Management of children with febrile seizures: a Greek nationwide survey

Among respondents, 27% (124/457) were male, and 48% were practicing in the capital city of Athens; 58% had their own private practice, 37% were practicing in a government-owned hospital, and fewer (6.3%) were practicing in a private hospital (note that multiple answers were allowed). Respondents’ characteristics and years of practice can be seen in Table 1. Even though 72% did not think that more aggressive management of fever (for example, more frequent antipyretic administration) could alter the onset of febrile seizures, 63% admitted that they alter their advice for fever management to parents of children with febrile seizures.

Almost one in three pediatricians (28%) answered that they assumed aggressive management of fever (i.e., frequent or early administration of antipyretics) could delay the onset of febrile seizures. Most pediatricians (63%) would give different advice on fever management to parents of children with a history of febrile seizures, compared to the ones without, with more frequent measurement of temperature (71%) and administration of antipyretics at a lower temperature (88%); the vast majority (85%) recommended administration at temperatures of or lower than 37.9 °C. A smaller proportion would ask parents to provide antipyretics systematically at set time intervals. Of 330 respondents who did not believe that aggressive management had an effect, almost half (161, 49%) would nonetheless give different advice on the management of temperature to the parents of children with febrile seizures; 79 (49%) were from Athens or Thessaloniki, and almost two out of three (105, 65%) were working in a private environment.

After a single episode of simple febrile seizures, 13% of pediatricians would refer the child to a neurologist; 46% would do so after the 2nd episode, and 88% would do so after a complex episode. In the setting of a family history of epilepsy, 64% of the pediatricians would make a referral to a child neurologist after any episode of febrile seizure, regardless of type. The parents’ wish for their child to be examined by a specialist was enough reason for 71% of pediatricians to make a referral to a neurologist.

One in five pediatricians (20%) believed that a following episode of simple febrile seizures, the child should be hospitalized. Of these pediatricians, 13% believed this unconditionally, and 6.9% provided specific conditions. Two out of three pediatricians (67%) advised parents to go to the hospital in the event of another episode of febrile seizures.

Pediatricians were asked to identify, from a set of 10 given sentences, the advice they usually give to parents for the management of a following episode of febrile seizures (Table 1). More than half (54%) would suggest a suppository antipyretic. From 5 to 10% of pediatricians stated they would not give advice to put the child in a recovery position, to avoid putting hands in the child’s mouth, or to record the duration of the episode. However, 27 (5.9%) would advise parents that “it is ok to put a spoon in the child’s mouth,” 12 (3%) that they should put the child under running water, and 7 (21.5%) that it is ok to slap the child.

Prior to a first episode, 38% of pediatricians would inform the parents of the existence of febrile seizures if there was a family history; 34% would inform the parents only after the 1st episode. Only 28% would inform all parents before a first episode, regardless of family history.

We looked at answers stratified by years of experience and found significant correlations. We found a statistically significant correlation between years of experience and the perception that “aggressive” temperature management can alter the onset of febrile seizures. Pediatricians with experience over 20 years were the ones who mostly answered “yes” or “maybe” to this belief (44%) compared to those with under 5 (18%), 5–10 (14%), or 11–20 years of experience (29%) (p = 0.001). Likewise, the percentage of pediatricians who would give different advice for fever management to the parents of children with febrile seizures increased as the years of experience increased (p = 0.001), from 42% (less than 5 years of experience) to 77% (more than 20 years of experience). Finally, the respondents with experience over 20 years were the ones who would most frequently inform all parents in advance about the existence of febrile seizures, prior to a first episode or regardless of a history (37%) vs under 5 (24%), 5–10 (26%), and 11–20 years of experience (23%) (p = 0.033).

It is now known that the increased temperature may be an epiphenomenon related to other processes (immunological, etc.) that may be responsible for the febrile seizures and that antipyretics are ineffective in preventing the temperature from rising during episodes which lead to febrile seizures [21‐24]. Even though one recent Japanese trial has shown a prophylactic effect of rectal acetaminophen every 6 h for 24 h on the short-term recurrence of seizures [25], a recent Cochrane systematic review concludes that there was no benefit in the use of acetaminophen, ibuprofen, or diclofenac in the management of febrile seizures [26]. Prior misconceptions that antipyretics can prevent febrile seizures or febrile seizures and brain damage [27‐29] can be perpetuated by physicians giving advice that may imply that antipyretics can have an effect on the emergence of fever and seizures. The misconception on the role of antipyretics has been described before in the literature among healthcare workers, and in some cases, aggressive management included alternating antipyretics [29] and could perpetuate parents’ misconceptions as well [6]. The relationship developed between pediatricians and caregivers can either be positive and make the caregivers confident in the way they manage their child’s fever, or, in the absence of trust, it can lead to fever phobia and fever overtreatment [7]. Additionally, evidence suggests that in children, rectal diazepam and midazolam (either intranasal, buccal, or IM) are probably effective at stopping seizures that last at least 5 min [30].

When managing convulsing children, bacterial meningitis is the major concern of a physician. However, the risk of bacterial meningitis in children 6 to 11 or 18 months of age with a first simple febrile seizure, without any other signs or symptoms, is very low [31, 32]. Since simple febrile seizures in children are not associated with an increased likelihood of urinary tract infections, pneumonia, bacteremia, or bacterial meningitis [33, 34], well-appearing children with simple febrile seizures do not need routine diagnostic testing, including laboratory exams, neuroimaging, or electroencephalography, unless required to determine the underlying cause of the fever [34].

Therefore, advising the parents to visit the hospital for a case of simple febrile seizures, in the absence of a concern for the presence of meningitis or intracranial infection or with another identified source for the fever, can lead to unnecessary hospitalization and further invasive diagnostic procedures (i.e., lumbar puncture, blood cultures, electroencephalograms, neuroimaging) and add an unnecessary burden to both families and the healthcare system. In our study, 13% of pediatricians surveyed would make a referral to a neurologist after a single case of a simple febrile seizure, and 67% would advise that the child be taken to the hospital on a subsequent episode.

The implementation of the 2011 AAP guidelines lead to a decrease in diagnostic procedures, hospital admissions, and total mean costs from $1523 in 2005 to $605 in 2019 [33]. Similarly, the introduction of the new guidelines in 2015 in Japan was followed by a reduction in lumbar punctures and blood examinations ordered [15]. Overall, there seems to be a paucity of data on the treatment costs of children with febrile seizure events, and they are mostly dependent on the clinical workup [6]. Even though there are no data for the burden of simple febrile seizures to the healthcare system in Greece, one can expect that adhering to best practices will lead to subsequent gains for the healthcare system as well as for parents, as they would not need to take days off to be at the hospital.

The literature shows that there are gaps in what the caregivers of children know and in the knowledge and practices of pediatricians and pediatric healthcare providers. Different aspects of the same problem have been reported in Korea [35], Iran [36], Turkey, the USA [37], Saudi Arabia [38], Iraq [39], India [40], Germany [6], and Japan [15, 41] among other countries. The reports span across at least the last 15 years, showing that it an ongoing problem that can affect different populations at different times. The common denominator is that there is still work to be done in the matter of increasing awareness and knowledge and implementing best practices in the management of children with febrile convulsions.

In the paper by Sakai et al. [41], pediatricians with experience over 20 years had a better understanding and management of febrile seizures. In our study, in contrast, it seems that increasing age is a factor for guideline non-compliant practices. At the same time, physicians with over 20 years of experience are more likely to inform all parents in advance about febrile seizures.

Pediatricians give information to parents on diet, nutrition, immunization, and techniques to avoid accidents. Well-planned educational initiatives on fever and febrile seizure management can lead to improved parental knowledge, less fear, and better practices in the management of fever [5] or febrile seizures [36]. In order to educate parents, however, one needs to educate the educator—in this case, the pediatrician—as our study showed. In this direction, the development of guidelines may lead to better practices [15]. Consensus statements [8] can be helpful in creating training programs for healthcare workers and providing parents with solid information and recommendations. Currently, in Greece, there is no requirement for re-certification or keeping up to date through training that offers CME or other accreditation, which can be problematic, especially for the pediatricians who are not affiliated or working with a hospital. The issuing of new guidelines can be tracked better when working within hospitals [15]. Training could be offered at pediatric seminars or even through the medical associations to which they are obliged to renew their membership yearly.

This study has certain limitations that arise from the way it was performed. The survey was first given in paper form with a 98% response rate, and it was then disseminated to pediatricians by email through their medical associations in many, but not all geographic regions of Greece. Not all associations responded to our call, and from the ones that did respond, we cannot account for emails sent successfully without bouncing for any reason or how many emails were actually read. Therefore, our results may not be generalizable since not all pediatricians were contacted, a survey response rate could not be calculated, and the survey was biased toward physicians who were comfortable with email and an online survey. At the same time, this may suggest that the problem we describe has been underestimated, as the doctors who took part in the survey are those who attend seminars and respond to emails—i.e., those who make use of the internet—and thus are probably highly motivated and educated pediatricians. However, it should be noted that in 2017, there were 3672 registered pediatricians throughout Greece [42], and we managed to receive responses from only 457, or 13%. Other information that could help us estimate if our sample was representative (of, for example, age, sex, and geographical area) was not available to us, and even though we contacted the Panhellenic Medical Association, we received no answer. Even though 73% of the respondents stated that they would never refer a patient to a neurologist for simple seizures, 46% responded they would refer after 2 or more episodes of simple febrile seizures. We cannot explain this discrepancy, especially since these questions were yes/no questions and not multiple choice. Even though our data are only from Greece, it is not clear that they can be generalized to other countries, in Europe or elsewhere, especially in view of different healthcare systems, training programs, and socioeconomic variables that may affect pediatricians’ level of education. However, the literature shows that this is an international and ongoing matter. Raising awareness could be the first step in identifying more countries with similar problems and ultimately bridging the gap between theory and practice.

Despite these limitations, our study provides ample evidence that there is a gap between the knowledge and practices of pediatricians in Greece in their management of febrile seizures.