Intended for healthcare professionals

Practice Change

Reducing unnecessary investigations in paediatric seizures in the emergency department

BMJ 2024; 385 doi: (Published 25 June 2024) Cite this as: BMJ 2024;385:e076814
  1. Deborah Schonfeld, physician, assistant professor1 2,
  2. Katie Gardner, physician, assistant professor3 4,
  3. Michèl A Willemsen, physician, professor5 6,
  4. Olivia Ostrow, physician, associate professor7 2
  1. 1The Hospital for Sick Children, Toronto, Ontario, Canada
  2. 2Department of Pediatrics, University of Toronto
  3. 3IWK Health, Halifax, Nova Scotia
  4. 4Department of Emergency Medicine, Dalhousie University, Halifax
  5. 5Amalia Children’s Hospital, Nijmegen, Netherlands
  6. 6Department of Pediatric Neurology, Radboud University Medical Center, Nijmegen
  7. 7The Hospital for Sick Children, Toronto
  1. Correspondence to K Gardner katie.gardner{at}

What you need to know

  • Simple febrile seizure or new onset afebrile seizure in children with no known comorbidities who return to their baseline neurological status do not require investigation by laboratory testing or urgent neuroimaging

  • Blood tests and computed tomography scans of the head are low yield, costly, and expose children to painful procedures and risks from radiation and sedation

  • Specific risk factors, noted during history and physical examination can identify the minority of patients who may benefit from laboratory testing or head imaging after a seizure

Seizures in children are common, representing ~1-2% of all visits to paediatric emergency departments in the US.1 Seizures in children are often categorised as febrile and afebrile. Febrile seizures are the most common neurological disorder in young children, with approximately 3-5% of children having a febrile seizure in the first five years of life.2 These seizures occur between the ages of 6 months and 6 years and are associated with fever, with no evidence of an acute disease of the central nervous system. Simple febrile seizures are generalised in nature, last less than 15 minutes, do not recur in a 24 hour period, and exclude children with known brain abnormalities.2

Afebrile seizures may be provoked (ie, precipitated by an identifiable factor, such as infection of the central nervous system, trauma, or acute neurological insult) or unprovoked. New onset unprovoked afebrile seizures may be the first presentation of an epilepsy syndrome or may represent an isolated event in an otherwise healthy child. Between 0.5% and 1% of children experience a non-recurrent, single unprovoked convulsive episode.3 Retrospective studies from the US, Europe, Asia, and the Middle East suggest that 43-87% of patients who present to the emergency department with unprovoked seizures undergo blood testing,456 while 46-55% undergo urgent neuroimaging.78 Comparatively, …

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