What is the initial treatment for infantile seizures?

Initial Treatment for Infantile Seizures

For infantile seizures, phenobarbital should be used as the first-line antiseizure medication regardless of etiology, unless a channelopathy is suspected. 1

Types of Infantile Seizures and Their Management

Infantile seizures can be broadly categorized into:

1. Febrile Seizures

   • Most common seizure disorder in childhood (2-5% of children)
   • Peak age: 14-18 months
   • 97% occur in children under 4 years 2

2. Afebrile Seizures

   • Include epileptic spasms (infantile spasms), focal seizures, and other seizure types
   • Often require more aggressive treatment

3. Neonatal Seizures

   • Require specific management approaches

Febrile Seizures Management

For simple febrile seizures:

• Acute management:

  • Position the child on their side in recovery position
  • Clear the area to prevent injury
  • Do not restrain the child or put anything in their mouth 3
  • Monitor the child until fully recovered

• Preventive treatment:

  • Neither continuous nor intermittent anticonvulsant therapy is recommended for simple febrile seizures 3
  • Antipyretics (acetaminophen, ibuprofen) do not prevent recurrence of febrile seizures but may provide comfort 3
  • Parental education about the benign nature and excellent prognosis is essential 2

Afebrile Seizures Management

For infantile spasms and other afebrile seizures:

• First-line treatment:

  • ACTH (adrenocorticotropic hormone) is preferred for short-term control of epileptic spasms (level B recommendation) 4
  • Oral steroids are probably effective in short-term control of spasms (level C recommendation) 4
  • Earlier treatment initiation may improve long-term neurodevelopmental outcome 4

• For focal seizures:

  • Levetiracetam is effective (strong evidence) 4
  • Carbamazepine and valproic acid may be considered first-line therapies 5

• For Dravet syndrome:

  • Stiripentol (in combination with valproate and clobazam) is effective (strong evidence) 4

Neonatal Seizures Management

• First-line treatment:

  • Phenobarbital is recommended as the first-line antiseizure medication 1
  • In a randomized controlled trial, phenobarbital was more effective than levetiracetam (80% vs 28% seizure freedom) 6

• Second-line options:

  • Phenytoin, levetiracetam, midazolam, or lidocaine may be used 1
  • For neonates with cardiac disorders, levetiracetam may be preferred 1

Treatment Algorithm

1. Identify seizure type:

   • Febrile vs. afebrile
   • Simple vs. complex
   • Neonatal vs. infantile

2. For febrile seizures:

   • Ensure safety during seizure
   • No anticonvulsant therapy recommended
   • Educate parents about benign nature

3. For afebrile seizures:

   • Infantile spasms: ACTH or oral steroids
   • Focal seizures: Levetiracetam, carbamazepine, or valproic acid
   • Neonatal seizures: Phenobarbital as first-line

4. For refractory cases:

   • Refer to tertiary care center
   • Consider additional treatment options including ketogenic diet, epilepsy surgery evaluation

Important Considerations

• Timing matters: Shorter interval from onset of spasms to treatment initiation may improve long-term neurodevelopmental outcome 4

• Diagnostic evaluation: EEG is essential for diagnosis of infantile spasms and should be performed promptly when suspected 4

• Avoid overtreatment: For febrile seizures, the toxicity of anticonvulsants outweighs the minimal risks of the seizures themselves 2

• Common pitfalls:

  • Delaying treatment for infantile spasms
  • Treating simple febrile seizures with anticonvulsants
  • Using antipyretics with the expectation they will prevent febrile seizure recurrence
  • Failing to distinguish between simple and complex febrile seizures

• Emergency situations: Activate emergency medical services for seizures lasting >5 minutes, seizures in infants <6 months, multiple seizures without return to baseline, or seizures with respiratory distress 3

By following this evidence-based approach to infantile seizures, clinicians can optimize outcomes while minimizing unnecessary treatments and their potential adverse effects.