Advertisement

European Journal of Pediatrics

, Volume 167, Issue 1, pp 17–27 | Cite as

Assessment of febrile seizures in children

  • Arne FetveitEmail author
Review

Abstract

Febrile seizures are the most common form of childhood seizures, affecting 2–5% of all children and usually appearing between 3 months and 5 years of age. Despite its predominantly benign nature, a febrile seizure (FS) is a terrifying experience for most parents. The condition is perhaps one of the most prevalent causes of admittance to pediatric emergency wards worldwide. FS, defined as either simple or complex, may be provoked by any febrile bacterial or (more usually) viral illness. No specific level of fever is required to diagnose FS. It is essential to exclude underlying meningitis in all children with FS, either clinically or, if any doubt remains, by lumbar puncture. There is no evidence, however, to support routine lumbar puncture in all children admitted with simple FS, especially when typical clinical signs of meningitis are lacking. The risk of epilepsy following FS is 1–6%. The association, however small, between FS and epilepsy may demonstrate a genetic link between FS and epilepsy rather than a cause and effect relationship. The effectiveness of prophylactic treatment with medication remains controversial. There is no evidence of the effectiveness of antipyretics in preventing future FS. Prophylactic use of paracetamol, ibuprofen or a combination of both in FS, is thus a questionable practice. There is reason to believe that children who have experienced a simple FS are over-investigated and over-treated. This review aims to provide physicians with adequate knowledge to make rational assessments of children with febrile seizures.

Keywords

Seizures Fever Child 

Notes

Acknowledgements

Jørund Straand and Per Lagerløv from the Department of General Practice and Community Medicine, University of Oslo, provided important input during the preparation of the manuscript.

References

  1. 1.
    Alldredge BK, Wall DB, Ferriero DM (1995) Effect of prehospital treatment on the outcome of status epilepticus in children. Pediatr Neurol 12:213–216PubMedCrossRefGoogle Scholar
  2. 2.
    Annegers JF, Hauser WA, Shirts SB, Kurland LT (1987) Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med 316:493–498PubMedCrossRefGoogle Scholar
  3. 3.
    Anonymous (1980) Consensus statement. Febrile seizures: long-term management of children with fever-associated seizures. Pediatrics 66:1009–1012Google Scholar
  4. 4.
    Anonymous (1991) Guidelines for the management of convulsions with fever. Joint Working Group of the Research Unit of the Royal College of Physicians and the British Paediatric Association. BMJ 303:634–636Google Scholar
  5. 5.
    Anonymous (1993) Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League against Epilepsy. Epilepsia 34:592–596Google Scholar
  6. 6.
    Anonymous (1996) Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Pediatrics 97:769–772; discussion 773–765Google Scholar
  7. 7.
    Appleton R, Martland T, Phillips B (2002) Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev:CD001905Google Scholar
  8. 8.
    Armon K, Stephenson T, MacFaul R, Hemingway P, Werneke U, Smith S (2003) An evidence and consensus based guideline for the management of a child after a seizure. Emerg Med J 20:13–20PubMedCrossRefGoogle Scholar
  9. 9.
    Barlow WE, Davis RL, Glasser JW, Rhodes PH, Thompson RS, Mullooly JP, Black SB, Shinefield HR, Ward JI, Marcy SM, DeStefano F, Chen RT, Immanuel V, Pearson JA, Vadheim CM, Rebolledo V, Christakis D, Benson PJ, Lewis N (2001) The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine. N Engl J Med 345:656–661PubMedCrossRefGoogle Scholar
  10. 10.
    Baumann RJ (1999) Technical report: treatment of the child with simple febrile seizures. Pediatrics 103:e86PubMedCrossRefGoogle Scholar
  11. 11.
    Baumann RJ, Duffner PK (2000) Treatment of children with simple febrile seizures: the AAP practice parameter. American Academy of Pediatrics. Pediatr Neurol 23:11–17PubMedCrossRefGoogle Scholar
  12. 12.
    Baumer JH (2004) Evidence based guideline for post-seizure management in children presenting acutely to secondary care. Arch Dis Child 89:278–280PubMedCrossRefGoogle Scholar
  13. 13.
    Baumer JH, David TJ, Valentine SJ, Roberts JE, Hughes BR (1981) Many parents think their child is dying when having a first febrile convulsion. Dev Med Child Neurol 23:462–464PubMedCrossRefGoogle Scholar
  14. 14.
    Berg AT (1992) Febrile seizures and epilepsy: the contributions of epidemiology. Paediatr Perinat Epidemiol 6:145–152PubMedCrossRefGoogle Scholar
  15. 15.
    Berg AT, Shinnar S, Shapiro ED, Salomon ME, Crain EF, Hauser WA (1995) Risk factors for a first febrile seizure: a matched case-control study. Epilepsia 36:334–341PubMedCrossRefGoogle Scholar
  16. 16.
    Berkovic SF, Howell RA, Hay DA, Hopper JL (1994) Epilepsies in twins. In: Wolf P (ed) Epileptic seizures and syndromes. Libbey, London, pp 157–164Google Scholar
  17. 17.
    Bethune P, Gordon K, Dooley J, Camfield C, Camfield P (1993) Which child will have a febrile seizure? Am J Dis Child 147:35–39PubMedGoogle Scholar
  18. 18.
    Camfield PR, Camfield CS, Shapiro SH, Cummings C (1980) The first febrile seizure—antipyretic instruction plus either phenobarbital or placebo to prevent recurrence. J Pediatr 97:16–21PubMedCrossRefGoogle Scholar
  19. 19.
    Cassano PA, Koepsell TD, Farwell JR (1990) Risk of febrile seizures in childhood in relation to prenatal maternal cigarette smoking and alcohol intake. Am J Epidemiol 132:462–473, discussion 474–468PubMedGoogle Scholar
  20. 20.
    Chang YC, Guo NW, Wang ST, Huang CC, Tsai JJ (2001) Working memory of school-aged children with a history of febrile convulsions: a population study. Neurology 57:37–42PubMedGoogle Scholar
  21. 21.
    Chin RF, Neville BG, Scott RC (2005) Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child 90:66–69PubMedCrossRefGoogle Scholar
  22. 22.
    Depiero AD, Teach SJ (2001) Febrile seizures. Pediatr Emerg Care 17:384–387PubMedCrossRefGoogle Scholar
  23. 23.
    Dunlop S, Taitz J (2005) Retrospective review of the management of simple febrile convulsions at a tertiary paediatric institution. J Paediatr Child Health 41:647–651PubMedCrossRefGoogle Scholar
  24. 24.
    El Bashir H, Laundy M, Booy R (2003) Diagnosis and treatment of bacterial meningitis. Arch Dis Child 88:615–620PubMedCrossRefGoogle Scholar
  25. 25.
    Ellenberg JH, Nelson KB (1978) Febrile seizures and later intellectual performance. Arch Neurol 35:17–21PubMedGoogle Scholar
  26. 26.
    El-Radhi AS, Barry W (2003) Do antipyretics prevent febrile convulsions? Arch Dis Child 88:641–642PubMedCrossRefGoogle Scholar
  27. 27.
    Farwell JR, Lee YJ, Hirtz DG, Sulzbacher SI, Ellenberg JH, Nelson KB (1990) Phenobarbital for febrile seizures—effects on intelligence and on seizure recurrence. N Engl J Med 322:364–369PubMedCrossRefGoogle Scholar
  28. 28.
    Flury T, Aebi C, Donati F (2001) Febrile seizures and parental anxiety: does information help? Swiss Med Wkly 131:556–560PubMedGoogle Scholar
  29. 29.
    Fortnum HM, Davis AC (1993) Epidemiology of bacterial meningitis. Arch Dis Child 68:763–767PubMedCrossRefGoogle Scholar
  30. 30.
    Freedman SB, Powell EC (2003) Pediatric seizures and their management in the emergency department. Clin Pediatr Emerg Med 4:195–206CrossRefGoogle Scholar
  31. 31.
    Freeman JM (1980) Febrile seizures: a consensus of their significance, evaluation, and treatment. Pediatrics 66:1009PubMedGoogle Scholar
  32. 32.
    Fukuyama Y, Kagawa K, Tanaka K (1979) A genetic study of febrile convulsions. Eur Neurol 18:166–182PubMedCrossRefGoogle Scholar
  33. 33.
    Gerber MA, Berliner BC (1981) The child with a ‘simple’ febrile seizure. Appropriate diagnostic evaluation. Am J Dis Child 135:431–433PubMedGoogle Scholar
  34. 34.
    Green SM, Rothrock SG, Clem KJ, Zurcher RF, Mellick L (1993) Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics 92:527–534PubMedGoogle Scholar
  35. 35.
    Greenwood R, Golding J, Ross E, Verity C (1998) Prenatal and perinatal antecedents of febrile convulsions and afebrile seizures: data from a national cohort study. Paediatr Perinat Epidemiol 12(Suppl 1):76–95PubMedCrossRefGoogle Scholar
  36. 36.
    Hall CB, Long CE, Schnabel KC, Caserta MT, McIntyre KM, Costanzo MA, Knott A, Dewhurst S, Insel RA, Epstein LG (1994) Human herpesvirus-6 infection in children. A prospective study of complications and reactivation. N Engl J Med 331:432–438PubMedCrossRefGoogle Scholar
  37. 37.
    Hamati-Haddad A, Abou-Khalil B (1998) Epilepsy diagnosis and localization in patients with antecedent childhood febrile convulsions. Neurology 50:917–922PubMedGoogle Scholar
  38. 38.
    Hasson F, Keeney S, McKenna H (2000) Research guidelines for the Delphi survey technique. J Adv Nurs 32:1008–1015PubMedCrossRefGoogle Scholar
  39. 39.
    Hauser WA (1994) The prevalence and incidence of convulsive disorders in children. Epilepsia 35(Suppl 2):S1–S6PubMedCrossRefGoogle Scholar
  40. 40.
    Hauser WA, Annegers JF, Anderson VE, Kurland LT (1985) The risk of seizure disorders among relatives of children with febrile convulsions. Neurology 35:1268–1273PubMedGoogle Scholar
  41. 41.
    Heijbel J, Blom S, Bergfors PG (1980) Simple febrile convulsions. A prospective incidence study and an evaluation of investigations initially needed. Neuropadiatrie 11:45–56PubMedCrossRefGoogle Scholar
  42. 42.
    Hirtz DG (1989) Generalized tonic-clonic and febrile seizures. Pediatr Clin North Am 36:365–382PubMedGoogle Scholar
  43. 43.
    Hirtz DG, Nelson KB, Ellenberg JH (1983) Seizures following childhood immunizations. J Pediatr 102:14–18PubMedCrossRefGoogle Scholar
  44. 44.
    Huang CC, Wang ST, Chang YC, Huang MC, Chi YC, Tsai JJ (1999) Risk factors for a first febrile convulsion in children: a population study in southern Taiwan. Epilepsia 40:719–725PubMedCrossRefGoogle Scholar
  45. 45.
    Huang MC, Liu CC, Chi YC, Huang CC, Cain K (2001) Parental concerns for the child with febrile convulsion: long-term effects of educational interventions. Acta Neurol Scand 103:288–293PubMedCrossRefGoogle Scholar
  46. 46.
    Huang MC, Liu CC, Huang CC, Thomas K (2002) Parental responses to first and recurrent febrile convulsions. Acta Neurol Scand 105:293–299PubMedCrossRefGoogle Scholar
  47. 47.
    Jaffe M, Bar-Joseph G, Tirosh E (1981) Fever and convulsions—indications for laboratory investigations. Pediatrics 67:729–731PubMedGoogle Scholar
  48. 48.
    Joffe A, McCormick M, DeAngelis C (1983) Which children with febrile seizures need lumbar puncture? A decision analysis approach. Am J Dis Child 137:1153–1156PubMedGoogle Scholar
  49. 49.
    Kajitani T, Kimura T, Sumita M, Kaneko M (1992) Relationship between benign epilepsy of children with centro-temporal EEG foci and febrile convulsions. Brain Dev 14:230–234PubMedGoogle Scholar
  50. 50.
    Karande S (2007) Febrile seizures: a review for family physicians. Indian J Med Sci 61:161–172PubMedCrossRefGoogle Scholar
  51. 51.
    Knudsen FU (1985) Recurrence risk after first febrile seizure and effect of short term diazepam prophylaxis. Arch Dis Child 60:1045–1049PubMedCrossRefGoogle Scholar
  52. 52.
    Knudsen FU (2000) Febrile seizures: treatment and prognosis. Epilepsia 41:2–9PubMedCrossRefGoogle Scholar
  53. 53.
    Knudsen FU, Vestermark S (1978) Prophylactic diazepam or phenobarbitone in febrile convulsions: a prospective, controlled study. Arch Dis Child 53:660–663PubMedCrossRefGoogle Scholar
  54. 54.
    McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse WP, Phillips B, Martland T, Berry K, Collier J, Smith S, Choonara I (2005) Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 366:205–210PubMedCrossRefGoogle Scholar
  55. 55.
    Minchom PE, Wallace SJ (1984) Febrile convulsions: electroencephalographic changes related to rectal temperature. Arch Dis Child 59:371–373PubMedCrossRefGoogle Scholar
  56. 56.
    Nelson KB, Ellenberg JH (1976) Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 295:1029–1033PubMedCrossRefGoogle Scholar
  57. 57.
    Nelson KB, Ellenberg JH (1978) Prognosis in children with febrile seizures. Pediatrics 61:720–727PubMedGoogle Scholar
  58. 58.
    Nelson KB, Ellenberg JH (1990) Prenatal and perinatal antecedents of febrile seizures. Ann Neurol 27:127–131PubMedCrossRefGoogle Scholar
  59. 59.
    Neville BG, Chin RF, Scott RC (2007) Childhood convulsive status epilepticus: epidemiology, management and outcome. Acta Neurol Scand 115:21–24PubMedCrossRefGoogle Scholar
  60. 60.
    O’Brien KL, Dowell SF, Schwartz B, Marcy SM, Phillips WR, Gerber MA (1998) Cough illness/bronchitis: principles of judicious use of antimicrobial agents. Pediatrics 101:S178–S181CrossRefGoogle Scholar
  61. 61.
    Offringa M, Moyer VA (2001) Evidence based Pediatrics: evidence based management of seizures associated with fever. BMJ 323:1111–1114PubMedCrossRefGoogle Scholar
  62. 62.
    Offringa M, Moyer VA (2001) An evidence-based approach to managing seizures associated with fever in children. West J Med 175:254–259PubMedCrossRefGoogle Scholar
  63. 63.
    Offringa M, Kroes AC, Derksen–Lubsen G (1990) Viral infections in febrile seizures. J Pediatr 117:510–511PubMedGoogle Scholar
  64. 64.
    Offringa M, Hazebroek-Kampschreur AA, Derksen-Lubsen G (1991) Prevalence of febrile seizures in Dutch schoolchildren. Paediatr Perinat Epidemiol 5:181–188PubMedCrossRefGoogle Scholar
  65. 65.
    Offringa M, Beishuizen A, Derksen-Lubsen G, Lubsen J (1992) Seizures and fever: can we rule out meningitis on clinical grounds alone? Clin Pediatr (Phila) 31:514–522CrossRefGoogle Scholar
  66. 66.
    Offringa M, Bossuyt PM, Lubsen J, Ellenberg JH, Nelson KB, Knudsen FU, Annegers JF, el-Radhi AS, Habbema JD, Derksen-Lubsen G, et al. (1994) Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data from five studies. J Pediatr 124:574–584PubMedCrossRefGoogle Scholar
  67. 67.
    Piperidou HN, Heliopoulos IN, Maltezos ES, Stathopoulos GA, Milonas IA (2002) Retrospective study of febrile seizures: subsequent electroencephalogram findings, unprovoked seizures and epilepsy in adolescents. J Int Med Res 30:560–565PubMedGoogle Scholar
  68. 68.
    Rantala H, Uhari M, Tuokko H (1990) Viral infections and recurrences of febrile convulsions. J Pediatr 116:195–199PubMedCrossRefGoogle Scholar
  69. 69.
    Rantala H, Tarkka R, Uhari M (1997) A meta-analytic review of the preventive treatment of recurrences of febrile seizures. J Pediatr 131:922–925PubMedCrossRefGoogle Scholar
  70. 70.
    Rosenstein N, Phillips WR, Gerber MA, Marcy M, Schwartz B, Dowell SF (1998) The common cold—principles of judicious use of microbial agents. Pediatrics 101:S181–S184Google Scholar
  71. 71.
    Rosman NP (2003) Evaluation of the child who convulses with fever. Paediatr Drugs 5:457–461PubMedGoogle Scholar
  72. 72.
    Rosman NP, Colton T, Labazzo J, Gilbert PL, Gardella NB, Kaye EM, Van Bennekom C, Winter MR (1993) A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med 329:79–84PubMedCrossRefGoogle Scholar
  73. 73.
    Rosser WW (2005) Fever and common childhood infections. In: Jones R, Britten N, Culpepper L, Gass D, Grol R, Mant D, Silagy C (eds) Oxford textbook of primary medical care. Oxford University Press, OxfordGoogle Scholar
  74. 74.
    Rutter N, Metcalfe DH (1978) Febrile convulsions-what do parents do? Br Med J 2:1345–1346PubMedCrossRefGoogle Scholar
  75. 75.
    Rutter N, Smales OR (1977) Role of routine investigations in children presenting with their first febrile convulsion. Arch Dis Child 52:188–191PubMedCrossRefGoogle Scholar
  76. 76.
    Scheffer IE, Berkovic SF (1997) Generalized epilepsy with febrile seizures plus. A genetic disorder with heterogeneous clinical phenotypes. Brain 120(Pt 3):479–490PubMedCrossRefGoogle Scholar
  77. 77.
    Schiottz-Christensen E (1973) Neurological findings in twins discordant for febrile convulsions. Acta Neurol Scand 49:368–378PubMedCrossRefGoogle Scholar
  78. 78.
    Schiottz-Christensen E, Bruhn P (1973) Intelligence, behaviour and scholastic achievement subsequent to febrile convulsions: an analysis of discordant twin-pairs. Dev Med Child Neurol 15:565–575PubMedCrossRefGoogle Scholar
  79. 79.
    Shinnar S, Glauser TA (2002) Febrile seizures. J Child Neurol 17(Suppl 1):S44–S52PubMedCrossRefGoogle Scholar
  80. 80.
    Shuper A, Gabbay U, Mimouni M (1996) Parental anxiety in febrile convulsions. Isr J Med Sci 32:1282–1285PubMedGoogle Scholar
  81. 81.
    Singh R, Scheffer IE, Crossland K, Berkovic SF (1999) Generalized epilepsy with febrile seizures plus: a common childhood-onset genetic epilepsy syndrome. Ann Neurol 45:75–81PubMedCrossRefGoogle Scholar
  82. 82.
    Singhi PD, Srinivas M (2001) Febrile seizures. Indian Pediatr 38:733–740PubMedGoogle Scholar
  83. 83.
    Srinivasan J, Wallace KA, Scheffer IE (2005) Febrile seizures. Aust Fam Physician 34:1021–1025PubMedGoogle Scholar
  84. 84.
    Stenklyft PH, Carmona M (1994) Febrile seizures. Emerg Med Clin North Am 12:989–999PubMedGoogle Scholar
  85. 85.
    Straand J, Rokstad KS, Sandvik H (1998) Prescribing systemic antibiotics in general practice. A report from the More & Romsdal Prescription Study. Scand J Prim Health Care 16:121–127PubMedCrossRefGoogle Scholar
  86. 86.
    Sweeney A, Gibbs J, Monteil F, Appleton R, Choonara I (1996) The management of febrile seizures in the Mersey Region. Dev Med Child Neurol 38:578–584PubMedCrossRefGoogle Scholar
  87. 87.
    Thoman JE, Duffner PK, Shucard JL (2004) Do serum sodium levels predict febrile seizure recurrence within 24 hours? Pediatr Neurol 31:342–344PubMedCrossRefGoogle Scholar
  88. 88.
    Trainor JL, Hampers LC, Krug SE, Listernick R (2001) Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med 8:781–787PubMedCrossRefGoogle Scholar
  89. 89.
    Tsuboi T, Okada S (1985) Exogenous causes of seizures in children: a population study. Acta Neurol Scand 71:107–113PubMedCrossRefGoogle Scholar
  90. 90.
    Uhari M, Rantala H, Vainionpaa L, Kurttila R (1995) Effect of acetaminophen and of low intermittent doses of diazepam on prevention of recurrences of febrile seizures. J Pediatr 126:991–995PubMedCrossRefGoogle Scholar
  91. 91.
    Van Esch A, Steyerberg EW, van Duijn CM, Offringa M, Derksen-Lubsen G, van Steensel-Moll HA (1998) Prediction of febrile seizures in siblings: a practical approach. Eur J Pediatr 157:340–344PubMedCrossRefGoogle Scholar
  92. 92.
    Van Stuijvenberg M, Derksen-Lubsen G, Steyerberg EW, Habbema JD, Moll HA (1998) Randomized, controlled trial of ibuprofen syrup administered during febrile illnesses to prevent febrile seizure recurrences. Pediatrics 102:E51PubMedCrossRefGoogle Scholar
  93. 93.
    Van Stuijvenberg M, de Vos S, Tjiang GC, Steyerberg EW, Derksen-Lubsen G, Moll HA (1999) Parents’ fear regarding fever and febrile seizures. Acta Paediatr 88:618–622PubMedCrossRefGoogle Scholar
  94. 94.
    Verity CM, Butler NR, Golding J (1985) Febrile convulsions in a national cohort followed up from birth. II. Medical history and intellectual ability at 5 years of age. Br Med J (Clin Res Ed) 290:1311–1315CrossRefGoogle Scholar
  95. 95.
    Verity CM, Butler NR, Golding J (1985) Febrile convulsions in a national cohort followed up from birth. I. Prevalence and recurrence in the first five years of life. Br Med J (Clin Res Ed) 290:1307–1310CrossRefGoogle Scholar
  96. 96.
    Verity CM, Greenwood R, Golding J (1998) Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med 338:1723–1728PubMedCrossRefGoogle Scholar
  97. 97.
    Vestergaard M, Basso O, Henriksen TB, Ostergaard JR, Olsen J (2002) Risk factors for febrile convulsions. Epidemiology 13:282–287PubMedCrossRefGoogle Scholar
  98. 98.
    Vestergaard M, Wisborg K, Henriksen TB, Secher NJ, Ostergaard JR, Olsen J (2005) Prenatal exposure to cigarettes, alcohol, and coffee and the risk for febrile seizures. Pediatrics 116:1089–1094PubMedCrossRefGoogle Scholar
  99. 99.
    Wadhwa N, Bharucha B, Chablani U, Contractor N (1992) An epidemiological study of febrile seizures with special reference to family history and HLA linkage. Indian Pediatr 29:1479–1485PubMedGoogle Scholar
  100. 100.
    Wallace SJ (1976) Neurological and intellectual deficits: convulsions with fever viewed as acute indications of life-long developmental defects. In: Brazier MAB, Coceani F (eds) Brain dysfunction in infantile febrile convulsions. Raven, New York, pp 259–277Google Scholar
  101. 101.
    Warden CR, Zibulewsky J, Mace S, Gold C, Gausche-Hill M (2003) Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 41:215–222PubMedCrossRefGoogle Scholar
  102. 102.
    Waruiru C, Appleton R (2004) Febrile seizures: an update. Arch Dis Child 89:751–756PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  1. 1.Department of General Practice and Community MedicineUniversity of OsloBlindern, OsloNorway

Personalised recommendations