Seizure Management in Children
Acute Seizure Management
For any child actively seizing, benzodiazepines are the immediate first-line treatment, with lorazepam preferred due to its longer duration of action. 1, 2
First-Line: Benzodiazepines
- Administer benzodiazepines immediately for any seizure lasting >5 minutes or consecutive seizures without recovery of consciousness (status epilepticus). 2
- Lorazepam is the preferred benzodiazepine over diazepam due to longer duration of action, though both are effective. 2, 3
- Rectal diazepam is the treatment of choice for acute management of prolonged febrile seizures or seizure clusters when IV access is unavailable. 3
When to Activate Emergency Services
Call EMS immediately if: 1
- First-time seizure
- Seizure in infant <6 months
- Seizure lasting >5 minutes
- Multiple seizures without return to baseline between episodes
- Child does not return to baseline within 5-10 minutes after seizure stops
- Seizure with traumatic injury, choking, or difficulty breathing
Second-Line Treatment (Refractory Status Epilepticus)
If seizures persist after benzodiazepines, immediately administer a second-line antiepileptic medication—valproate or levetiracetam are preferred over phenytoin. 2, 4
- Valproate: 30 mg/kg IV at 6 mg/kg/hour achieves 88% seizure cessation within 20 minutes. 2, 4
- Levetiracetam: 30 mg/kg IV at 5 mg/kg/minute demonstrates 73% response rate in refractory status epilepticus. 2, 4
- Both agents show equivalent efficacy (valproate 46% vs levetiracetam 47% cessation at 60 minutes). 4
- Phenytoin/fosphenytoin (20 mg/kg IV at 50 mg/minute) is less preferred due to higher risk of hypotension (12% vs 0% with valproate). 2
Critical Pitfall: Avoid valproate in young children (<2 years) due to hepatotoxicity risk and in females of childbearing potential due to teratogenic effects. 1, 4
Long-Term Seizure Management by Type
Focal (Partial) Onset Seizures
Carbamazepine or oxcarbazepine are first-line treatments for children with focal seizures, with lamotrigine and levetiracetam as equally appropriate alternatives. 4, 3, 5
- Carbamazepine and oxcarbazepine are treatments of choice based on established efficacy and favorable side effect profiles. 4, 3
- Lamotrigine performs better than most other treatments including carbamazepine in terms of treatment failure (HR 1.26,95% CI 1.10-1.44). 5
- Levetiracetam shows no significant difference from lamotrigine for treatment failure and both perform better than other AEDs. 5
- Avoid phenobarbital and phenytoin as first-line due to unfavorable adverse event profiles, particularly behavioral disturbances. 6, 3
Generalized Tonic-Clonic Seizures
Valproate is the treatment of choice for generalized tonic-clonic seizures, with lamotrigine and topiramate as first-line alternatives. 3, 5
- Valproate demonstrates superior efficacy compared to all other treatments for generalized onset seizures. 5
- Lamotrigine (HR 1.06,95% CI 0.81-1.37) and levetiracetam (HR 1.13,95% CI 0.89-1.42) show no significant difference from valproate and are appropriate alternatives. 5
- Critical consideration: For adolescent females, lamotrigine is preferred over valproate due to teratogenic risks. 3
Absence Seizures
Ethosuximide is the treatment of choice for childhood absence epilepsy, with valproate and lamotrigine also first-line. 3
- For juvenile absence epilepsy, valproate and lamotrigine are treatments of choice. 3
Myoclonic Seizures and Lennox-Gastaut Syndrome
Valproate is the treatment of choice for symptomatic myoclonic seizures and Lennox-Gastaut syndrome, with topiramate and lamotrigine also first-line. 3
- Zonisamide or topiramate are first-line agents for mixed generalized epilepsies. 7
Infantile Spasms (West Syndrome)
Treatment selection depends on underlying etiology: 7, 3
- Vigabatrin is treatment of choice for tuberous sclerosis-related infantile spasms, with ACTH also first-line. 3
- ACTH is treatment of choice for cryptogenic (no identified cause) infantile spasms, with topiramate also first-line. 3
- For symptomatic infantile spasms (other than tuberous sclerosis), zonisamide is recommended. 7
Febrile Seizure Management
Long-term antiepileptic prophylaxis is NOT recommended for simple febrile seizures—the risks of medication toxicity outweigh the benign nature of febrile seizures. 1
Key Evidence
- Simple febrile seizures are benign events in children 6-60 months with excellent prognosis. 1
- Although phenobarbital, primidone, valproic acid, and intermittent oral diazepam reduce recurrence risk, potential toxicities outweigh benefits. 1
- Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizures, though they may improve comfort. 1
- Intermittent oral diazepam at fever onset may be considered only when parental anxiety is severe. 1
Critical Pitfall: Carbamazepine and phenytoin are ineffective for febrile seizure prevention and should never be used. 1
General Principles
Monotherapy Priority
Always use monotherapy when possible—never use polytherapy if monotherapy achieves seizure control. 4
- Monotherapy minimizes adverse effects, drug interactions, and improves compliance. 4
When NOT to Start Antiepileptic Drugs
Do not routinely prescribe antiepileptic drugs after a first unprovoked seizure. 4
- Prophylactic anticonvulsants without documented seizures may be associated with worse outcomes. 8
Treatment Discontinuation
Consider discontinuing antiepileptic drugs after 2 seizure-free years, taking into account clinical, social, and personal factors. 4