
create a Federal Emergency Medical Services for
Children (EMSC) program, aimed at addressing the
needs of children in emergency medical services.11 This
legislation has led to each state and United States territory over time establishing a statewide EMSC program.
Following this initiative, in 1994, Illinois EMSC was
established and since has received grants to establish
and enhance the ability to serve children in times of
emergency. This project was funded through the EMSC
targeted issues grant with the primary objective, to
assess the overall management of pediatric patients with
SFS presenting to emergency departments (EDs), as a
preliminary step in a QIC.

Methods
Participants
From January 2010 through April 2011, the Illinois
EMSC program conducted a statewide ED QI monitor,
which was approved by the Loyola University Chicago
Institutional Review Board, consisting of an Internetbased survey investigating the practice and policy of
care of pediatric patients presenting with SFS. Each participating ED identified individuals involved in completing the survey, which could include Pediatric Quality
Coordinator or qualified ED staff nurse, educator, medical director, or physician. Although the clinical roles differ in the ED, all survey responders were knowledgeable
about pediatric emergency care.

patient/parent education, discharge instructions, and

staff education. A multidisciplinary team composed of
QI specialists, pediatric nurses, pediatricians, emergency medicine physicians and nurses, and data analysts
collaborated in the development of a survey tool to
extract data reflective of an EDs general approach to
pediatric seizure management. A 17-question survey
was designed after an initial planning meeting that
included pediatric neurologists, pediatricians, ED medical and nursing staff, prehospital staff, a school nurse
representative, and a parent whose children were diagnosed with epilepsy. The survey was reviewed extensively by the Illinois EMSC Facility Recognition
Committee and QI Subcommittee composed of ED and
pediatric critical care physicians, nurses, and midlevel
practitioners as well as QI personnel and statisticians.
Each ED facility reported the defined age ranges for
their pediatric patients and their corresponding annual
ED pediatric volume. Additional questions addressed
the areas that potentially affect the quality of pediatric
seizure management in the ED, including access to a
pediatric neurologist; documentation of a seizure policy/
guideline that is used in the approach to these patients,
and whether it specifically addresses pediatric patients;
and laboratory and radiological measures used in treatment, plans for follow-up care, and patient/parent education (see Appendix A for the full list of questions).
Record Review.To determine whether survey findings
correlated with clinical practice, a retrospective chart
review was performed. Each participating institution
was concomitantly requested to randomly select and
review ED charts for up to 10 children presenting to the
ED with a diagnosis of SFS from January 2010 through
April 2011. Each institution was provided a chart
abstraction form (see Appendix B for full list of questions), developed by the Illinois EMSC QI Subcommittee. The record review tool included 24 questions
consisting of 30 components. This form sought to gather
information characterizing the clinical approach to initial assessment and management of children with seizures. Inclusion criteria for the review were limited to
children between the ages of 1 month and 15 years
treated by ED physicians and nursing staff.

Study Design

Statistical Analysis

Internet-Based Survey. The 119 participating EDs were

asked to complete an Internet-based survey of practices
regarding their management of SFS including policies
or clinical guidelines, laboratory and radiologic measures, documentation, treatment, neurological services,

Pearson 2 tests were used to evaluate differences

between these groups in both the surveys (P < .05) and
record reviews (P < .01). All analyses were performed
using SPSS statistical software version 17 (IBM
Corporation, Somers, NY).

994

Clinical Pediatrics 54(10)

Table 2. Emergency Department (ED) Record Review
Results.

Table 1. Survey Results.

Routine evaluation
Complete blood count with differential
Urine analysis
Serum blood glucose
Electrolytes
Blood culture
Chest radiograph
Computed tomography scan of head
Lumbar puncture
Electroencephalogram
Routine documentation
Neurologic status
Medication history
Respiratory status
Seizure semiology
Immunization status
Past medical and surgical history
Previous seizure activity
Cardiovascular status
Signs of infection
Family history
Potential exposure or ingestion
Discharge instructions
Explanation of simple febrile seizure
Fever management
Management of second seizure
Primary care provider referral
ED return/call 911
Recurrence risk
Neurologist referral

74%
69%
64%
59%
58%
36%
10%
2%
1%
96%
95%
94%
92%
92%
91%
90%
87%
81%
65%
57%
96%
95%
93%
93%
90%
60%
21%

Results
Survey Results
In 2010-2011, 119 EDs actively participated in the
Illinois EMSC QIC. Of the 119 participants, 105
responded to the survey, yielding a response rate of
88%.
Evaluation (Table 1) commonly included laboratory
tests, such as blood and urine studies, less frequently
chest radiograph, and much less frequently lumbar
puncture, neuroimaging, or neurodiagnostic testing. The
criteria used for performing a lumbar puncture largely
consisted of physician decision without any set criteria
(74%) and/or clinical presentation (63%). Only 12% of
facilities reported that criteria included immunization
status of child (unknown or deficient in Haemophilus
influenzae and Streptococcus pneumoniae immunizations), and 7% based their decision on recent antibiotic
pretreatment. A higher percentage of large (6000 or
more ED pediatric visits per year) facilities (21%)
included immunization status in lumbar puncture criteria than small (less than 6000 ED pediatric visits per

ED evaluation
Serum blood glucose
Lumbar puncture
Computed tomography scan of head
ED documentation
Neurologic status assessed
Documented past medical history
Documented seizure semiology
Documented evaluation for fever source
ED discharge plan and instructions
Discharge home
Follow-up with primary care provider
Follow-up with neurologist
Outpatient electroencephalogram
Home with rectal diazepam
Home with anti-epileptic medication

40%
4%
12%
96%
96%
90%
97%
87%
97%
5%
3%
2%
2%

year) facilities (2%). Documentation (Table 1) of neurological status was reported by most facilities; however,
signs of infection, family history (of seizures), and
exposure risk were less frequently documented.
Discharge instructions (Table 1) and patient education
typically included an explanation of febrile seizure and
primary care physician referral. Risk of recurrence was
only included 60% of the time, and about one fifth of the
facilities recommended neurology follow-up.

Record Review Results

One hundred hospitals provided data for the record
review, yielding 751 charts available for review. A total
of 47% of patients were 6 to 23 months of age and 53%
were 24 to 60 months of age.
Sixty-one percent of patients arrived to the ED via
prehospital transport. ED evaluation (Table 2) less commonly included laboratory evaluation as compared to
the survey responses related to routine testing. The frequency of cerebrospinal fluid testing with lumbar puncture was low and consistent with the survey results. The
majority of EDs documented (Table 2) past medical history and neurological status as well as seizure semiology. An assessment to identify the fever source was
documented in almost all of the patient records. The
majority of patients were discharged home. Disposition
instructions frequently included a follow-up appointment with primary care physician, but rarely included
outpatient neurology referral.

Discussion
As recommended in the 2011 American Academy of
Pediatrics Guidelines, best practice management for

995

Carapetian et al
SFS includes not performing routine laboratory testing
(blood, cerebrospinal fluid, urine) and imaging but
instead shifting the workup to identify the source of
fever. In this survey of over hundred Illinois EDs, laboratory tests (eg, complete blood count with differential,
electrolytes, urine analysis) would be performed as part
of the routine evaluation of patients with SFS despite the
American Academy of Pediatrics best practice guidelines.3,4 These recommendations were defined from
multiple observational studies demonstrating that these
studies are invasive and costly and would not provide a
clear benefit.3,12-15 Since this survey and the 2010-2011
record review were done mainly at community hospitals, it is likely that the ED physicians were not pediatricians, and would not have been as familiar with the 2011
American Academy of Pediatrics guidelines. This can
help explain the continued use of laboratory testing,
especially complete blood count and urinalysis. The
decreased use of lumbar puncture is likely due to the
decreased incidence of meningitis seen in the postvaccine era.7,9
The study by Trainor et al6 demonstrated in a predominantly community hospital setting, in the pre
Haemophilus influenzae, Streptococcus pneumoniae,
and varicella vaccine era, 57% of children with SFS
either had an uncomplicated infection as the source of
fever (otitis media, upper respiratory tract infection, gastroenteritis, varicella infection) or no source identified
(34%). In the groups tested, pneumonia was diagnosed
by chest radiograph in 12.5% of patients (46% tested),
5.9% were diagnosed with a urinary tract infection (38%
tested), 4 patients (1.3%) were diagnosed with S pneumoniae bacteremia (69% tested), and no patients were
diagnosed with meningitis (30% tested).
In our study, the survey evaluation for source of the
fever was underreported as compared to the record
review. As the new recommendations suggest, clinical
and laboratory evaluation of the fever source should
guide the workup and thus be clearly documented in the
patients chart.
Shaked et al,5 in a retrospective chart review from
2001 to 2005, evaluated the frequency and need for lumbar punctures performed on children 6 to 12 months of
age. Their study was done in the post-7-valent pneumococcal conjugate vaccination era, and showed that concomitant with the declining incidence of meningitis
secondary to more sophisticated immunizations, practitioners were not following the American Academy of
Pediatrics 1996 SFS management guidelines with
respect to lumbar puncture testing. Only 50% of their
patients with SFS underwent a lumbar puncture, which
at the time was urged as a strong consideration from
the American Academy of Pediatrics. Additionally, they

showed that, of the patients who underwent cerebrospinal fluid testing, none had pleocytosis or a positive culture. The authors argued that performing lumbar
puncture in patients 6 to 12 months of age was conceived
in a different epidemiologic era with data not representative of current issues, thus suggesting the need for
guideline revision.
In 2009, Kimia et al7 published a large retrospective
chart review, from 1995 to 2006, of children 6 to 18
months of age with SFS and evaluated the incidence of
meningitis. Of the 271 patients with cerebrospinal fluid
testing, none had bacterial meningitis. The authors concluded that there is no evidence that FSFS [first simple
febrile seizure] represents any increase in risk for meningitis, compared with children in the same age group
with fever but without FSFS. They urged physicians to
direct their decision to perform a lumbar puncture based
on the patients clinical presentation rather than focusing
on age. Additionally, the authors reviewed the frequency
of which lumbar punctures were performed, demonstrating that, among all age groups, there was a decrease in
lumbar puncture testing over time. This sentiment was
echoed in the 2009 American Academy of Pediatrics
Grand Rounds,16 thus prompting the revised guidelines
and urging clinicians to focus on symptoms and signs of
meningitis as to help determine whether a lumbar puncture is performed.
The aim of this study is to evaluate how practitioners
would work up a child with SFS after guideline revision
in 2011. From this study, survey and retrospective record
review results indicate that lumbar puncture testing was
done infrequently, consistent with best practice
guidelines.
Because of the benign nature of SFS and good prognosis, including low likelihood of future development of
epilepsy,1 the American Academy of Pediatrics recommends against long-term medication management of
SFS with anti-epileptic drugs.17 The survey and record
review results indicate that disposition with anti-epileptic drugs is rare, consistent with best practice
guidelines.
Finally, there is a correlation between survey
responses and chart reviews in regard to the performance of a lumbar puncture and head computed tomography scan, as well as documentation of neurological
status, seizure semiology, and past medical history, indicating that what the respondents of the survey state correlates with their actual management decisions.

Limitations and Future Implications

There are several limitations to this study. The survey
completion differed by facility, sometimes performed by

996

Clinical Pediatrics 54(10)

a nurse, less frequently by a physician, and sometimes by

multiple staff members. A second limitation of this study
is that data collected from the record review does not
include information about the frequency of blood and
urine laboratory studies. Without this information, we are
unable to make comparisons of actual practice to reported
practice. A third limitation of this study is that the data
from the record review stratifies children into 2 age
groups, 6 months to 23 months old and 2 years to 5 years
old, whereas it would have been helpful to look closely at
the ED practices with children under 12 months of age.
Despite these limitations, this multicenter QIC demonstrates that the Illinois EDs participating in this project have changed their practice with respect to routinely
performing a lumbar puncture in SFS patients, but also
shows that ED management of SFS still includes routine
laboratory studies. An online learning module has been
created to educate ED personnel about the best practice
guidelines for SFS workup. Future studies would include
examining the response to the learning module and
changes in practice, specifically with respect to laboratory and imaging studies.

Conclusions
This study demonstrates that there is an opportunity to
improve management of SFS by directing efforts toward
finding the source of the fever rather than the seizure,
and thus away from unnecessary laboratory and imaging
studies. This QIC shows that medical professionals, in
SFS evaluation, both report a low incidence of routine
lumbar puncture and in practice are infrequently performing lumbar punctures, but are underreporting their
clinical evaluation for the fever source, whereas in practice are performing a thorough clinical evaluation.

Appendix A
Pediatric Simple Febrile Seizure in the ED
Survey Questions
1. How does your emergency department define the pediatric
population?
2. What is the average volume of pediatric (defined as 0 through 15
years old) ED visits per year in your facility?
3. What is the average volume of ALL patient (adult and pediatric)
ED visits per year in your facility?
4. Does your ED have a documented protocol/policy/guideline/
clinical pathway that addresses the clinical management of seizures
(eg, Seizure, Altered Level of Consciousness, Fever)?
a. Does your EDs protocol/policy/guideline/clinical pathway
specifically address pediatrics?
5. What laboratory and radiologic measure(s) does your ED
routinely require for the management of Simple Febrile
Seizures? Check all that apply
(continued)

Appendix A (continued)
a. CBC with differential
b. Blood cultures
c. Blood glucose
d. Urinalysis
e. Urine culture
f. Electrolytes
g. Strep/RSV swab
h. BUN and Creatinine
i. Lumbar puncture
j. Chest x-ray
k. Head CT
l. EEG
m. MRI/MRA
n. EKG
o. None
6. What documentation does your ED routinely require for the
management of Simple Febrile Seizures? Check all that apply
a. Respiratory status
b. Cardiovascular status
c. Neurologic status
d. Signs of infection
e. Description of presenting seizure
f. Immunization history/status
g. Previous seizure activity
h. Medication history (include antibiotics)
i. Medical/surgical history
j. Exposure or ingestion history
k. Familial history of seizure
l. None
7. For Simple Febrile Seizure patients, what are your EDs
criteria for doing an LP? Check all that apply
a. Based on childs age (eg, every child under 12 months)
b. Based on clinical presentation (signs/symptoms of meningitis/
bacteremia; child looks toxic)
c. Based on childs immunization status (unknown or deficient in
H influenzae and S pneumoniae immunizations)
d. Based on if child has/has been previously/recently treated with
antibiotics
e. Per physician decision (no set criteria)
f. LPs are not done on patients presenting with simple febrile
seizures
g. I dont know
8. What component(s) are included on your EDs seizure discharge
instructions/patient education for Simple Febrile Seizure?
Check all that apply
a. Explanation of febrile seizure
b. What to do if another seizure occurs
c. When to return to ED/call 911
d. Provide reassurance
e. Fever management
f. Review risk of reoccurrence
g. Conduct medication reconciliation
h. Review seizure precautions
i. Primary Care Physician referral
j. Neurology referral
k. None
9. In the past year, has your ED staff received education related to
pediatric seizure disorders?
10. Does your hospital conduct chart reviews of patients with any
type of Seizure diagnoses for QI purposes?

997

Carapetian et al

Appendix B
Pediatric Simple Febrile Seizure in the ED
Medical Record Review
1. What was the patients mode of arrival?
Prehospital: If a patient arrived via EMS from the scene,
answer Questions #1a-e.
a. What level of prehospital service was used?
b. Was the childs airway controlled appropriately?
c. Was the childs neurologic status assessed?
d. Was blood glucose level checked by prehospital
provider?
e. W
 as a description of the seizure documented (for
example: who witnessed seizure, what did the seizure
look like, how long did it last, how was the child acting
right before seizure, how was the child acting the day
before, etc)?
Initial ED Assessment:
2. Age of patient (in months or years)
3. Was the child actively seizing upon arrival to the ED?
4. Was the neurologic status assessed?
5. Was blood glucose checked? Choose N/A if blood
glucose was checked prehospital.
6. Was full medical and seizure history documented (for
example: medications given prior to arrival to treat fever,
child/family seizure hx, antibiotic/antiepileptic medication
hx, immunization status, hx of incontinence, last feeding/
meal, recent hx of trauma, underlying health problems,
surgical hx, recent ingestion, recent exposure, childs
baseline status, age-related assessments, bruising, bites,
etc)?
7. Was a description of seizure documented (for example:
who witnessed seizure, what did the seizure look like,
how long did it last, how was the child acting right before
seizure, how was the child acting the day before, etc)?
8. Was an assessment performed to identify the source of
the fever?
ED Management:
9. Was the childs airway controlled appropriately?
10. Was a LP performed?
11. Was a head CT performed while child was in the ED?
12. If the child was febrile in the ED (temp.
100.4F/38.0C), was an antipyretic administered? Choose
N/A if parent/caregiver gave antipyretic prior to arrival OR if
patient no longer febrile.
13. If child was actively seizing, was an anticonvulsant
administered? Choose N/A if child was not actively seizing
13a. If yes, was it administered within 15 minutes of childs
arrival?
Disposition/Discharge:
14. Was the childs neurologic status reassessed before
disposition?
15. Was the childs temperature reassessed prior to
discharge?
16. What was the childs disposition from the ED?
a. Transferred (T) = transferred to a higher level of care
(answer Q.16a)
(continued)

Appendix B (continued)
b. PICU Admission (P) = admitted to PICU/ICU (in same
hospital)
c. Intermediate Care Admission (I) = admitted to an
intermediate care bed (in same hospital)
d. General Admission (F) = admitted to a general care
floor (in same hospital)
e. Observed (O) = admitted to an observation unit/
general floor and/or observed in the ED for 23 hours
(in same hospital)
f. Home (H) = discharged home after a brief period of
observation (6 hours) (answer Q.17-23)
g. Expired (E) = expired in the ED
16a. If transferred, what level/type of patient transport
service was used?
a. Specialty/Transport Team (S)
b. ALS/ILS (A)
c. ALS/ILS (with nurse) (A/n)
d. BLS (B)
e. BLS (with nurse) (B/n)
f. Private vehicle (PV)
17. Was an outpatient EEG ordered upon discharge from the
ED? Choose N/A if child was transferred or if hospital
policy does not require EEG.
18. Was rectal diazepam prescribed in the ED for home use?
Choose N/A if already prescribed or if the child was
transferred.
19. Was an oral antiepileptic drug (for example:
phenobarbital, phenytoin, valproate, etc) prescribed in
the ED for home use? Choose N/A if already prescribed or if
the child was transferred.
20. Did the child/family receive pediatric seizure patient
education prior to discharge? Choose N/A if child was
transferred.
21. Did the child/family receive pediatric fever management
education prior to discharge? Choose N/A if child was
transferred.
22. Was the child/family instructed to follow up with
a Primary Care Physician? Choose N/A if child was
transferred.
23. Was the child/family instructed to follow up with a
Neurologist? Choose N/A if child was transferred.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Emergency Medical Services for Children targeted issues grant.

References
1. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med.
1976;295:1029-1033.

998
2. Waruiru C, Appleton R. Febrile seizures: an update. Arch
Dis Child. 2004;89:751-756.
3. AAP Subcommittee on Febrile Seizures. Febrile seizures: guideline for the neurodiagnostic evaluation of the
child with a simple febrile seizure. Pediatrics. 2011;127:
389-394.

4.
Provisional Committee on Quality Improvement,
Subcommittee on Febrile Seizures. Practice parameter:
the neurodiagnostic evaluation of the child with a first
simple febrile seizure. Pediatrics. 1996;97:769-772.
5. Shaked O, Pena BM, Linares MY, Baker RL. Simple
febrile seizures: are the AAP guidelines regarding lumbar punctures being followed? Pediatr Emerg Care.
2009;25:8-11.
6. Trainor JL, Hampers LC, Krug SE, Listernick R. Children
with first-time simple febrile seizures are at low risk
of serious bacterial illness. Acad Emerg Med. 2001;8:
781-787.
7. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper
MB. Utility of a lumbar puncture for first simple febrile
seizure among children 6 to 18 months of age. Pediatrics.
2009;123:6-12.
8. Green SM, Rothrock SG, Clem KJ, Zurcher RF, Mellick
L. Can seizures be the sole manifestation of meningitis in
febrile children? Pediatrics. 1993;92:527-534.
9. Bergman DA. Evidence-based guidelines and critical
pathways for quality improvement. Pediatrics. 1999;103
(1 suppl E):225-232.

Clinical Pediatrics 54(10)

10. Margolis P, Provost LP, Schoettker PJ, Britto MT. Quality
improvement, clinical research, and quality improvement
research: opportunities for integration. Pediatr Clin North
Am. 2009;56:831-841.
11. Federal Emergency Medical Services for Children. http://
www.ncsl.org/issues-research/health/emergency-medicalservices-for-children-laws.aspx. Accessed August 20,
2013.
12. Jaffe M, Bar-Joseph G, Tirosh E. Fever and convulsions:
indications for laboratory investigations. Pediatrics.
1981;67:729-731.
13. Gerber MA, Berliner BC. The child with a simple

febrile seizure: appropriate diagnostic evaluation. Am J
Dis Child. 1981;135:431-443.
14. Heijbel J, Blom S, Bergfors PG. Simple febrile con
vulsions: a prospective incidence study and an evaluation of investigations initially needed. Neuropadiatrie.
1980;11:45-56.
15. Thoman JE, Duffner PK, Shucard JL. Do serum sodium
levels predict febrile seizure recurrence within 24 hours?
Pediatr Neurol. 2004;31:342-344.
16. Millichap JG. Indications for LP following first febrile
seizure reconsidered. AAP Grand Rounds. 2009;21:25.
17. Steering Committee on Quality Improvement and

Management, Subcommittee on Febrile Seizures. Febrile
seizures: clinical practice guideline for the long-term
management of the child with simple febrile seizures.
Pediatrics. 2008;121:1281-1286.

Copyright of Clinical Pediatrics is the property of Sage Publications Inc. and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.