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The first febrile seizure: A study of current pediatric practice
MEDICAL CARE
The first febrile seizure: A current pediatric practice
of
A nationwide survey of pediatricians was conducted to ascertain their methods of evaluation and of management of a child who had had a 'first'febrile seizure. Two hundred and sixty (58%) of the sample of 445 pediatricians responded to the single mailing. Nearly one-quarter (24%) routinely hospitalized the child. A wide variation in utilization of diagnostic studies for this condition was reported. Those procedures for which the highest proportion of respondents indicated routine performance were: lumbar puncture (41%); measurements of concentrations of serum calcium (38%) and of blood sugar (43%)," and electroencephologram (36%). Of the 260 respondents, only 15% prescribed phenobarbital therapy for a defined period of time after the occurrence of the first febrile seizures. F~'ty-four percent of pediatricians advised parents to administer phenobarbital only when the child had a febrile illness. The results demonstrate that practicing pediatricians vary widely in the evaluation and management of children with an initial febrile seizure. Lack of consensus among pediatric practitioners concerning the management of this and other conditions will seriously hamper future peer review efforts.
Russell S. Asnes, M.D.,* Lloyd F. Noviek, M.D., N e w York, N. Y., J a m e s Nealis, M.D., Boston, Mass. and M y L i e n Nguyen, M . P . H . , N e w York, N. Y.
THE ONSET OF SEIZURE ACTIVITY in a febrile child is a problem commonly encountered by the clinician. An estimated 3% of all children will experience at least one such seizure by their fifth birthday? Seizures that occur in children in association with fever can be divided into two categories: Category 1--epileptic seizures precipitated by fever, and Category II--simple febrile convulsions. 2 Included in Category I are those children who have prolonged seizures or focal convulsions of any duration, who are over 6 years of age, and who have specific electroencephalographic abnormalities. Category II includes children who have experienced a generalized seizure of brief duration (usually less than 5 minutes), occurring soon after an elevation of body temperature, with no evidence of meningitis or encephalitis, and who have a normal electroencephalogram within 2 weeks after the febrile episode. Separating patients into these two From the Pediatric Ambulatory Care Division of the Department of Pediatrics and the Center for Community Health Systems, Columbia University College of Physicians and Surgeons. *Reprint address: 168th St. & Broadway, New York, N. Y. 10032.
diagnostic categories is helpful for the purposes of planning a diagnostic evaluation, prescribing a therapeutic regimen, and providing family counseling. Although there seems to be little difference of opinion in the approach to patients with epileptic seizures precipitated by fever, there is disagreement as to the appropriate diagnostic evaluation, management, and significance of simple febrile seizures. 3-6 This paper describes the results of a nationwide survey undertaken to ascertain the current opinions and practices of pediatric practitioners caring for children with a first febrile seizure. The results of this study have implications for the adequacy of diagnostic and therapeutic approaches to this problem; for pediatric graduate and postgraduate teaching programs; and for peer review mechanisms such as the professional standards review organizations. METHOD A nationwide survey of pediatricians was conducted to ascertain opinions, practices, and experiences regarding the management of children with febrile seizures. A random sample of 445 pediatricians was selected from the The Journal of PEDIATRICS Vol. 87, No. 3, pp. 485-488
485
486
Asnes et al.
The Journal of Pediatrics September 1975
Table I. Number of children seen by respondents annually with first febrile seizure No. of children per physician
No. of physicians
Percen rage
0 1-5 6-10 11-15 16-20 21-25 26 + Not indicated
3 77 83 30 27 11 20 9
1.2 29.6 31.9 11.5 10.4 4.2 7.7 3.5
Total physicians
260
100.0
RESULTS
The percentagesdo not alwaysadd to 100%because of rounding. Table II. Diagnostic studies ordered by respondents for children with first febrile seizure Frequency of ordering Never Diagnostic Study
Serum electrolytes Blood sugar Serum calcium Blood urea nitrogen Lumbar puncture Roentgenograms Skull Chest Electroencephatogram
Occasionally
commonly employed in caring for children with these conditions. An opportunity was provided for the respondents to comment on each of the areas covered by the questionnaire. The questionnaire was accompanied by a letter which included a description of the purpose of the study and the following definition of a febrile seizure: a generalized seizure of brief duration (usually less than 5 minutes), occurring soon after an elevation of temperature, with no evidence of meningitis or encephalitis.
Routinely
No.
%
No.
%
No.
%
57 29 46 58 12
21.9 11.2 17.7 22.3 4.6
135 114 109 108 142
51.9 43.8 41.9 41.5 54.6
57 112 98 83 106
21.9 43.1 37.7 31.9 40.8
60 49 30
23.1 18.8 11.5
128 150 129
49.2 57.7 49.6
63 44 93
24.2 16.9 35.8
fellowship list of the American Academy of Pediatrics.' Excluded from selection were those pediatricians whose address was listed as a hospital or university. The sample included physicians from all 50 states. A questionnaire was designed to elicit the following information from the responding physicians: number of children seen annually with a first febrile seizure, frequency of hospitalization of these patients, and frequency of neurologic consultation. In addition, the physicians were queried as to their utilization of diagnostic'studies and procedures for this condition including laboratory measurements of serum electrolytes, blood sugar, serum calcium, blood urea nitrogen, lumbar puncture, electroencephalograms, and skull and chest roentgenograms. Inquiries were directed at clinical entities which should be differentiated from febrile seizures including bacterial meningitis, hypoglycemia, hypocalcemia, and renal disease. These physicians were also requested to indicate the treatment regimens they
Two hundred sixty (58%) of the sample of 445 pediatricians responded to the single mailing. Ninety-nine percent of the respondents reported that they care for at least one child per year with a first febrile seizure (Table I). Approximately 30% cared for one to five children, and an additional 32% cared for six to ten children annually with this condition. Hospitalization, consultation, and evaluation. Nearly one-quarter of the physicians routinely hospitalized children with their first febrile seizure. Sixty-two percent of the pediatricians indicated that they only occasionally hospitalize and 12% never hospitalize these patients. Twenty-four of the respondents commented that they hospitalized children with a first febrile seizure if the parents were highly anxious and lacked the capability to cope with the situation. Neurologic consultation was never sought by 40% of the respondents and occasionally sought by 54%. Less than 5% routinely requested such consultation. A wide variation was apparent in utilization of diagnostic studies for the evaluation of children with a first febrile seizure (Table II). For example, approximately one-half of the respondents replied that they occasionally ordered measurements of serum electrolytes; the remainder were evenly divided between never ordering and routinely ordering this study. Those procedures for which the highest proportion of respondents indicated routine performance were lumbar puncture (41%), measurements of serum calcium (38%) and of blood sugar (43%), and electroencephalogram (36%). Those studies which were indicated by approximately one-fifth of the respondents as never performed included estimation of serum electrolytes (22%), blood urea nitrogen (22%), serum calcium (17%), and skull (23%) and chest (19%) roentgenograms. Thus the largest proportion of respondents indicated that specific procedures were utilized only occasionally, implying that most physicians do not employ a routine plan for the diagnostic evaluation of children with a first febrile seizure. Responding pediatricians commented that their diagnostic evaluations were influenced by suspicion of underlying disease, whether the child was hospitalized, the age of the child, and
Volume 87 Number 3
whether or not there was a family history of seizure disorder. An attempt was made to ascertain the frequency with which pediatricians encountered children who had presented with an apparent febrile seizure which proved to be secondary to or associated with bacterial meningitis, hypoglycemia, hypocalcemia, and renal disease. In response to the question, "Have you ever seen a child with bacterial meningitis present with a 'typical' febrile seizure?" 58% of the physicians indicated that they had encountered this situation. With regard to other abnormalities, 26% of the physicians had encountered children with hypoglycemia, and 12% and 19%, respectively, had encountered this situation with hypocalcemia and renal disease. Treatment. Of the 260 responding pediatricians, only 15% prescribed continuous phenobarbital therapy for a defined period of time, usually for one to three years following the occurrence of the first febrile seizure (Table III). Fifty-four percent of the 260 responding .physicians advised parents to administer phenobarbital only when the child had a febrile illness. A number of physicians commented that they employed this therapy primarily for parental reassurance. Approximately one-fifth of the physicians were of the opinion that antipyretics are extremely effective in preventing a recurrence of a febrile seizure. DISCUSSION The results of this study demonstrate that practicing pediatricians vary widely in their approach to the diagnostic evaluation and therapeutic management of children with first febrile seizures. A previous survey of 35 university pediatric departments revealed that at these institutions, evaluations for this condition routinely included: lumbar puncture; blood glucose, serum calcium, and serum phosphorus determinations; electroencephalogram; and skull roentgenogram. 8 The cost of this evaluation at our institution exceeds $175.00. The pharmacotherapeutic approach to the child following his first febrile seizure continues to be actively debated.2. 3, 8 Three commonly proposed approaches are: (1) continuous phenobarbital therapy for one to four years following the first seizure, (2) the administration o f phenobarbital only during thecourse of the febrile illness, and (3) no anticonvulsant therapy for the child following his first febrile seizure. The results of this survey indicate that the majority of practitioners (61%) prescribe phenobarbital 0nly during febrile illnesses. The reported study clearly indicates that a spectrum of diagnostic and therapeutic practices exists among pediatric practitioners. Furthermore, the diagnostic evaluations utilized by the majority of pediatricians surveyed is
The first febrile seizure
487
Table IlL Treatment regiments utilized for children after occurence of first febrile seizure
Number I Percentage No anticonvulsant Phenobarbital only at onset of febrile illnesses Phenobarbital continuously for 1-3 yr after first seizure Diphenylhydantoin only at onset of febrile illnesses Diphenylhydantoin continuously for 1-3 yr after first seizure Combination of phenobarbital and diphenylhydantoin, either intermittently or continuously Other
37 139
14.5 54.7
33
13.0
0
0.0
0
0.0
33
13.0
12
4.7
Total physicians
254
99.9
different from those carried out in the academic setting. Two possible explanations of these findings emerged from the comments of the responding pediatricians: (1) private pediatricians tailor the evaluation and treatment regimen to the individual patient and (2) private pediatricians have received conflicting guidance about the appropriate diagnostic and therapeutic measures to employ for this condition. Responses of pediatricians indicated an individualistic approach to this clinical problem. Factors considered relevant to the diagnostic evaluation or treatment plan utilized included: age of the child, distance of child's home from the physician's office or hospital, parental anxiety, and presence of known focus of infection. Children who were hospitahzed also received more extensive diagnostic evaluation when compared to those treated on an outpatient basis. A number of the responding pediatricians expressed support for the objectives of the study and were interested in the results. Lack of clarity was apparent regarding the benefits of an extensive diagnostic evaluation and the choice of a suitable treatment regimen. The finding of wide variation of practice among these pediatricians may be related to an appraisal by them that the yield of diagnostic studies is small relative to the attendant cost and inconvenience. As uncertainty exists at academic institutions on these issues, no clear direction is given to the practicing pediatrician. There is an apparent need for
investigation of the yield of commonly performed diagnostic procedures for this condition as well asfor further controlled prospective studies of various treatment plans.* *Such studies are long overdue. We have been informed that a controlled study to evaluate currently employed plans of treatment is under way. The importanceof it is of the first order. Editor
488
Asnes et al.
The implications of the reported study extend beyond the m a n a g e m e n t of the child with the first febrile seizure. As peer review of medical care becomes more widespread with the implementation of professional standards review organizations legislation, recommended norms for the diagnosis and treatment of diseases will be established. The difficulty of arriving at realistic standards for conditions such as the first febrile seizure in children has been demonstrated by this study. There is divergence a m o n g practicing pediatricians in diagnostic evaluation and therapy. No single approach to the evaluation and treatment of the condition can be justified on the basis of existing studies. The lack of a capability to establish reasonable standards is probably reflected in the lack of consensus of pediatric practitioners in managing this condition and will seriously hamper attempts at peer review. The authors gratefully acknowledge the assistance given by the members of the American Academy of Pediatrics who participated in this study and the secretarial assistance of Ms. Nancy Queen and Ms. Vicky Marlette-Brown.
The Journal of Pediatrics September I975
REFERENCES
1. Van den Berg BJ, and Yerushalmy J: Studies on convulsive disorders in young children. I. Incidence of febrile and nonfebrile convulsions by age and other factors, Pediatr Res 3:298, 1969. 2. Livingston S: Seizure disorders, in Gellis SS, and Kagen BM, editors: Current pediatric therapy, ed 6, Philadelphia, 1970, WB Saunders Company, p 129. 3. Carter S, and Gold A: Convulsions in children, N Engl J Med 278:315, 1968. 4. Millichap JG: Febrile convulsions, New York, 1968, The Macmillan Company, p 130. 5. Van den Berg BJ, and Yerushalmy J: Studies on convulsive disorders in children. II. Intermittent phenobarbital prophylaxis and recurrence of febrile convulsions, J Pediatr 78:1004, 1971. 6. Barnett HL, editor: Febrile convulsions. Pediatrics, ed 15, New York, 1972, Appleton-Century-Crofts, Inc., p 1001. 7. American Academy of Pediatrics 1974 Fellowship List, January 1974, executive office, Evanston, Ill. 8. Asnes RS, and Nealis JR: The management of febrile seizures at 35 university hospitals, unpublished report, Columbia University Center for Community Health Systems, 1973.
The first febrile seizure: A current pediatric practice
of
A nationwide survey of pediatricians was conducted to ascertain their methods of evaluation and of management of a child who had had a 'first'febrile seizure. Two hundred and sixty (58%) of the sample of 445 pediatricians responded to the single mailing. Nearly one-quarter (24%) routinely hospitalized the child. A wide variation in utilization of diagnostic studies for this condition was reported. Those procedures for which the highest proportion of respondents indicated routine performance were: lumbar puncture (41%); measurements of concentrations of serum calcium (38%) and of blood sugar (43%)," and electroencephologram (36%). Of the 260 respondents, only 15% prescribed phenobarbital therapy for a defined period of time after the occurrence of the first febrile seizures. F~'ty-four percent of pediatricians advised parents to administer phenobarbital only when the child had a febrile illness. The results demonstrate that practicing pediatricians vary widely in the evaluation and management of children with an initial febrile seizure. Lack of consensus among pediatric practitioners concerning the management of this and other conditions will seriously hamper future peer review efforts.
Russell S. Asnes, M.D.,* Lloyd F. Noviek, M.D., N e w York, N. Y., J a m e s Nealis, M.D., Boston, Mass. and M y L i e n Nguyen, M . P . H . , N e w York, N. Y.
THE ONSET OF SEIZURE ACTIVITY in a febrile child is a problem commonly encountered by the clinician. An estimated 3% of all children will experience at least one such seizure by their fifth birthday? Seizures that occur in children in association with fever can be divided into two categories: Category 1--epileptic seizures precipitated by fever, and Category II--simple febrile convulsions. 2 Included in Category I are those children who have prolonged seizures or focal convulsions of any duration, who are over 6 years of age, and who have specific electroencephalographic abnormalities. Category II includes children who have experienced a generalized seizure of brief duration (usually less than 5 minutes), occurring soon after an elevation of body temperature, with no evidence of meningitis or encephalitis, and who have a normal electroencephalogram within 2 weeks after the febrile episode. Separating patients into these two From the Pediatric Ambulatory Care Division of the Department of Pediatrics and the Center for Community Health Systems, Columbia University College of Physicians and Surgeons. *Reprint address: 168th St. & Broadway, New York, N. Y. 10032.
diagnostic categories is helpful for the purposes of planning a diagnostic evaluation, prescribing a therapeutic regimen, and providing family counseling. Although there seems to be little difference of opinion in the approach to patients with epileptic seizures precipitated by fever, there is disagreement as to the appropriate diagnostic evaluation, management, and significance of simple febrile seizures. 3-6 This paper describes the results of a nationwide survey undertaken to ascertain the current opinions and practices of pediatric practitioners caring for children with a first febrile seizure. The results of this study have implications for the adequacy of diagnostic and therapeutic approaches to this problem; for pediatric graduate and postgraduate teaching programs; and for peer review mechanisms such as the professional standards review organizations. METHOD A nationwide survey of pediatricians was conducted to ascertain opinions, practices, and experiences regarding the management of children with febrile seizures. A random sample of 445 pediatricians was selected from the The Journal of PEDIATRICS Vol. 87, No. 3, pp. 485-488
485
486
Asnes et al.
The Journal of Pediatrics September 1975
Table I. Number of children seen by respondents annually with first febrile seizure No. of children per physician
No. of physicians
Percen rage
0 1-5 6-10 11-15 16-20 21-25 26 + Not indicated
3 77 83 30 27 11 20 9
1.2 29.6 31.9 11.5 10.4 4.2 7.7 3.5
Total physicians
260
100.0
RESULTS
The percentagesdo not alwaysadd to 100%because of rounding. Table II. Diagnostic studies ordered by respondents for children with first febrile seizure Frequency of ordering Never Diagnostic Study
Serum electrolytes Blood sugar Serum calcium Blood urea nitrogen Lumbar puncture Roentgenograms Skull Chest Electroencephatogram
Occasionally
commonly employed in caring for children with these conditions. An opportunity was provided for the respondents to comment on each of the areas covered by the questionnaire. The questionnaire was accompanied by a letter which included a description of the purpose of the study and the following definition of a febrile seizure: a generalized seizure of brief duration (usually less than 5 minutes), occurring soon after an elevation of temperature, with no evidence of meningitis or encephalitis.
Routinely
No.
%
No.
%
No.
%
57 29 46 58 12
21.9 11.2 17.7 22.3 4.6
135 114 109 108 142
51.9 43.8 41.9 41.5 54.6
57 112 98 83 106
21.9 43.1 37.7 31.9 40.8
60 49 30
23.1 18.8 11.5
128 150 129
49.2 57.7 49.6
63 44 93
24.2 16.9 35.8
fellowship list of the American Academy of Pediatrics.' Excluded from selection were those pediatricians whose address was listed as a hospital or university. The sample included physicians from all 50 states. A questionnaire was designed to elicit the following information from the responding physicians: number of children seen annually with a first febrile seizure, frequency of hospitalization of these patients, and frequency of neurologic consultation. In addition, the physicians were queried as to their utilization of diagnostic'studies and procedures for this condition including laboratory measurements of serum electrolytes, blood sugar, serum calcium, blood urea nitrogen, lumbar puncture, electroencephalograms, and skull and chest roentgenograms. Inquiries were directed at clinical entities which should be differentiated from febrile seizures including bacterial meningitis, hypoglycemia, hypocalcemia, and renal disease. These physicians were also requested to indicate the treatment regimens they
Two hundred sixty (58%) of the sample of 445 pediatricians responded to the single mailing. Ninety-nine percent of the respondents reported that they care for at least one child per year with a first febrile seizure (Table I). Approximately 30% cared for one to five children, and an additional 32% cared for six to ten children annually with this condition. Hospitalization, consultation, and evaluation. Nearly one-quarter of the physicians routinely hospitalized children with their first febrile seizure. Sixty-two percent of the pediatricians indicated that they only occasionally hospitalize and 12% never hospitalize these patients. Twenty-four of the respondents commented that they hospitalized children with a first febrile seizure if the parents were highly anxious and lacked the capability to cope with the situation. Neurologic consultation was never sought by 40% of the respondents and occasionally sought by 54%. Less than 5% routinely requested such consultation. A wide variation was apparent in utilization of diagnostic studies for the evaluation of children with a first febrile seizure (Table II). For example, approximately one-half of the respondents replied that they occasionally ordered measurements of serum electrolytes; the remainder were evenly divided between never ordering and routinely ordering this study. Those procedures for which the highest proportion of respondents indicated routine performance were lumbar puncture (41%), measurements of serum calcium (38%) and of blood sugar (43%), and electroencephalogram (36%). Those studies which were indicated by approximately one-fifth of the respondents as never performed included estimation of serum electrolytes (22%), blood urea nitrogen (22%), serum calcium (17%), and skull (23%) and chest (19%) roentgenograms. Thus the largest proportion of respondents indicated that specific procedures were utilized only occasionally, implying that most physicians do not employ a routine plan for the diagnostic evaluation of children with a first febrile seizure. Responding pediatricians commented that their diagnostic evaluations were influenced by suspicion of underlying disease, whether the child was hospitalized, the age of the child, and
Volume 87 Number 3
whether or not there was a family history of seizure disorder. An attempt was made to ascertain the frequency with which pediatricians encountered children who had presented with an apparent febrile seizure which proved to be secondary to or associated with bacterial meningitis, hypoglycemia, hypocalcemia, and renal disease. In response to the question, "Have you ever seen a child with bacterial meningitis present with a 'typical' febrile seizure?" 58% of the physicians indicated that they had encountered this situation. With regard to other abnormalities, 26% of the physicians had encountered children with hypoglycemia, and 12% and 19%, respectively, had encountered this situation with hypocalcemia and renal disease. Treatment. Of the 260 responding pediatricians, only 15% prescribed continuous phenobarbital therapy for a defined period of time, usually for one to three years following the occurrence of the first febrile seizure (Table III). Fifty-four percent of the 260 responding .physicians advised parents to administer phenobarbital only when the child had a febrile illness. A number of physicians commented that they employed this therapy primarily for parental reassurance. Approximately one-fifth of the physicians were of the opinion that antipyretics are extremely effective in preventing a recurrence of a febrile seizure. DISCUSSION The results of this study demonstrate that practicing pediatricians vary widely in their approach to the diagnostic evaluation and therapeutic management of children with first febrile seizures. A previous survey of 35 university pediatric departments revealed that at these institutions, evaluations for this condition routinely included: lumbar puncture; blood glucose, serum calcium, and serum phosphorus determinations; electroencephalogram; and skull roentgenogram. 8 The cost of this evaluation at our institution exceeds $175.00. The pharmacotherapeutic approach to the child following his first febrile seizure continues to be actively debated.2. 3, 8 Three commonly proposed approaches are: (1) continuous phenobarbital therapy for one to four years following the first seizure, (2) the administration o f phenobarbital only during thecourse of the febrile illness, and (3) no anticonvulsant therapy for the child following his first febrile seizure. The results of this survey indicate that the majority of practitioners (61%) prescribe phenobarbital 0nly during febrile illnesses. The reported study clearly indicates that a spectrum of diagnostic and therapeutic practices exists among pediatric practitioners. Furthermore, the diagnostic evaluations utilized by the majority of pediatricians surveyed is
The first febrile seizure
487
Table IlL Treatment regiments utilized for children after occurence of first febrile seizure
Number I Percentage No anticonvulsant Phenobarbital only at onset of febrile illnesses Phenobarbital continuously for 1-3 yr after first seizure Diphenylhydantoin only at onset of febrile illnesses Diphenylhydantoin continuously for 1-3 yr after first seizure Combination of phenobarbital and diphenylhydantoin, either intermittently or continuously Other
37 139
14.5 54.7
33
13.0
0
0.0
0
0.0
33
13.0
12
4.7
Total physicians
254
99.9
different from those carried out in the academic setting. Two possible explanations of these findings emerged from the comments of the responding pediatricians: (1) private pediatricians tailor the evaluation and treatment regimen to the individual patient and (2) private pediatricians have received conflicting guidance about the appropriate diagnostic and therapeutic measures to employ for this condition. Responses of pediatricians indicated an individualistic approach to this clinical problem. Factors considered relevant to the diagnostic evaluation or treatment plan utilized included: age of the child, distance of child's home from the physician's office or hospital, parental anxiety, and presence of known focus of infection. Children who were hospitahzed also received more extensive diagnostic evaluation when compared to those treated on an outpatient basis. A number of the responding pediatricians expressed support for the objectives of the study and were interested in the results. Lack of clarity was apparent regarding the benefits of an extensive diagnostic evaluation and the choice of a suitable treatment regimen. The finding of wide variation of practice among these pediatricians may be related to an appraisal by them that the yield of diagnostic studies is small relative to the attendant cost and inconvenience. As uncertainty exists at academic institutions on these issues, no clear direction is given to the practicing pediatrician. There is an apparent need for
investigation of the yield of commonly performed diagnostic procedures for this condition as well asfor further controlled prospective studies of various treatment plans.* *Such studies are long overdue. We have been informed that a controlled study to evaluate currently employed plans of treatment is under way. The importanceof it is of the first order. Editor
488
Asnes et al.
The implications of the reported study extend beyond the m a n a g e m e n t of the child with the first febrile seizure. As peer review of medical care becomes more widespread with the implementation of professional standards review organizations legislation, recommended norms for the diagnosis and treatment of diseases will be established. The difficulty of arriving at realistic standards for conditions such as the first febrile seizure in children has been demonstrated by this study. There is divergence a m o n g practicing pediatricians in diagnostic evaluation and therapy. No single approach to the evaluation and treatment of the condition can be justified on the basis of existing studies. The lack of a capability to establish reasonable standards is probably reflected in the lack of consensus of pediatric practitioners in managing this condition and will seriously hamper attempts at peer review. The authors gratefully acknowledge the assistance given by the members of the American Academy of Pediatrics who participated in this study and the secretarial assistance of Ms. Nancy Queen and Ms. Vicky Marlette-Brown.
The Journal of Pediatrics September I975
REFERENCES
1. Van den Berg BJ, and Yerushalmy J: Studies on convulsive disorders in young children. I. Incidence of febrile and nonfebrile convulsions by age and other factors, Pediatr Res 3:298, 1969. 2. Livingston S: Seizure disorders, in Gellis SS, and Kagen BM, editors: Current pediatric therapy, ed 6, Philadelphia, 1970, WB Saunders Company, p 129. 3. Carter S, and Gold A: Convulsions in children, N Engl J Med 278:315, 1968. 4. Millichap JG: Febrile convulsions, New York, 1968, The Macmillan Company, p 130. 5. Van den Berg BJ, and Yerushalmy J: Studies on convulsive disorders in children. II. Intermittent phenobarbital prophylaxis and recurrence of febrile convulsions, J Pediatr 78:1004, 1971. 6. Barnett HL, editor: Febrile convulsions. Pediatrics, ed 15, New York, 1972, Appleton-Century-Crofts, Inc., p 1001. 7. American Academy of Pediatrics 1974 Fellowship List, January 1974, executive office, Evanston, Ill. 8. Asnes RS, and Nealis JR: The management of febrile seizures at 35 university hospitals, unpublished report, Columbia University Center for Community Health Systems, 1973.