1. Shake & BakeShake & Bake
Evaluation and Management of First Time PediatricEvaluation and Management of First Time Pediatric
SeizuresSeizures
Tricia Falgiani, MDTricia Falgiani, MD
Assistant ProfessorAssistant Professor
Department of Emergency MedicineDepartment of Emergency Medicine
Division of Pediatric Emergency MedicineDivision of Pediatric Emergency Medicine

2. ObjectivesObjectives
 At the end of this session, the participant willAt the end of this session, the participant will
be able to:be able to:
– Discuss indications for laboratory andDiscuss indications for laboratory and
radiographic studies in a child with first timeradiographic studies in a child with first time
afebrile seizure.afebrile seizure.
– Discuss indications for testing and treatment of aDiscuss indications for testing and treatment of a
child with a febrile seizurechild with a febrile seizure
– Discuss the differences in evaluation andDiscuss the differences in evaluation and
treatment of the very young infant with first timetreatment of the very young infant with first time
seizures.seizures.

3. First Time SeizuresFirst Time Seizures
Who cares?Who cares?
 Seizures are the most commonSeizures are the most common
pediatric neurologic disorderpediatric neurologic disorder
 4 – 6 % of children will have at least4 – 6 % of children will have at least
one seizure in the first 16 years of lifeone seizure in the first 16 years of life
 The greatest incidence occurs in thoseThe greatest incidence occurs in those
under 3 years of ageunder 3 years of age

4. Seizure DefinitionSeizure Definition
 ““A transient, involuntary alteration ofA transient, involuntary alteration of
consciousness, behavior, motorconsciousness, behavior, motor
activity, sensation, or autonomicactivity, sensation, or autonomic
function caused by an excessive ratefunction caused by an excessive rate
and hypersynchrony of dischargesand hypersynchrony of discharges
from a group of cerebral neurons”from a group of cerebral neurons”
Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53
(2006)(2006)

5. Pediatric SeizuresPediatric Seizures
Differential DiagnosisDifferential Diagnosis
 Disorders with altered consciousnessDisorders with altered consciousness
– Apnea and syncopeApnea and syncope
– Breath-holding spellsBreath-holding spells
– Cardiac dysrhythmiasCardiac dysrhythmias
– Atypical migrainesAtypical migraines
 Gastroesophageal refluxGastroesophageal reflux

6. Pediatric SeizuresPediatric Seizures
Differential DiagnosisDifferential Diagnosis
 Paroxysmal movement disordersParoxysmal movement disorders
– Acute dystoniaAcute dystonia
– Benign myoclonusBenign myoclonus
– PseudoseizuresPseudoseizures
– Shuddering attacksShuddering attacks
– Spasmus nutansSpasmus nutans
– TicsTics
 Sleep disordersSleep disorders
 Psychological disordersPsychological disorders

7. SeizuresSeizures
TreatmentTreatment --Acute StabilizationAcute Stabilization
Establish ABCsEstablish ABCs
Consider IV glucose, naloxone, or pyridoxineConsider IV glucose, naloxone, or pyridoxine
First dose of benzodiazepineFirst dose of benzodiazepine
Phenytoin or Fosphenytoin (20 mg/kg IV)Phenytoin or Fosphenytoin (20 mg/kg IV)
Phenobarbital (20mg/kg IV)Phenobarbital (20mg/kg IV)
reassess, consider intubationreassess, consider intubation
Continuous Infusion of BarbiturateContinuous Infusion of Barbiturate
intubate nowintubate now
General anesthesiaGeneral anesthesia

8. Nonfebrile SeizuresNonfebrile Seizures
Practice ParameterPractice Parameter
 Based on recommendations publishedBased on recommendations published
in Neurology in 2000in Neurology in 2000
 Comprehensive review of 66 articlesComprehensive review of 66 articles
 Children 1 month – 21 yearsChildren 1 month – 21 years
 1st time seizures not explained by1st time seizures not explained by
immediate, obvious, provoking causeimmediate, obvious, provoking cause
 Seizure lasting < 30 minutesSeizure lasting < 30 minutes

9. Nonfebrile SeizuresNonfebrile Seizures
Laboratory evaluationLaboratory evaluation
EvidenceEvidence
 Eisner, et alEisner, et al
– 30 children (0-18) and 133 adults30 children (0-18) and 133 adults
– CBC, BMP, Ca, Mg doneCBC, BMP, Ca, Mg done
– 1 case of unsuspected hyperglycemia1 case of unsuspected hyperglycemia
 Turnbull, et alTurnbull, et al
– 136 new onset seizures136 new onset seizures
– No clinically significant lab abnormalities in theNo clinically significant lab abnormalities in the
16 children in the study (12-19 years old)16 children in the study (12-19 years old)

10. Nonfebrile SeizuresNonfebrile Seizures
Laboratory evaluationLaboratory evaluation
Evidence, cont.Evidence, cont.
 Larger retrospective studies (Nypaver et alLarger retrospective studies (Nypaver et al
and Smith et al)and Smith et al)
– 507 children total- febrile and nonfebrile seizures507 children total- febrile and nonfebrile seizures
– Lab did not contribute to diagnosis orLab did not contribute to diagnosis or
managementmanagement
 FarrarFarrar
– 47 infants < 6 months of age47 infants < 6 months of age
– 70% with hyponatremia70% with hyponatremia

11. Nonfebrile SeizuresNonfebrile Seizures
Laboratory evaluationLaboratory evaluation
RecommendationsRecommendations
 Laboratory tests should be ordered basedLaboratory tests should be ordered based
on individual clinical circumstances thaton individual clinical circumstances that
include suggestive historic or clinicalinclude suggestive historic or clinical
findingsfindings
(think hard about electrolytes in children under 6(think hard about electrolytes in children under 6
months of age)months of age)
 Toxicology screening should be consideredToxicology screening should be considered
if there is any question of exposure orif there is any question of exposure or
substance abusesubstance abuse

12. Nonfebrile SeizuresNonfebrile Seizures
Lumbar PunctureLumbar Puncture
 EvidenceEvidence
– Rider et alRider et al
 57 CSF samples in children with nonfebrile57 CSF samples in children with nonfebrile
seizures (2-24 months old)seizures (2-24 months old)
 12.3% with >5 leukocytes/mm312.3% with >5 leukocytes/mm3
 None with meningitisNone with meningitis
 RecommendationRecommendation
– Lumbar Puncture is of limited value and shouldLumbar Puncture is of limited value and should
only be used if there is clinical concern foronly be used if there is clinical concern for
meningitis or encephalitismeningitis or encephalitis

13. Nonfebrile SeizuresNonfebrile Seizures
EEGEEG
 EvidenceEvidence
– Multiple studiesMultiple studies
 EEGs are the best predictors of recurrence in childrenEEGs are the best predictors of recurrence in children
who are neurologically normalwho are neurologically normal
 Helps determine seizure type, epilepsy syndrome andHelps determine seizure type, epilepsy syndrome and
risk of recurrencerisk of recurrence
 Optimal timing is not clearOptimal timing is not clear
 RecommendationRecommendation
– The EEG is recommended as part of theThe EEG is recommended as part of the
evaluation of the child with first timeevaluation of the child with first time
nonprovoked seizures (nonprovoked seizures (StandardStandard))

14. Nonfebrile SeizuresNonfebrile Seizures
NeuroimagingNeuroimaging
EvidenceEvidence
 Multiple studiesMultiple studies
– Abnormalities found in up to 1/3, but most did not influenceAbnormalities found in up to 1/3, but most did not influence
management decisionsmanagement decisions
– 2% clinically significant findings2% clinically significant findings
Most of those done because of focality of seizure or specificMost of those done because of focality of seizure or specific
clinical findingsclinical findings
– EmergentEmergent imaging is to detect a serious condition that mayimaging is to detect a serious condition that may
require immediate interventionrequire immediate intervention
– Non-urgentNon-urgent imaging detects abnormalities that may affectimaging detects abnormalities that may affect
prognosis, and thus have an impact on long termprognosis, and thus have an impact on long term
managementmanagement

15. Nonfebrile SeizuresNonfebrile Seizures
ImagingImaging
 Sharma et alSharma et al
– 500 nonfebrile first time seizures500 nonfebrile first time seizures
– Mean age 46 months (0 – 21 years)Mean age 46 months (0 – 21 years)
– 95% were imaged95% were imaged
 91% CT, 4% MRI91% CT, 4% MRI
– 83% normal83% normal
– 9% clinically insignificant abnormalities9% clinically insignificant abnormalities
– 8% (38 pts) clinically significant8% (38 pts) clinically significant
 Only 6 patients defined as “low risk”Only 6 patients defined as “low risk”

16. Nonfebrile SeizuresNonfebrile Seizures
ImagingImaging
 RecommendationsRecommendations
– If neuroimaging is obtained, MRI is preferred modalityIf neuroimaging is obtained, MRI is preferred modality
((guidelineguideline))
– Emergent imagingEmergent imaging should be performed in a child whoshould be performed in a child who
exhibits a post-ictal focal deficit not quickly resolving , orexhibits a post-ictal focal deficit not quickly resolving , or
who does not return to baseline within several hourswho does not return to baseline within several hours
((optionoption))
– Non-urgent imagingNon-urgent imaging with MRI should be considered in anywith MRI should be considered in any
child with a significant cognitive or motor impairment ofchild with a significant cognitive or motor impairment of
unknown etiology, unexplained abnormalities onunknown etiology, unexplained abnormalities on
neurological exam, a seizure of partial (focal) onset, anneurological exam, a seizure of partial (focal) onset, an
EEG that does not represent a benign partial epilepsy ofEEG that does not represent a benign partial epilepsy of
childhood or primary generalized epilepsy, or in childrenchildhood or primary generalized epilepsy, or in children
under 1 year of age. (under 1 year of age. (optionoption))

17. Nonfebrile SeizuresNonfebrile Seizures
TreatmentTreatment
 Practice ParameterPractice Parameter
– Defined first seizure to include multipleDefined first seizure to include multiple
seizures in a 24 hour periodseizures in a 24 hour period
– Excluded seizures with a knownExcluded seizures with a known
precipitating causeprecipitating cause
– Asked several key questionsAsked several key questions

18. Nonfebrile SeizuresNonfebrile Seizures
TreatmentTreatment
 ConclusionConclusion
– Majority of children will have few or noMajority of children will have few or no
recurrencesrecurrences
– Treatment with anti-epileptic drug (AED) afterTreatment with anti-epileptic drug (AED) after
first seizure does not improve prognosis for long-first seizure does not improve prognosis for long-
term remissionterm remission
– Treatment does reduce risk of recurrenceTreatment does reduce risk of recurrence
– AED therapy does have potential seriousAED therapy does have potential serious
pharmacologic and psychosocial side effectspharmacologic and psychosocial side effects
– There is no evidence whether treatment after aThere is no evidence whether treatment after a
first afebrile seizure alters risk of suddenfirst afebrile seizure alters risk of sudden
unexplained death in epilepsy patientsunexplained death in epilepsy patients

19. Nonfebrile SeizuresNonfebrile Seizures
TreatmentTreatment
 Recommendations:Recommendations:
– Treatment with AED isTreatment with AED is notnot indicated forindicated for
the prevention of the development ofthe prevention of the development of
epilepsyepilepsy
– Treatment with AEDTreatment with AED may be consideredmay be considered
in circumstances where benefits ofin circumstances where benefits of
reducing the risk of second seizurereducing the risk of second seizure
outweigh the risks of side effectsoutweigh the risks of side effects

20. Nonfebrile SeizuresNonfebrile Seizures
DischargeDischarge
 Patient may go home if returns to baselinePatient may go home if returns to baseline
– Must be able to follow up with primaryMust be able to follow up with primary
– Should have EEG doneShould have EEG done
– Neurology follow-upNeurology follow-up
– What to tell family:What to tell family:
 Sudden death or significant injury is extremelySudden death or significant injury is extremely
uncommonuncommon
 General safety precautionsGeneral safety precautions
 Follow-up EEG recommendedFollow-up EEG recommended

21. Febrile SeizuresFebrile Seizures
 DefinitionDefinition
– Any seizure occurring in an infant or young childAny seizure occurring in an infant or young child
(6 months – 5 years of age) in conjunction with a(6 months – 5 years of age) in conjunction with a
fever or history of recent fever without evidencefever or history of recent fever without evidence
of previous seizure or underlying causeof previous seizure or underlying cause
– Simple febrile seizures last less than 15 minutes,Simple febrile seizures last less than 15 minutes,
are generalized, and occur only once in a 24are generalized, and occur only once in a 24
hour periodhour period

22. Febrile SeizuresFebrile Seizures
 EpidemiologyEpidemiology
– 2-5% of children2-5% of children
– No racial, geographic or ethnicNo racial, geographic or ethnic
differencesdifferences
– 25 – 40% have family history of febrile25 – 40% have family history of febrile
seizures in first degree relativesseizures in first degree relatives
– Etiology is most commonly viralEtiology is most commonly viral
– Rate of SBI is same as in children withRate of SBI is same as in children with
fever and no seizurefever and no seizure

23. Febrile SeizuresFebrile Seizures
 Risk of recurrenceRisk of recurrence
– Higher if:Higher if:
 first seizure occursfirst seizure occurs << 15 months of age15 months of age
 history of epilepsy or febrile seizure in first degree relativehistory of epilepsy or febrile seizure in first degree relative
 many episodes of fevermany episodes of fever
 initial seizure is complexinitial seizure is complex
– 10% recurrence if no risk factors10% recurrence if no risk factors
– 25-50% recurrence if 1-2 risk factors25-50% recurrence if 1-2 risk factors
– 50-100% if50-100% if >>3 risk factors3 risk factors
– Risk also higher if lower fever when seizure occurs orRisk also higher if lower fever when seizure occurs or
shorter duration of fever when seizure occursshorter duration of fever when seizure occurs
Knudsen and Berg et alKnudsen and Berg et al

24. Febrile SeizuresFebrile Seizures
 Risk of complex febrile seizuresRisk of complex febrile seizures
– Increased if:Increased if:
 <12 months old at onset<12 months old at onset
 family history of febrile seizuresfamily history of febrile seizures
 lower rectal temp during initial seizure (<40 C)lower rectal temp during initial seizure (<40 C)
– Offringa et alOffringa et al
 Risk of developing epilepsyRisk of developing epilepsy
– 1 simple febrile seizure- slightly higher than1 simple febrile seizure- slightly higher than
general population (1%)general population (1%)
– <12 months at onset- 2-4% risk<12 months at onset- 2-4% risk
– Complex seizures – 30 – 50 times risk of generalComplex seizures – 30 – 50 times risk of general
pop.pop.

25. Febrile SeizuresFebrile Seizures
Evaluation and managementEvaluation and management
 StabilizeStabilize
– ABCsABCs
– Benzodiazepines first lineBenzodiazepines first line
– Phenytoin or phenobarbital secondPhenytoin or phenobarbital second
 Good history and physical examGood history and physical exam
 Routine labs NOT indicatedRoutine labs NOT indicated
– Maybe bedside glucoseMaybe bedside glucose

26. Febrile SeizuresFebrile Seizures
Evaluation and managementEvaluation and management
 LP studiesLP studies
– GreenGreen
 503 patients with meningitis (2 mon – 15 yrs)503 patients with meningitis (2 mon – 15 yrs)
 No cases presented as isolated seizureNo cases presented as isolated seizure
– Al-EissaAl-Eissa
 200 children with fever and seizure200 children with fever and seizure
 51% had LP51% had LP
 1.5% had bacterial meningitis- all had1.5% had bacterial meningitis- all had
complex sz. And most had altered sensoriumcomplex sz. And most had altered sensorium

27. Febrile SeizuresFebrile Seizures
Evaluation and managementEvaluation and management
 LP studiesLP studies
– Lorber and SunderlindLorber and Sunderlind
 15/452 with meningitis- all looked ill or had classic15/452 with meningitis- all looked ill or had classic
signs of meningitissigns of meningitis
– Joffe et alJoffe et al
 11/241 had bacterial meningitis11/241 had bacterial meningitis
 All had either:All had either:
– Visit to physician within prior 48 hoursVisit to physician within prior 48 hours
– Seizure in EDSeizure in ED
– Focal seizure ORFocal seizure OR
– Suspicious finding on examSuspicious finding on exam

28. Febrile SeizuresFebrile Seizures
Evaluation and managementEvaluation and management
 Lumbar Puncture?????Lumbar Puncture?????
– 2011 AAP recommendations2011 AAP recommendations
 Any child with meningeal signs or hx/PEAny child with meningeal signs or hx/PE
suggestive of meningitis (level B)suggestive of meningitis (level B)
 Any infant 6-12 mo if deficient inAny infant 6-12 mo if deficient in
immunizations (Hib, prevnar) (level D)immunizations (Hib, prevnar) (level D)
 Any child that has been treated withAny child that has been treated with
antibiotics (level D)antibiotics (level D)
– HOWEVER- no documented cases ofHOWEVER- no documented cases of
occult bacterial meningitis in patientsoccult bacterial meningitis in patients
presenting with simple febrile seizurespresenting with simple febrile seizures
alonealone

29. Febrile SeizuresFebrile Seizures
Who to tap…Who to tap…
 Strongly consider if less than 18 months old with:Strongly consider if less than 18 months old with:
– History of irritability, poor feeding or lethargyHistory of irritability, poor feeding or lethargy
– Abnormal appearance or mental status on initial examAbnormal appearance or mental status on initial exam
after post-ictal periodafter post-ictal period
– Physical signs of meningitisPhysical signs of meningitis
– Any complex featuresAny complex features
– Slow post-ictal clearing of mentationSlow post-ictal clearing of mentation
– Pretreatment with antibioticsPretreatment with antibiotics
Warden et al, ”Evaluation and Management of Febrile Seizures in the Out-of-Warden et al, ”Evaluation and Management of Febrile Seizures in the Out-of-
Hospital and Emergency Department Settings”, Ann Emerg Med. 2003Hospital and Emergency Department Settings”, Ann Emerg Med. 2003

30. Febrile SeizuresFebrile Seizures
Who to scan…Who to scan…
 Routine neuroimaging NOTRoutine neuroimaging NOT
recommendedrecommended
 Consider urgent imaging if:Consider urgent imaging if:
– Unable to clinically exclude increasedUnable to clinically exclude increased
intracranial pressure on examintracranial pressure on exam
– Status epilepticus or complex featuresStatus epilepticus or complex features
– Evidence of traumaEvidence of trauma
– Presence of a CSF shuntPresence of a CSF shunt

31. Febrile SeizuresFebrile Seizures
EEG and LabsEEG and Labs
 2011 AAP Recommendations2011 AAP Recommendations
– EEG should not be preformed inEEG should not be preformed in
neurologically normal child with simpleneurologically normal child with simple
febrile seizurefebrile seizure
– Serum electrolytes, ca, phos, mg, cbc, orSerum electrolytes, ca, phos, mg, cbc, or
blood glucose should NOT be performedblood glucose should NOT be performed
for the sole purpose of identifying thefor the sole purpose of identifying the
cause of a simple febrile seizurecause of a simple febrile seizure

32. Febrile SeizuresFebrile Seizures
DispositionDisposition
 Simple febrile seizuresSimple febrile seizures
– Home if adequate follow-upHome if adequate follow-up
– Anticipatory guidance about the benign nature ofAnticipatory guidance about the benign nature of
febrile seizures, recurrence risks and returnfebrile seizures, recurrence risks and return
precautionsprecautions
 Complex febrile seizuresComplex febrile seizures
– May need admission for monitoring and furtherMay need admission for monitoring and further
evaluationevaluation
– If discharge, arrange follow-up with PCP orIf discharge, arrange follow-up with PCP or
neurologist, or bothneurologist, or both

33. Febrile SeizuresFebrile Seizures
PProphylaxisrophylaxis
 Phenobarbital no longer used routinelyPhenobarbital no longer used routinely
 Antipyretics not effective in preventingAntipyretics not effective in preventing
recurrencerecurrence
 Rectal diazepam on stand-by forRectal diazepam on stand-by for
repeat offendersrepeat offenders

34. Neonatal SeizuresNeonatal Seizures
 Often harder toOften harder to
differentiatedifferentiate
 Jittery baby vs.Jittery baby vs.
seizureseizure
 Over 2/3 will haveOver 2/3 will have
significantsignificant
underlyingunderlying
pathologypathology
 May look wellMay look well

35. Neonatal SeizuresNeonatal Seizures
CausesCauses
– 50 - 60% secondary to hypoxic-ischemic50 - 60% secondary to hypoxic-ischemic
insultinsult
– 15% secondary to intracranial, subdural15% secondary to intracranial, subdural
or subarachnoid bleedor subarachnoid bleed
– 10% due to inborn errors of metabolism,10% due to inborn errors of metabolism,
infection, metabolic disease or toxinsinfection, metabolic disease or toxins
– Pyridoxine deficiencyPyridoxine deficiency
– Benign familial neonatal convulsionsBenign familial neonatal convulsions
– Benign idiopathic neonatal convulsionsBenign idiopathic neonatal convulsions

36. Neonatal SeizuresNeonatal Seizures
TypesTypes
 SubtleSubtle
 TonicTonic
 ClonicClonic
 MyoclonicMyoclonic

37. Neonatal SeizuresNeonatal Seizures
EvaluationEvaluation
 Detailed birth historyDetailed birth history
 ImagingImaging
– All should be imaged (US, CT, or MRI)All should be imaged (US, CT, or MRI)
 LabsLabs
– Electrolytes, glucose, Ca, Mg, phosElectrolytes, glucose, Ca, Mg, phos
– Toxicology screenToxicology screen
– UA with micro and cultureUA with micro and culture
– CBC and Blood cultureCBC and Blood culture
– CSF studiesCSF studies
 ExtrasExtras
– Consider blood for amino acids, lactate, ammonia,Consider blood for amino acids, lactate, ammonia,
pyruvate and urine for organic acidspyruvate and urine for organic acids

38. Neonatal SeizuresNeonatal Seizures
TreatmentTreatment
 ABC’sABC’s
 Correct electrolyte abnormalitiesCorrect electrolyte abnormalities
 AntibioticsAntibiotics
 BenzodiazepinesBenzodiazepines
 Phenobarbital before phenytoinPhenobarbital before phenytoin
 Consider pyridoxineConsider pyridoxine
 Consider acyclovirConsider acyclovir
 ADMITADMIT

39. Questions?Questions?

40. ReferencesReferences
 Friedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N AmFriedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N Am
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 Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a firstHirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first
nonfebrile seizure in children. Neurology 2000;55:616-623.nonfebrile seizure in children. Neurology 2000;55:616-623.
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41. ReferencesReferences
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Ann Emerg Med 2003;41:215-222.Ann Emerg Med 2003;41:215-222.
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