What is the guideline for managing seizures in children?

Guidelines for Managing Seizures in Children

For children with seizures, the primary management approach should focus on safety measures during the seizure, appropriate emergency response for concerning features, and avoiding unnecessary long-term anticonvulsant therapy for simple febrile seizures due to their benign nature and potential medication adverse effects.

Classification of Seizures in Children

• Seizures in children are broadly classified as febrile and afebrile seizures 1, 2
• Febrile seizures occur in children between 6 and 60 months of age with fever, without intracranial infection, metabolic disturbance, or history of afebrile seizures 1, 2
• Simple febrile seizures last <15 minutes, are generalized, and occur once in 24 hours 1, 2
• Complex febrile seizures last >15 minutes, are focal, or occur more than once in 24 hours 1, 2
• Febrile seizures affect 2-5% of children, with peak incidence around 18 months of age 2, 3

Immediate Management During a Seizure

• First aid providers should activate EMS for first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, seizures in water, seizures with traumatic injuries/breathing difficulties/choking, seizures in infants <6 months, seizures in pregnant individuals, or if the child doesn't return to baseline within 5-10 minutes after seizure activity stops 1
• Minimize risk of injury by helping the child to the ground, placing them on their side in recovery position, and clearing the area around them 1
• Stay with the child having a seizure 1
• Do not restrain the person having a seizure 1
• Do not put anything in the mouth and avoid giving food, liquids, or oral medicines during a seizure or when the child has decreased responsiveness after a seizure 1

Management of Febrile Seizures

• Antipyretics such as acetaminophen, ibuprofen, or paracetamol are not effective for stopping a seizure or preventing subsequent febrile seizures 1, 4, 3
• Treat fever to promote comfort and prevent dehydration, with paracetamol being the antipiretic of choice 4
• Neither continuous nor intermittent anticonvulsant therapy is recommended for children with one or more simple febrile seizures 1, 2
• Despite evidence that continuous anticonvulsant therapy with phenobarbital, primidone, or valproic acid and intermittent therapy with diazepam are effective in reducing febrile seizure recurrence, the potential toxicities associated with these agents outweigh the relatively minor risks of simple febrile seizures 1
• Potential adverse effects include behavioral disturbances in up to 30% of children on phenobarbital and up to 36% in benzodiazepine-treated groups 3
• Valproic acid carries risks of fatal hepatotoxicity (especially in children <2 years), thrombocytopenia, weight changes, and gastrointestinal disturbances 1, 2

Diagnostic Evaluation

• In children under 1 year with febrile seizure, lumbar puncture is generally indicated to rule out meningitis 4
• Lumbar puncture should also be performed if there are signs of meningitis, complex febrile seizure, excessive somnolence, irritability, systemic illness, or incomplete recovery after one hour 4
• For neuroimaging, MRI is preferred as the standard study at tertiary care level 5

Risk Factors and Prognosis

• Risk factors for recurrence include age <12 months at first seizure (50% recurrence risk) and family history of epilepsy 2
• Children >12 months have approximately 30% recurrence risk 1, 2
• Children with simple febrile seizures have excellent long-term outcomes with no decline in IQ, academic performance, or behavior 1, 2
• The risk of developing epilepsy by age 7 is approximately 1%, similar to the general population 1, 2
• Children with multiple simple febrile seizures, first seizure <12 months, and family history of epilepsy have slightly higher risk (2.4%) of developing epilepsy by age 25 1, 2

Special Considerations for Status Epilepticus

• Seizures lasting >5 minutes and multiple seizures occurring one after another represent status epilepticus, a critical medical emergency 1
• For prolonged seizures, emergency medical intervention with anticonvulsant medications may be necessary 1

Common Pitfalls to Avoid

• Overtreatment with anticonvulsants for simple febrile seizures when the risks outweigh the benefits 1
• Failure to recognize signs requiring immediate medical attention (seizures >5 minutes, multiple seizures, incomplete recovery) 1
• Using antipyretics with the expectation they will prevent seizure recurrence 1, 3
• Restraining a child during a seizure or placing objects in their mouth 1