Treatment of Seizures in Children
For simple febrile seizures (the most common seizure type in children aged 6-60 months), neither continuous nor intermittent anticonvulsant prophylaxis is recommended, as the potential toxicities outweigh the minimal risks associated with these benign seizures. 1
Simple Febrile Seizures: No Prophylactic Treatment
The American Academy of Pediatrics provides unequivocal guidance based on aggregate evidence quality B (randomized controlled trials with minor limitations) that prophylactic anticonvulsants should not be prescribed for simple febrile seizures. 2
Key Clinical Characteristics
- Simple febrile seizures are brief (<15 minutes), generalized, occur once in 24 hours, and affect children aged 6-60 months during fever without intracranial infection or metabolic disturbance. 1
- These seizures affect 2-5% of children, making them the most common childhood seizure disorder. 2
- Complex febrile seizures (prolonged >15 minutes, focal, or multiple within 24 hours) are a different entity and require different management considerations. 1
Why No Prophylaxis?
- No long-term adverse outcomes: Simple febrile seizures do not cause decline in IQ, academic performance, neurocognitive function, or behavioral abnormalities. 1
- Epilepsy risk is minimal: Children with simple febrile seizures have approximately 1% risk of developing epilepsy by age 7 (same as general population), and no evidence shows that prophylactic treatment reduces this risk, which is likely due to genetic predisposition rather than structural brain damage. 1
- Medication toxicities outweigh benefits: While phenobarbital, primidone, valproic acid, and intermittent diazepam can reduce febrile seizure recurrence, their potential harms (valproic acid's rare fatal hepatotoxicity, phenobarbital's hyperactivity and irritability, diazepam's lethargy and risk of masking evolving CNS infection) clearly outweigh benefits. 1, 2
What About Antipyretics?
- Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they may improve comfort during febrile illness. 2
Recurrence Risk Counseling
- Children <12 months at first seizure: ~50% recurrence risk. 1
- Children >12 months at first seizure: ~30% recurrence risk; of those with a second seizure, 50% have at least one additional recurrence. 1
Acute Seizure Management: When Intervention Is Needed
For actively seizing children requiring immediate intervention (seizures lasting >5 minutes or status epilepticus), a stepwise pharmacologic approach is essential. 3, 4
Emergent Treatment (First-Line)
Urgent Treatment (Second-Line)
If seizures persist after benzodiazepines, administer one of the following: 4
- Fosphenytoin/phenytoin (IV)
- Phenobarbital (IV)
- Levetiracetam (IV)
- Valproate sodium (IV)
Refractory Status Epilepticus
For seizures persisting despite emergent and urgent treatments, continuous infusions are required: 5, 4
- Midazolam infusion
- Pentobarbital infusion
- These patients require PICU admission with intensive vital function support. 3, 4
Chronic Epilepsy Management (Not Febrile Seizures)
For children with established epilepsy (two or more unprovoked seizures), antiepileptic drug (AED) therapy is indicated. 6
Partial Onset Seizures
- Levetiracetam: Start 20 mg/kg/day divided BID (ages 4-16 years), increase by 20 mg/kg every 2 weeks to target 60 mg/kg/day (maximum 3000 mg/day). 7
- Valproic acid: Start 10-15 mg/kg/day, increase by 5-10 mg/kg/week to achieve optimal response, typically <60 mg/kg/day (therapeutic range 50-100 mcg/mL). 8
Generalized Tonic-Clonic Seizures
- Levetiracetam: Ages 6-16 years, start 20 mg/kg/day divided BID, increase by 20 mg/kg every 2 weeks to 60 mg/kg/day. 7
- Valproic acid: Start 15 mg/kg/day, increase by 5-10 mg/kg/week, maximum 60 mg/kg/day. 8
Absence Seizures
- Valproic acid: Start 15 mg/kg/day, increase by 5-10 mg/kg/week until seizures controlled, maximum 60 mg/kg/day. 8
Critical Pitfalls to Avoid
- Never prescribe prophylactic anticonvulsants for simple febrile seizures—this is explicitly contraindicated by AAP guidelines. 1, 2
- Never tell parents that antipyretics prevent febrile seizures—they do not reduce recurrence risk. 2
- Never delay benzodiazepine administration in active seizures—early treatment prevents progression to refractory status epilepticus. 3, 4
- Never use IM diazepam for acute seizures due to erratic absorption; use IV lorazepam, IM midazolam, or rectal diazepam instead. 2
- Never restrain a seizing child or place anything in their mouth—position in recovery position and clear the area. 2
When to Activate Emergency Services
Call emergency services for: 2
- First-time seizures
- Seizures lasting >5 minutes
- Multiple seizures without return to baseline
- Seizures with traumatic injuries, breathing difficulties, or choking