Lumbar puncture following febrile convulsion.

uch of the medicine we practice is enshrined in dogma. The management of children following febrile seizures is no exception. Every 5–10 years, the value and need for various investigations or treatment has been revisited in the medical press. However , despite the commonness of this clinical problem, consensus over management remains elusive. In particular, the need for lumbar puncture following a febrile seizure in infancy continues to be debated despite many attempts to assess its value. This article examines current guidelines, practice, and the available evidence of the value (and potential risks) of lumbar puncture following a febrile convulsion. CURRENT GUIDELINES The most recently available national guidelines for the management of convulsions with fever in the United Kingdom were issued in 1991. 1 These were published in the British Medical Journal under the heading " For debate " and were agreed by a panel of 21 invited participants. This paper began by defining febrile convulsions as " an epileptic seizure occurring in a child aged from 6 months to 5 years, precipitated by fever arising from infection outside the nervous system in a child who is otherwise neurologically normal ". The guidelines suggested that doctors should " almost certainly " perform a lumbar puncture in children under 1 year, even in the absence of signs of meningitis. However, the guidelines went on to comment that " an experienced doctor may decide on clinical grounds that a lumbar puncture is unnecessary ". The American Academy of Pediatrics published its " practice parameter " in 1996. 2 It too, fell short of recommending lumbar puncture for all children under 12 months, but suggested that lumbar puncture be " strongly considered " , because the clinical signs and symptoms of meningitis may be subtle. There has undoubtedly been a gradual shift in practice in the United Kingdom over the past 20 years. A study in the 1970s showed that nearly all children (96%) received a lumbar puncture following their first febrile seizure. 3 By the early 1980s this number had fallen to two thirds (67%), 4 and by the early 1990s reported rates for lumbar puncture following a febrile seizure had fallen to a mere 16%. 5 The most recent large scale survey of practice was conducted in the mid 1990s in the Mersey region. 6 This study revealed a wide variation in lum-bar puncture rates between hospitals but showed an overall …