Recommendation(s)

1. The following diagnostic tests should be performed in children with acute seizures and/or altered consciousness:

• Blood glucose
• Blood sodium in children with severe dehydration or diarrhoea
• Lumbar puncture in febrile children with signs of meningitis

2. Lumbar puncture should be considered in any infant or child who appears severely ill (e.g., high fever with altered consciousness or seizure) with any of the following:

• Age less than 18 months (and especially in those less than 6 months of age)
• Complex febrile seizures (prolonged, focal or recurrent during the same febrile illness)
• Where antimicrobials have been given prior to assessment
• Those not immunised against Haemophilius influenza type b or Streptococcus pneumoniae

3. Lumbar puncture should be delayed in infants/children with any of the following clinical signs:

• Coma (based on ETAT AVPU scale: Alert (A), responds to your Voice (V), responds to Pain (P), Unresponsive (U)))
• Focal neurological signs
• Brainstem signs of herniation
• Signs of raised intracranial pressure
• Signs of respiratory compromise
• ETAT signs of shock
• Infections in the skin overlying the site of the proposed lumbar puncture
• Evidence of a bleeding disorder

The lumbar puncture should be performed when these complications have been managed.

4. Neuroimaging (ultrasound in young infants, CT or MRI) should be considered in children with altered consciousness or a new focal neurological deficit.

Strength of recommendation: STRONG
Quality of evidence: VERY LOW