The utility of Lumbar Puncture in the rst episode of Simple Febrile Seizure in Children between 6 to 18 months of age

Introduction : Febrile seizures are the most common seizures occurring in children and are exclusive to childhood. It is the most common pediatric emergency and the most common type of seizure every pediatrician is dealing with. It accounts for 2.5% of all seizures in children. Despite progress in the understanding of febrile seizure and development of consensus statement about diagnostic evaluation and management there exists a diversity of opinion regarding blood investigations, neuro-imaging, Electro Encephalogram (EEG) and the need for routine lumbar punctures (LP)during a febrile seizure. Aim & objectives : To determine the utility of lumbar puncture in identifying the group of children aged 6 to18 months having the first episode of fever with seizures that would benefit from the procedure. Observation: Most common cause of fever in febrile seizures was found to be upper respiratory tract infection (38%) in children followed by AGE(15%). Family history was present in 12.77% of cases of SFS. The most common symptom is cough and cold apart from fever and seizure saw in children. Most common clinical sign was transient lethargy lasting less than <15 minutes seen in 18% of cases. In 11.7% of cases of SFS a diagnosis of meningitis was made at the time of admission. Out of these only 1 case (2.4%) was suggestive of meningitis in the age group of 6 to 12 months. Conclusion: Lumbar puncture is necessary to rule out meningitis in all children between the ages of 6 months to 12 months presenting with the first episode of fever with seizure to rule out meningitis.


Introduction
Seizures are a common problem in pediatric practice. The approximate prevalence of seizures in children is around 10% [1]. They are more common than in the adult population as the brain is still developing. Childhood seizures differ from adult seizure since the brain is developing organ. Many types of seizures are exclusive to childhood. The clinical picture is not static and pattern and type of seizures keep changing with age and brain development unlike adults, most seizures in children are provoked by somatic disorders originating outside the brain such as high fever, infection,  Transcranial ultrasound, C T Scan of the brain (plain, contrast).

Statistical analysis:
Results on continuous measurements are presented on Mean ± SD (Min-Max) and results on categorical measurements are presented in Number (%).
Significance is assessed at a 5 % level of significance.
The following assumptions on data are made: Student t-test (two-tailed, dependent) has been used to find the significance of study parameters on the continuous scale within each group. Chi-square/ Fisher Exact test has been used to find the significance of study parameters on a categorical scale between two or more groups.   The most common cause of fever in febrile seizure was found to be upper respiratory tract infection (URTI) in 38% of Cases followed by AGE in 15%. No focus was found in 42.6%. In our study, all cases presented with fever and convulsion(100%) as these were the inclusion criteria.
In addition to this, the most common associated symptom was cough and cold which was found in 36(38.2%) cases followed by irritability and loose stools found in 18% and 15% cases respectively.
Not a single case presented with neck stiffness.  Clinical diagnosis of meningitis was made in 11.7% cases of SFS at the time of admission.   Reports of C S F shows within normal limits  There was no death. No focal neurological deficits and sequelae were noticed following the seizure.
Recurrence of seizure was seen in 6.3% of cases during a hospital stay. So, SFS has a good prognosis but long term follow up study is needed to find any neurological abnormality in future.  [28] in their study found the familial prevalence was 20% and the commonest relative was a sibling. In my study familial prevalence was 12.77% in between the studies. Variation is due to genetic differences and other regional factors.

Discussion
B Rharucha et al [28] showed URTI was the most common infection in SFS. Kodah IH found viruses are the most common cause of illness presenting in the form of URTI in children admitted to the hospital with a first febrile seizure.
Jun-Hwa Lee et al [29] & Margaretha et al [30], both studies showed URTI was the most common infection in SFS. Aetiology of fever was either UTI or URTI in a study done by Gunduz et al [31]. Viruses are the most common cause of illnesses in children admitted to the hospital with SFS [32,33] The second most common cause of fever in our study was ADD 14(15%)which is similar to a study done by Margaretha et al [30] 5 (20%). The cause of fever was undetermined in 40(42.6%) in our study and was 62 (25%) in the study by Jun-Hwa Lee et al [29].
Since the most common cause of SFS was URTI, the commonest clinical symptom was cough and cold seen in 38.2% of cases. Clinical signs are minimal present in 34%cases only. The most common clinical sign was lethargy seen in 18% of cases which were transient, lasting for around 10 to 15 minutes followed by normal sensorium.
None of the patients had focal neurological deficits and loss of consciousness following the seizure. No studies could be found for comparison in this regard.
We have incidentally found three cases of microcephaly (<-3SD) among FSFS and they were included in our study because these cases did not have development delay, neonatal seizure or afebrile seizure earlier. They presented as SFS for the first time. Therefore follow up study is required to estimate the probability of these cases going into future epilepsy. Two cases had bulged fontanelles but on LP meningitis was ruled out. Here, bulged fontanelle may be a false interpretation for meningitis by a physician due to excessive cry.
In 11.7% of cases of SFS a diagnosis of meningitis Though the association between febrile seizure and meningitis came out to be statistically insignificant, meningitis being a rapidly deteriorating disease, we should not miss even a single case as it is highly preventable. In our study,1 out of 30 cases in the age group of 6-12 months came out to be ABM, equivalent to about 33/1000 cases proportionately, which can contribute to significant morbidity and mortality.
However, in the age group of 12-18 months, no single case of meningitis was detected. So our aim should be not to miss even a single case of meningitis. Hence, LP should be mandatory in the age group of 6-12 months to rule out meningitis.

Conclusion
It was found that meningitis is a presentation in a few cases of apparent simple febrile seizure mainly in the age group 6 to 12 months, so meningitis should always be considered as a differential diagnosis.
Lumbar puncture is necessary to rule out meningitis in all children between the ages of 6 months to 12 months presenting with the first episode of fever with seizure to rule out meningitis, even in the absence of meningeal signs so that we may not miss a single case of meningitis which has significant morbidity and mortality.
What does the study add to the existing knowledge?
Lumbar puncture is necessary to rule out meningitis in all children between the ages of 6 months to 12 months presenting with the first episode of fever with seizure to rule out meningitis.  [Crossref] 22. Teach SJ, Geil PA. Incidence of bactermia, urinary tract infections, and unsuspected bacterial meningitis in children with febrile seizures. Pediatr Emerg Care. 1999 Feb;15(1)9-12. [Crossref] 23. Hampers LC, Thompson DA, Bajaj L, Tseng BS, Rudolph JR. Febrile seizure-measuring adherence to AAP guidelines among community ED physicians. Pediatr Emerg Care.
A prospective incidence study of febrile convulsions. Acta pediatric Scandinavia.