What is the recommended loading dose of Keppra (Levetiracetam) for pediatric patients?

Pediatric Levetiracetam (Keppra) Loading Dose

The recommended loading dose of levetiracetam (Keppra) for pediatric patients is 40 mg/kg intravenously (maximum 2,500 mg). This loading dose is appropriate for managing acute seizures and status epilepticus in children 1.

Dosing Guidelines by Clinical Scenario

For Non-Convulsive Status Epilepticus:

• Initial management: Assess circulation, airway, breathing; provide oxygen; check blood glucose
• First-line: Lorazepam 0.05 mg/kg IV (maximum 1 mg), repeatable every 5 minutes up to 4 doses
• Second-line: Levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1
• If seizures persist, transfer to PICU and add phenobarbital

For Convulsive Status Epilepticus:

• Initial management: Assess circulation, airway, breathing; provide oxygen; check blood glucose
• First-line: Lorazepam 0.1 mg/kg IV (maximum 2 mg), repeatable after 1 minute (up to 2 doses)
• Second-line: Levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1
• If seizures persist, add phenobarbital IV at loading dose of 10-20 mg/kg (maximum 1,000 mg)

Maintenance Dosing After Loading

After administering the loading dose, maintenance therapy should be initiated within 12-24 hours:

• For non-convulsive status epilepticus: Levetiracetam 15 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1
• For convulsive status epilepticus: Levetiracetam 30 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1

Age-Based Considerations

According to the FDA label for levetiracetam 2:

• For children 4-16 years: Initial treatment should start at 20 mg/kg/day in 2 divided doses
• Titration: Increase by 20 mg/kg increments every 2 weeks
• Target dose: 60 mg/kg/day (30 mg/kg twice daily)
• For patients ≤20 kg: Use oral solution
• For patients >20 kg: Can use either tablets or oral solution

Efficacy and Safety Considerations

Research shows that levetiracetam is effective and well-tolerated in pediatric patients:

• A retrospective study found that 89% of children remained seizure-free at 1 hour after receiving levetiracetam at a mean dose of 29.4 mg/kg 3
• Higher doses (up to 275 mg/kg/day) have been used in refractory cases with 44% of children achieving >50% seizure reduction, though this is beyond standard recommendations 4

Important Clinical Considerations

1. Loading dose administration: Administer IV levetiracetam over 15 minutes to minimize side effects
2. Monitoring: Watch for behavioral side effects, which are the most common adverse effects in children (reported in approximately 12% of patients) 4
3. Renal adjustment: Dose adjustments are necessary for patients with impaired renal function
4. Advantages: Levetiracetam has minimal drug interactions and does not require serum level monitoring for toxicity
5. Caution: Recent research suggests that higher loading doses (>40 mg/kg) may be associated with increased rates of intubation 5

Practical Application

For a typical pediatric patient requiring acute seizure management:

1. Calculate the 40 mg/kg dose (maximum 2,500 mg)
2. Administer IV over 15 minutes
3. Monitor for clinical response and adverse effects
4. Begin maintenance dosing 12 hours after loading dose

Levetiracetam is particularly valuable in pediatric seizure management due to its favorable safety profile, minimal drug interactions, and effectiveness in various seizure types.