Management of Febrile Seizures in Pediatrics: Is a Lumbar Puncture Necessary?

Doctor comforting child in hospital.
Senior female doctor checking on girl in hospital bed
Researchers analyzed the trends in evaluation and management of children with simple febrile seizures at US Children’s hospitals before and after the AAP’s updated guidelines.

Children with simple febrile seizures (SFS) can be managed without lumbar puncture (LP) testing, according to findings published in Pediatrics.

With Haemophilus influenzae and conjugated pneumococcal vaccines, the prevalence of bacterial meningitis has decreased dramatically in pediatric patients. In 2011, the American Academy of Pediatrics (AAP) began advising doctors not to conduct routine LP in children under 1 year old and only use it for children with signs and symptoms of meningitis, if they are not fully vaccinated, or have been pretreated with antibiotics. The AAP also advised against routine hematologic testing, neuroimaging, or electroencephalography (EEG).

The objective of the current study was to analyze the impact of this change in practice guidelines as it relates to the clinical management of children SFSs at emergency departments at children’s hospitals in the US.

The researchers analyzed data from the Pediatric Health Information System (PHIS) of data from 49 not-for-profit, tertiary care pediatric hospitals affiliated with the Children’s Hospital Association. They included first emergency department visits between 2015 and 2019 of children aged 6 to 60 months diagnosed with SFS. They excluded patients who died during the ED encounter and those with preexisting complex chronic conditions. Delayed diagnosis of bacterial meningitis was defined as diagnosis at a revisit within 3 days of an index encounter that did not include LP.

The researchers identified 49,668 visits before and 92,453 visits after publication of the AAP guidelines. Patients’ (42.4% females) median age at presentation was 20.8 months.

The percentage of children who underwent LP decreased from 11.6% in 2005 to 0.6% in 2019 (P <.001), particularly among children aged 6 to less than 12 months (28.3% to 1.0%). The percentage of children aged 1 year to 5 years who received the procedure dropped from 9.4% in 2005 to 0.6% in 2019.

While 3-day revisits increased from 0.5% in 2005 to 1.4% in 2019, decreases in head computed tomography (CT) (10.6% in 2005; 1.6% in 2019), complete blood counts (38.8% in 2005; 10.9% in 2019), serum chemistries (27.5% in 2005; 11.0% in 2019), and urinalysis (31.4% in 2005; 22.3% in 2019), intravenous antibiotics (17.7% in 2005; 3.3% in 2019), and SFSs (19.2% in 2005; 5.2% in 2019) over the period (P <.001 for all) did not reverse with the 2011 AAP guideline change.

Adjusting for health care inflation, the researchers found that mean inflation-adjusted costs decreased from $1,523 in 2005 to $605 in 2019 (P <.001).

Declines in hospital admissions and costs plateaued after the 2011 AAP guidelines. The rate of delayed diagnosis of bacterial meningitis did not significantly decrease during the period.

Study limitations included lack of knowledge of presenting signs and symptoms, inability to exclude underimmunized children, uncertainty of whether the patients had previous febrile seizures outside the facilities or the time period, and identification by SFS code.

“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,” concluded the researchers.


Raghavan VR, Porter JJ, Neuman MI, et al. Trends in management of simple febrile seizures at US children’s hospitals. Pediatrics. November 1, 2021. doi: 10.1542/peds.2021-051517