Low adherence to a new guideline for managing febrile infants ≤59 days.

Background: Management of young febrile infants is challenging. Therefore, several guidelines have been developed over the last decades. However, knowledge regarding the impact of introducing guidelines for febrile infants is limited. We assessed the impact of and adherence to a novel guideline for managing febrile infants aged ≤59 days. Methods: This retrospective cross-sectional study was conducted in 2 pediatric emergency departments in Sweden between 2014 and 2021. We compared the management of infants aged ≤59 days with fever without a source (FWS) and the diagnosis of serious bacterial infections (SBIs) before and after implementing the new guideline. Results: We included 1,326 infants aged ≤59 days with FWS. Among infants aged ≤21 days, urine cultures increased from 49% to 67% (p = 0.001), blood cultures from 43% to 63% (p < 0.001), lumbar punctures from 16% to 33% (p = 0.003), and antibiotics from 38% to 57% (p = 0.002). Only 39 of 142 (28%) infants aged ≤21 days received recommended management. The SBI prevalence was 16.7% (95% CI, 11.0-23.8) and 17.6% (95% CI, 11.7-24.9) before and after the implementation, respectively. Among infants aged ≤59 days, there were 3 infants (0.6%; 95% CI, 0.1-1.7) in the pre-implementation period and 3 infants (0.6%; 95% CI, 0.1-1.7) in the post-implementation period with delayed treated urinary tract infections. Conclusions: Investigations and antibiotics increased significantly after implementation of the new guideline. However, doing more did not improve the diagnosis of SBIs. Thus, the low adherence to the new guideline may be considered justified. Future research should consider strategies to safely minimize interventions when managing infants with FWS.

Idiopathic Intracranial Hypertension in an Adolescent With Recent Human Immunodeficiency Virus (HIV) Diagnosis: A Challenging Etiological Dilemma.

Idiopathic intracranial hypertension (IIH) or benign intracranial hypertension affects the neuro-ophthalmological system and leads to elevated intracranial pressure. Elevated opening pressure during lumbar puncture is diagnostic of IIH. Here in, we present an interesting case of a 15-year-old girl, recently immigrated and with a high BMI, presenting with recurrent fever, abdominal issues, weight loss, and other symptoms, leading to a diagnosis of pelvic inflammatory disease (PID) and HIV infection. After treatment with antibiotics (doxycycline) and antiretroviral therapy, she developed IIH, manifesting as sudden-onset headache and vision problems. MRI and lumbar puncture confirmed the diagnosis. She responded well to acetazolamide and was discharged with continued medication and follow-up appointments. This case underscores the complexity of IIH development, especially in the setting of acute HIV infection and antibiotic treatment, highlighting the need for a comprehensive diagnostic approach and multidisciplinary management.

Ultrasound-guided paramedian approach: A novel technique for lumbar puncture in the Emergency Department.

Lumbar puncture is performed to evaluate for multiple neurologic conditions, including meningitis and subarachnoid hemorrhage. However, success rates with the landmark-based technique are limited. Ultrasound is most commonly used for pre-marking without dynamic guidance, which presents several limitations, including absence of real-time guidance and lack of reliability if any patient movement occurs after skin marking. We describe a novel, ultrasound-guided paramedian approach which was successfully performed in the Emergency Department setting for lumbar puncture. Physicians should consider this technique as an alternate model using real-time guidance to reduce needle passes in those with difficult anatomy.

Headache and Other Factors Modifying Cerebrospinal Fluid Opening Pressure in Pediatric Patients.

Cerebrospinal fluid opening pressure values are associated with various neurologic diseases; however, numerous factors can modify this measurement. This study aims to describe factors related to modifications in opening pressure measurements in pediatric patients. Methods: A retrospective analysis of lumbar punctures in pediatric patients conducted by the neuropediatrics group with institutional standardization. Bivariate and linear regression analyses were performed to determine the association between opening pressure and variables included in the study. Results: 544 events, median age 107 months, median opening pressure 19.7 cm H2O. Bivariate analysis found no association with medication use; anesthetics that increased opening pressure were remifentanil (P = .02) and propofol (P = .05), along with a positive linear correlation between opening pressure and age (P < .0001). Multiple linear regression analysis revealed that age, BMI, male gender, and remifentanil use were associated with an increase in opening pressure, whereas corticosteroid withdrawal was associated with a reduction in opening pressure. There is an interaction between age and headache, with an association with increased opening pressure up to around 140 months. Conclusion: This study identifies factors associated with changes in opening pressure, crucial for estimating normal opening pressure values in children. Headaches, anesthetic use, and corticosteroid withdrawal are confirmed as significant factors.

Evaluation of clinical predictors of postoperative outcomes in tegmen defect patients with and without concurrent superior semicircular canal dehiscence and cerebrospinal fluid leak.

OBJECTIVES: Tegmen and superior semicircular canal defects have been well studied, yet the factors contributing to their onset and progression are widely debated. The clinical utility of intraoperative intracranial pressure measurements has yet to be tested. This report aims to use intraoperative opening pressure and concurrent superior semicircular canal dehiscence (SSCD) to analyze factors influencing disease course and clinical outcomes in patients with tegmen dehiscence. METHODS: A retrospective analysis of 61 patients who underwent tegmen defect repair was performed. Multiple variables of interest including body mass index (BMI), presence of SSCD, presence of dural venous sinus stenosis, opening pressure, and acetazolamide therapy use were recorded. The cohort was divided into those with or without concurrent SSCD and those presenting with or without cerebrospinal fluid (CSF) leak for analysis. RESULTS: A linear relationship between opening pressure and BMI (p = 0.009) was noted; however, intraoperative opening pressure was not associated with disease outcome. Concurrent SSCD was present in 25 % of patients, while 62 % presented with CSF leak. The concurrent SSCD group exhibited higher opening pressure, higher likelihood of having dural sinus stenosis, and higher likelihood of being discharged on acetazolamide. The CSF leak group had higher likelihood of obstructive sleep apnea and persistent symptoms. CONCLUSIONS: In patients undergoing tegmen defect repair, concurrent SSCD suggests increased disease severity. The presence of preoperative CSF leak predicts persistent symptoms following repair. BMI is linearly correlated with intracranial pressure in these patients.

Comparison of international guidelines for CT prior to lumbar puncture in patients with suspected meningitis.

PURPOSE: To compare the performance of multiple international guidelines in selecting patients for head CT prior to lumbar puncture (LP) in suspected meningitis, focusing on identification of potential contraindications to immediate LP. METHODS: Retrospective study of 196 patients with suspected meningitis presenting to an emergency department between March 2013 and March 2023 and undergoing head CT prior to LP. UK Joint Specialist Society Guidelines (UK), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Infectious Diseases Society of America (IDSA) guidelines were evaluated by cross-referencing imaging criteria with clinical characteristics present at time of presentation. Sensitivity of each guideline for recommending neuroimaging in cases with brain shift on CT was evaluated, along with the number of normal studies and incidental or spurious findings. RESULTS: 2/196 (1%) patients had abnormal CTs with evidence of brain shift, while 14/196 (7%) had other abnormalities on CT without brain shift. UK, ESCMID and IDSA guidelines recommended imaging in 10%, 14% and 33% of cases respectively. All three guidelines recommended imaging pre-LP in 2/2 (100%) cases with brain shift. IDSA guidelines recommended more CT studies with normal findings (59 vs 16 and 24 for UK and ESCMID guidelines respectively) and CT abnormalities without brain shift (4 vs 1 and 2 respectively) than the other guidelines. CONCLUSION: UK, ESCMID and IDSA guidelines are all effective at identifying the small cohort of patients who benefit from a head CT prior to LP. Following the more selective UK/ESCMID guidelines limits the number of normal studies and incidental or spurious CT findings.

Novice providers' success in performing lumbar puncture: a randomized controlled phantom study between a conventional spinal needle and a novel bioimpedance needle.

BACKGROUND: Lumbar puncture (LP) is an important yet difficult skill in medical practice. In recent years, the number of LPs in clinical practice has steadily decreased, which reduces residents' clinical exposure and may compromise their skills and attitude towards LP. Our study aims to assess whether the novel bioimpedance needle is of assistance to a novice provider and thus compensates for this emerging knowledge gap. METHODS: This randomized controlled study, employing a partly blinded design, involved 60 s- and third-year medical students with no prior LP experience. The students were randomly assigned to two groups consisting of 30 students each. They performed LP on an anatomical lumbar model either with the conventional spinal needle or the bioimpedance needle. Success in LP was analysed using the independent samples proportion procedure. Additionally, the usability of the needles was evaluated with pertinent questions. RESULTS: With the conventional spinal needle, 40% succeeded in performing the LP procedure, whereas with the bioimpedance needle, 90% were successful (p < 0.001). The procedures were successful at the first attempt in 5 (16.7%) and 15 (50%) cases (p = 0.006), respectively. Providers found the bioimpedance needle more useful and felt more confident using it. CONCLUSIONS: The bioimpedance needle was beneficial in training medical students since it significantly facilitated the novice provider in performing LP on a lumbar phantom. Further research is needed to show whether the observed findings translate into clinical skills and benefits in hospital settings.

Lumbar Puncture Complications: A Review of Current Literature.

PURPOSE OF REVIEW: This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS: Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Calibre e formato de agulhas e sua relação com a incidência de cefaleia pós-punção dural: uma revisão sistemática / Needles gauge and shape and its relation to post-dural puncture headache incidence: a systematic review

Introdução: A cefaleia pós punção dural (CPPD) é uma complicação da punção lombar, um procedimento que, apesar de bem tolerado, está sujeito a adversidades, ocorrendo devido a um vazamento persistente do líquido cefalorraquidiano (LCR) do local da punção dural. A incidência de CPPD pode estar relacionada às características dos pacientes e dos procedimentos. Notou-se que em mulheres jovens até 30 anos, o risco de CPPD é maior quando comparado aos homens, não apresentando diferença a partir da quinta década de vida. Objetivo: investigar os diferentes sintomas e efeitos gerados pelos diferentes tipos de agulha, como calibre e modo de inserção, que visem reduzir a CPPD. Métodos: Trata-se de uma revisão sistemática de literatura realizada no período de 2 de agosto a 20 de novembro de 2023 por meio de pesquisas no PubMed. Foram utilizados os descritores: "Post-Dural Puncture Headache" e suas variações do MeSH, sendo submetidos aos critérios de inclusão: estudos em humanos, nos últimos 10 anos, ensaios clínicos e ensaios clínicos controlados e randomizados. Para garantir a qualidade da revisão sistemática foi aplicada a lista de verificação PRISMA de 2020. Resultados: Após investigação estatística, observou-se que as agulhas 25W e 25S demandaram maior tempo médio para a coleta de LCR (15 e 7 min, respectivamente). Ao se comparar 25W com 20Q (3 min), 22S (5 min) e 25S quanto à esta variável, observouse diferença significativa em todas as comparações. Conclusão: As agulhas do tipo atraumática foram associadas com redução do risco de desenvolvimento de CPPD quando comparadas às convencionais. Foi constatado que, dentre as agulhas convencionais, a traumática de 25G é melhor para a prevenção de CPPD que a de 22G.

Introduction: Post-Dural Puncture Headache (PDPH) is a complication of lumbar puncture, a procedure that, despite being well-tolerated, is subject to adversities, occurring due to a persistent leakage of cerebrospinal fluid (CSF) from the site of dural puncture. The incidence of PDPH may be related to patient and procedural characteristics. It has been noted that in young women up to 30 years old, the risk of CPPD is higher compared to men, with no difference between sexes from the fifth decade of life onward. Objective: To investigate the different symptoms and effects generated by different types of needles, such as gauge and insertion method, aiming to reduce CPPD. Methods: Is a systematic literature review conducted from August to October 2023 through searches on PubMed. The descriptors "Post-Dural Puncture Headache" and its MeSH variations were used. A total of 1,839 articles were found, which were then subjected to inclusion criteria: studies conducted in the last 10 years, controlled trials, and randomized clinical trials. Results: After statistical investigation, it was observed that the 25W and 25S needles required a longer average time for cerebrospinal fluid collection (15 and 7 minutes, respectively). When comparing 25W with 20Q (3 minutes), 22S (5 minutes), and 25S regarding this variable, a significant difference was observed in all comparisons. Conclusion: Atraumatic needles were associated with a reduction in the risk of developing CPPD compared to conventional needles. It was found that among conventional needles, the traumatic 25G needle is better for preventing CPPD than the 22G needle.

Clinical characteristics of children with Borrelia-related peripheral facial palsy and utility of cerebrospinal fluid testing.

AIM: To describe the aetiology and clinical characteristics of acute peripheral facial palsy (PFP) in children and investigate the utility of the European Federation of Neurological Societies (EFNS) criteria for diagnosing Borrelia-related PFP (BPFP) based on cerebrospinal fluid (CSF) testing and the Centers for Disease Control and Prevention (CDC) criteria based on serology. METHODS: We retrospectively identified children aged <18 years diagnosed with acute PFP between 2014 and 2020. We used the EFNS criteria as the gold standard and the CDC criteria for diagnosing BPFP. RESULTS: Out of 257 children with PFP, 93 (36%) fulfilled the EFNS or CDC criteria for BPFP. We found a discrepancy between the EFNS criteria with CSF testing and the CDC without CSF testing in 27 (14%) of the 190 children with available data. Of the 37 children with PFP and ≥2 symptoms of fever, fatigue, nausea/vomiting or meningeal symptoms, 31 (84%) fulfilled the EFNS criteria for BPFP. CONCLUSION: Borrelia is a common cause of PFF in children, and its prevalence is higher in children with systemic symptoms. Also, CSF testing did not have decisive management implications in most cases. Therefore, clinical evaluation and Borrelia serology could be the initial steps in the diagnosis of PFP in children.

An intervention to improve lumbar puncture rates for meningitis surveillance in children at four secondary health facilities in Malawi: A before/after analysis.

OBJECTIVES: A lumbar puncture (LP) procedure plays a key role in meningitis diagnosis. In Malawi and other sub-Saharan African countries, LP completion rates are sometimes poor, making meningitis surveillance challenging. Our objective was to measure LP rates following an intervention to improve these during a sentinel hospital meningitis surveillance exercise in Malawi. METHODS: We conducted a before/after intervention analysis among under-five children admitted to paediatric wards at four secondary health facilities in Malawi. We used local and World Health Organization (WHO) guidelines to determine indications for LP, as these are widely used in low- and middle-income countries (LMIC). The intervention comprised of refresher trainings for facility staff on LP indications and procedure, use of automated reminders to perform LP in real time in the wards, with an electronic data management system, and addition of surveillance-specific clinical officers to support existing health facility staff with performing LPs. Due to the low numbers in the before/after analysis, we also performed a during/after analysis to supplement the findings. RESULTS: A total of 13,375 under-five children were hospitalised over the 21 months window for this analysis. The LP rate was 10.4% (12/115) and 60.4% (32/53) in the before/after analysis, respectively, and 43.8% (441/1006) and 72.5% (424/599) in the supplemental during/after analysis, respectively. In our intervention-specific analysis among the three individual components, there were improvements in the LP rate by 48% (p < 0.001) following the introduction of surveillance-specific clinical officers, 10% (p < 0.001) following the introduction of automated reminders to perform an LP and 13% following refresher training. CONCLUSIONS: This analysis demonstrated a rise in LP rates following our intervention. This intervention package may be considered for planning future facility-based meningitis surveillances in similar low-resource settings.

Role of inflammatory markers in the assessment of meningitis in adult patients with fever and headache.

BACKGROUND: Meningitis, especially of bacterial origin, is a medical emergency that must be diagnosed promptly. However, due to the associated risks of complications of lumbar puncture, it is crucial to identify individuals who truly need it. The aim of this study was to assess the diagnostic role of inflammatory markers in distinguishing among patients without meningitis, those with aseptic meningitis, and those with bacterial meningitis. METHODS: This was a retrospective, diagnostic study at an acute care hospital, involving adult patients who presented to either ambulatory care or the emergency department with fever and headache, but without altered mental status or neurological deficits. Inflammatory markers (C-reactive protein [CRP], mean platelet volume, neutrophil-lymphocyte ratio, and red cell distribution width) were assessed as index tests. An expert panel classified patients into three groups: no meningitis, aseptic meningitis, and bacterial meningitis using predefined criteria. RESULTS: Of the 80 patients, 52 had no meningitis, 27 had aseptic meningitis, and 1 had bacterial meningitis. Of the inflammatory markers investigated, only CRP showed potential usefulness in differentiating these three diagnostic groups, with median values of 5.6 (interquartile range [IQR] 2.1, 11.3) mg/dL in those without meningitis, 0.2 (IQR 0.1, 1.2) mg/dL in those with aseptic meningitis, and notably elevated at 21.7 mg/dL in the patient with bacterial meningitis. CONCLUSION: In adult patients presenting with fever and headache in an emergency setting, CRP was the only marker that demonstrated potential diagnostic utility in distinguishing among those with no meningitis, aseptic meningitis, and bacterial meningitis.

Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group.

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

Persistent Elevation of Opening Pressure Despite Treatment and Symptom Resolution in Pediatric Intracranial Hypertension.

BACKGROUND: Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist. METHODS: An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence. RESULTS: Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H2O, 30.7 cm H2O, and 31.1 cm H2O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H2O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17). CONCLUSIONS: This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course.

Proportion of Successful Lumbar Punctures in Infants Younger Than Three Months.

It is important to perform lumbar punctures (LPs) without a single traumatic tap in infants younger than three months owing to the risk of serious complications. The proportion of LPs in which clear cerebrospinal fluid (CSF) was obtained has been previously reported, but some of the procedures involved a traumatic tap. The present study aimed to identify the proportion of LPs in which clear CSF was obtained without a single traumatic tap and the factors associated with successful LPs in infants younger than three months. This retrospective, observational study included children younger than three months who underwent an LP in the pediatric emergency department between April 2018 and March 2021. The primary outcome was the proportion of successful LPs, defined as LPs obtaining clear CSF without a single traumatic tap. Multiple logistic regression analysis was used to identify factors related to successful LPs. Of 126 eligible patients, 121 were included. Among these, 83 (69%) were in the successful group. No factors significantly associated with successful LPs were found. Larger studies based on an accurate definition of successful LPs, such as that provided by this study, are needed to investigate related factors to increase the rate of successful LPs in this age group.

Accuracy of automated analyzers for the estimation of CSF cell counts: A systematic review and meta-analysis.

This systematic review evaluates the evidence for accuracy of automated analyzers that estimate cerebrospinal fluid (CSF) white blood cell counts (WBC) compared to manual microscopy. Inclusion criteria of original research articles included human subjects, English language, and manual microscopy comparator. PUBMED, EMBASE and Cochrane Review databases were searched through 2019 and QUADAS-2 Tool was used for assessment of bias. Data were pooled and analyzed by comparison method, using random effects estimation. Among 652 titles, 554 abstracts screened, 104 full-text review, 111 comparisons from 41 studies were included. Pooled estimates of sensitivity and specificity (n = 7) were 95% (95%-CI 93%-97%) and 84% (95%-CI: 64%-96%), respectively. Pooled R2 estimates (n = 29) were 0.95 (95%-CI: 0.95-0.96); Pooled spearman rho correlation (n = 27) estimates were 0.95 (95% CI 0.95-0.96). Among those comparisons using Bland-Altman analysis (n = 11) pooled mean difference was estimated at 0.98 (95% CI-0.54-2.5). Among comparisons using Passing-Bablok regressions (n = 14) the pooled slope was estimated to be 1.05 (95% CI 1.03-1.07). Q tests of homogeneity were all significant with the exception of the Bland-Altman comparisons (I2 10%, p value 0.35). There is good overall accuracy for CSF WBC by automated hematologic analyzers. These findings are limited by the small sample sizes and inconsistent validation methodology in the reviewed studies.

Treatment and Prevention of Post-dural Puncture Headaches: A Systematic Review.

Post-dural puncture headache (PDPH) is occasionally an inevitable side effect of neuraxial anesthesia, which can happen after spinal anesthesia or if an accidental dural puncture (ADP) happens during epidural anesthesia. The treatment and prevention options for PDPH differ widely from one institution to another. The management of PDPH is heterogeneous in many institutions because of the absence of clear guidelines and protocols for the management of PDPH. This study aimed to summarize all articles published during the past decade that discussed the treatment or prevention of PDPH. From 2013 to 2023, 345 publications were filtered for all treatment and prevention approaches used for PDPH patients. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines were followed for conducting this systematic review, and 38 articles were included for analysis and review. Existing data come from small randomized clinical trials and retrospective or prospective cohort studies. This review supports the effect of oral pregabalin and intravenous aminophylline in both treatment and prevention. Intravenous mannitol, intravenous hydrocortisone, triple prophylactic regimen, and neostigmine plus atropine combination showed effective and beneficial outcomes. On the other hand, neither neuraxial morphine nor epidural dexamethasone showed promising results. Consequently, the use of neuraxial morphine or epidural dexamethasone for the prevention of PDPH remains questionable. Regarding the posture of the patient and its consequences on the incidence of the headache, lateral decubitus is better than a sitting position, and a prone position is better than a supine position. Smaller non-cutting needles play a role in avoiding PDPH. Minimally invasive nerve blocks, including sphenopalatine ganglion or greater occipital nerves, are satisfyingly effective. Epidural blood patches remain the more invasive but the gold standard and ultimate solution in patients resisting medical therapy. This study highlights the need for larger research to define the best approach to prevent and treat PDPH.

Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department.

OBJECTIVE: To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN: We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS: In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS: Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.