What are the recommendations for a pediatric patient, four years old, experiencing a first-time seizure?

From the Guidelines

For a pediatric four-year-old experiencing a first-time seizure, the primary recommendation is not to start antiepileptic medication immediately, but rather to focus on evaluation, monitoring, and education, as the risk of recurrence is relatively low and antiepileptic drugs can have significant side effects 1. Key steps to consider:

• Perform a thorough medical history and physical examination to identify any underlying conditions that may have contributed to the seizure.
• Order an electroencephalogram (EEG) to assess brain activity and determine if there are any abnormal patterns that may indicate a higher risk of recurrence.
• Consider neuroimaging (MRI preferred over CT) if there are focal neurological deficits or other concerning features, as the presence of focal features is independently associated with clinically relevant abnormalities on neuroimaging 1.
• Educate parents on seizure first aid and safety measures, including how to respond during a seizure and when to seek emergency care.
• Schedule a follow-up appointment within 1-2 weeks to monitor the child's condition and adjust the treatment plan as needed. Medication is typically not initiated after a single unprovoked seizure because:
• About 50-70% of children will not have a recurrence.
• Antiepileptic drugs can have significant side effects.
• Early treatment does not alter long-term prognosis in most cases. If seizures recur or if the EEG shows epileptiform abnormalities, then consider starting medication, with common first-line options including:
• Levetiracetam: 10-20 mg/kg/day divided twice daily
• Oxcarbazepine: 8-10 mg/kg/day divided twice daily
• Valproic acid: 10-15 mg/kg/day divided twice daily The choice of medication depends on seizure type, potential side effects, and patient factors, and it is essential to start at a low dose and titrate up as needed. Provide parents with a seizure action plan and educate them on when to seek emergency care, such as seizures lasting >5 minutes, multiple seizures without full recovery between episodes, to ensure optimal patient care.

From the FDA Drug Label

Pediatric Patients Ages 4 To <16 Years Treatment should be initiated with a daily dose of 20 mg/kg in 2 divided doses (10 mg/kg BID). The daily dose should be increased every 2 weeks by increments of 20 mg/kg to the recommended daily dose of 60 mg/kg (30 mg/kg BID).

For a pediatric patient, four years old, experiencing a first-time seizure, the recommended initial dose of levetiracetam is 20 mg/kg/day in 2 divided doses. The dose should be increased every 2 weeks by 20 mg/kg to a maximum recommended daily dose of 60 mg/kg. It is essential to note that the patient's weight should be considered when determining the dose, and the dose should be adjusted accordingly. The patient should be dosed with oral solution if their body weight is ≤20 kg. 2

• Key considerations:
  • Initial dose: 20 mg/kg/day in 2 divided doses
  • Dose increment: 20 mg/kg every 2 weeks
  • Maximum recommended daily dose: 60 mg/kg
  • Dosing formulation: oral solution for patients with body weight ≤20 kg
  • Monitoring and adjustment of dose based on patient's response and weight.

From the Research

Recommendations for a Pediatric Patient Experiencing a First-Time Seizure

• The pediatrician should have a good understanding of the diagnosis and management of a child's first seizure 3.
• A careful history and examination should be taken to confirm that the presenting seizure is truly the initial event and to identify other possible risk factors for recurrence 4, 5.
• Identification of provoking factors, such as fever, illness, head trauma, electrolyte disturbance, or central nervous system infection, is important for determining prognosis and likelihood of recurrence 5.
• An electroencephalogram (EEG) performed during wakefulness and sleep is recommended for children with a first unprovoked seizure 5.
• Neuroimaging with magnetic resonance imaging (MRI) study is recommended for children with new-onset seizures, particularly focal seizures or status epilepticus 5.
• The decision to start therapy should be made by the clinician and a fully informed patient, taking into account the risk of recurrence and the potential adverse effects of anti-seizure medication (ASM) 4, 6.
• The risk of a second seizure is about 36% at 2 years and 46% after 5 years, and is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma 7.
• For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient's weight and needs 7.
• First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines, and second-phase treatment is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital 7, 4.