What is the step-wise approach for managing seizure disorder in pediatric patients?

Step-wise Management of Pediatric Seizure Disorders

The management of pediatric seizure disorders should follow a systematic approach based on seizure classification, etiology identification, and appropriate treatment selection to optimize outcomes related to morbidity, mortality, and quality of life.

Initial Assessment and Classification

• Classify the seizure type: simple partial (without impairment of consciousness), complex partial (with impaired consciousness), or generalized tonic-clonic 1
• Determine if the seizure is febrile (occurring in children 6-60 months with fever) or afebrile 2, 3
• For febrile seizures, further classify as simple (brief <15 minutes, generalized, occurring once in 24 hours) or complex (>15 minutes, focal, or multiple in 24 hours) 2, 3
• Evaluate for signs of status epilepticus, defined as prolonged or repetitive seizures without recovery of consciousness between episodes 4

Diagnostic Evaluation

For First Seizure:

• Obtain detailed history including seizure description, duration, associated symptoms, and risk factors 5
• Perform thorough neurological examination to identify focal deficits 5
• Laboratory studies should be ordered based on clinical circumstances (not routinely) 2:
  • Consider electrolytes, glucose, and toxicology screening if clinically indicated 5
• Neuroimaging considerations:
  • Emergent neuroimaging for patients with postictal focal deficit, altered mental status, or signs of increased intracranial pressure 2
  • MRI is preferred over CT when neuroimaging is indicated 2
  • Routine neuroimaging is not necessary for simple febrile seizures 2, 3
• EEG is recommended as part of the neurodiagnostic evaluation for first unprovoked seizure 2
• Lumbar puncture should be performed if meningitis or encephalitis is suspected 2

Acute Management

For Active Seizure:

1. Ensure patient safety 6:

   • Position patient on side to prevent aspiration
   • Remove harmful objects from vicinity
   • Do not restrain or place objects in mouth
   • Protect head from injury
   • Monitor vital signs

2. For seizures lasting >5 minutes (Status Epilepticus) 4:

   • First-line: Benzodiazepines
     • Lorazepam 0.05-0.1 mg/kg IV (max 4 mg)
     • Diazepam 0.2-0.5 mg/kg IV/rectal (max 10 mg)
     • Midazolam 0.2 mg/kg IM/intranasal (max 10 mg)
   • Second-line (if seizures continue after 5-10 minutes):
     • Fosphenytoin 20 mg PE/kg IV (max 1500 mg PE)
     • Valproic acid 20-40 mg/kg IV (max 3000 mg)
     • Levetiracetam 20-60 mg/kg IV (max 4500 mg)
   • Third-line (refractory status epilepticus):
     • Continuous EEG monitoring
     • Midazolam, pentobarbital, or propofol infusion

For Febrile Seizures:

• Simple febrile seizures typically require only supportive care 2, 3
• Treat underlying fever with antipyretics, though antipyretics have not been shown to prevent recurrence of febrile seizures 2, 3
• Neither continuous nor intermittent anticonvulsant therapy is recommended for children with simple febrile seizures due to potential toxicities outweighing benefits 2, 3

Long-term Management

For Epilepsy:

1. Monotherapy is preferred initial approach 7, 8:

   • For children 4-16 years:
     • Oxcarbazepine: Start at 8-10 mg/kg/day (divided twice daily), titrate to effective dose based on weight 7
     • Topiramate: Start at 25 mg nightly, titrate by 1-3 mg/kg/day at 1-2 week intervals 8
   • Titrate to lowest effective dose before considering polytherapy 7, 8

2. If first medication fails:

   • Try alternative monotherapy before considering polytherapy 7
   • Consider referral to pediatric neurologist for medication management 2

3. Follow-up monitoring:

   • Regular neurological assessment 2
   • EEG monitoring as indicated 2
   • Monitor for medication side effects 7, 8

For Special Considerations:

• For seizures associated with specific syndromes (e.g., cardio-facio-cutaneous syndrome), follow syndrome-specific protocols 2
• For patients with infantile spasms, consult with cardiologist before steroid management due to risk of cardiomyopathy 2
• For patients receiving CAR T-cell therapy with seizure risk, consider prophylaxis with levetiracetam (10 mg/kg, max 500 mg per dose) every 12 hours for 30 days 2

Surgical Considerations

• Consider epilepsy surgery evaluation for medication-resistant seizures 1
• Refer to specialized epilepsy centers for comprehensive evaluation 1

Follow-up Care

• Regular follow-up with neurologist for ongoing seizure management 2
• Early intervention services for developmental support if indicated 2
• Speech, physical, and occupational therapy as needed based on evaluation 2

Common Pitfalls to Avoid

• Delaying treatment of status epilepticus (treat promptly if seizure lasts >5 minutes) 4
• Routine use of neuroimaging for simple febrile seizures (not recommended) 2, 3
• Prescribing continuous anticonvulsant therapy for simple febrile seizures (risks outweigh benefits) 2, 3
• Polytherapy before optimizing monotherapy (increases side effect risk without proportional benefit) 7, 8
• Inadequate dosing of rescue medications during acute seizures 4