What is the initial approach to managing pediatric seizures?

Initial Approach to Pediatric Seizures

The initial approach to pediatric seizures requires immediate assessment of airway, breathing, and circulation, followed by age-specific classification (neonatal, febrile vs. afebrile) and seizure type (simple vs. complex), with benzodiazepines as first-line treatment for seizures lasting >5 minutes, while avoiding routine neuroimaging for simple febrile seizures. 1

Immediate Acute Management

Active Seizure Protocol

• Position the patient on their side, remove harmful objects from the environment, and protect the head from injury 1, 2
• Never restrain the patient or place anything in the mouth during active seizure activity 2
• Establish IV access, monitor vital signs continuously, and ensure equipment for airway management is immediately available 3, 4

Pharmacologic Intervention for Prolonged Seizures (>5 minutes = Status Epilepticus)

• First-line treatment: Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 1, 3
• Alternative benzodiazepines when IV access unavailable: midazolam IM or diazepam rectally 5, 4
• Second-line treatment if seizures persist after 10-15 minutes: Valproic acid 20-40 mg/kg IV (maximum 3000 mg), phenytoin/fosphenytoin, phenobarbital, or levetiracetam 1, 5
• For refractory status epilepticus (>60 minutes): continuous infusions of midazolam or pentobarbital 5, 6

Age-Specific Classification and Diagnostic Approach

Neonatal Seizures (0-29 days)

• Hypoxic-ischemic injury accounts for 46-65% of neonatal seizures, followed by intracranial hemorrhage and perinatal stroke (10-12%) 7
• MRI with diffusion-weighted imaging is the most sensitive modality for detecting hypoxic-ischemic injury and cortical malformations 7
• Cranial ultrasound serves as a useful bedside screening tool for unstable neonates, identifying intraventricular hemorrhage, hydrocephalus, and white matter changes, but has low sensitivity for hypoxic-ischemic injury 7
• Non-contrast CT is indicated specifically for suspected hemorrhagic lesions in the setting of birth trauma, low hematocrit, or coagulopathy 7

Simple Febrile Seizures (6 months to 5 years)

• Defined as generalized seizures lasting <15 minutes, occurring once in 24 hours, in febrile children (temperature ≥100.4°F/38°C) without intracranial infection 7, 2
• Routine neuroimaging is NOT indicated for simple febrile seizures 7, 1, 2
• Routine diagnostic testing is not required except as needed to identify the fever source 2
• Do NOT prescribe prophylactic anticonvulsants (continuous or intermittent) for simple febrile seizures—the risks outweigh benefits 7, 2
• Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizure recurrence, though they may improve comfort 7, 2

Complex Febrile Seizures (6 months to 5 years)

• Defined as seizures lasting >15 minutes, focal features, or multiple episodes within 24 hours 7, 2
• Neuroimaging with MRI (preferred over CT) is indicated to exclude underlying structural abnormalities or intracranial infection 7, 1
• Consider intermittent diazepam prophylaxis during febrile illnesses for complex febrile seizures 2

First Afebrile Seizure (All Ages)

• EEG is recommended as part of the neurodiagnostic evaluation for first unprovoked seizure 1
• Emergent neuroimaging (MRI preferred over CT) is indicated for: postictal focal deficit, altered mental status not returning to baseline, or signs of increased intracranial pressure 1

Critical Red Flags Requiring Immediate Intervention

• Non-blanching rash with fever and altered consciousness = bacterial meningitis/sepsis until proven otherwise—administer IV ceftriaxone immediately without waiting for lumbar puncture or imaging 8
• Seizures in neonates beyond day 7 of life suggest infection, genetic disorders, or cortical malformations requiring urgent MRI 7
• First-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, or seizures with traumatic injuries/breathing difficulties require emergency medical services activation 2

Long-Term Management Considerations

• Monotherapy is the preferred initial approach for epilepsy management, with medications such as oxcarbazepine, topiramate, or levetiracetam 1
• Refer to pediatric neurology if the first antiepileptic medication fails 1
• Regular neurological assessment, EEG monitoring, and medication side effect surveillance are essential for ongoing care 1

Common Pitfalls to Avoid

• Do not delay antibiotics for diagnostic procedures when bacterial meningitis is suspected with non-blanching rash 8
• Do not assume fever explains everything—bacterial co-infections can occur even with other identified viral illnesses 8
• Do not order routine neuroimaging for simple febrile seizures—this represents unnecessary radiation exposure and cost without clinical benefit 7, 2
• Do not prescribe prophylactic anticonvulsants for simple febrile seizures despite parental anxiety—the evidence clearly demonstrates harm outweighs benefit 7, 2

Prognosis and Parent Education

• Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, or neurocognitive function 7
• Risk of developing epilepsy after simple febrile seizures is extremely low (similar to general population), and prophylactic treatment does not reduce this risk 7, 2
• Recurrence rate for febrile seizures is approximately 30% overall, higher in younger children (<12 months at first seizure have ~50% recurrence risk) 7, 2
• Educate caregivers about the benign nature of simple febrile seizures, practical home management, and when to seek emergency care 2