What is the management of pediatric seizures?

Management of Pediatric Seizures

Immediate Management of Active Seizures

For any pediatric seizure lasting >5 minutes, administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) at 2 mg/min as first-line treatment. 1

Acute Stabilization

• Position the child on their side, remove dangerous objects, and protect the head from injury 1
• Never restrain the patient or place anything in the mouth during active seizure activity 1
• Assess airway, breathing, and circulation immediately, followed by age-specific classification and seizure type identification 1

When to Activate Emergency Services

• First-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, or seizures with traumatic injuries, breathing difficulties, or choking all require emergency medical services 2

Alternative Benzodiazepine Routes

• Buccal midazolam is significantly more effective than rectal diazepam, achieving 70% seizure control with only 8% recurrence rate 3
• When IV access is unavailable, rectal diazepam should be administered, or IM phenobarbital may be considered 2
• Intranasal lorazepam is as effective as intramuscular paraldehyde and represents an easy-to-use alternative 3

Refractory Status Epilepticus

• Intravenous valproate exhibits faster seizure cessation and a safer profile than diazepam as third-line therapy, even in infancy 3
• Both IV midazolam and valproate are equally effective to IV diazepam in refractory cases 3

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Management of Simple Febrile Seizures

Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for children with simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 4, 2

Definition and Risk Stratification

• Simple febrile seizures are generalized seizures lasting <15 minutes, occurring once in 24 hours, in febrile children (temperature ≥100.4°F/38°C) aged 6-60 months without intracranial infection 1, 2
• Complex febrile seizures are prolonged (>15 minutes), focal, or occur more than once within 24 hours 4, 2

Recurrence Risk

• Children younger than 12 months at first simple febrile seizure have approximately 50% probability of recurrence 4
• Children older than 12 months at first event have approximately 30% probability of a second febrile seizure 4

Epilepsy Risk

• The risk of developing epilepsy after simple febrile seizures is approximately 1% (same as general population) 4
• Children with multiple simple febrile seizures, age <12 months at first seizure, and family history of epilepsy have 2.4% risk of developing epilepsy by age 25 years 4
• No study has demonstrated that successful treatment of simple febrile seizures can prevent later development of epilepsy 4

Why Prophylaxis Is Not Recommended

• The harm-benefit analysis clearly favors no treatment 4, 2
• Valproic acid carries risk of rare fatal hepatotoxicity (especially in children <2 years who are at greatest risk of febrile seizures), thrombocytopenia, weight changes, gastrointestinal disturbances, and pancreatitis 4
• Phenobarbital causes hyperactivity, irritability, lethargy, sleep disturbances, and hypersensitivity reactions 4
• Intermittent diazepam causes lethargy, drowsiness, ataxia, and risks masking an evolving CNS infection 4

Role of Antipyretics

• Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they may improve comfort during febrile illness 2

Diagnostic Evaluation

• Routine neuroimaging is NOT indicated for simple febrile seizures 1
• For well-appearing children with simple febrile seizures, routine diagnostic testing is not required except as indicated to identify the source of fever 2

Parent Education

• Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, or neurocognitive function 1, 2
• Educate caregivers about the benign nature, practical home management, and when to seek emergency care 1, 2

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Long-Term Management of Epilepsy

Monotherapy with medications such as levetiracetam, oxcarbazepine, or topiramate is the preferred initial approach for pediatric epilepsy. 1

Medication Selection by Seizure Type

• For focal seizures, levetiracetam is effective (strong evidence) 5, 6
• For generalized seizures, levetiracetam, valproate, lamotrigine, topiramate, and clobazam have weak supporting evidence 6
• Refer to pediatric neurology if the first antiepileptic medication fails 1

Monitoring Requirements

• Regular neurological assessment, EEG monitoring, and medication side effect surveillance are essential for ongoing care 1
• Infants with recurrent seizures warrant urgent assessment for initiation of antiepileptic drugs 6

Surgical Considerations

• Identification of patients as potential candidates for epilepsy surgery should be part of standard practice at all care levels 6
• Tertiary care facilities with epilepsy surgery experience should screen surgical candidates 6

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Diagnostic Approach

Neuroimaging

• MRI with diffusion-weighted imaging is the most sensitive modality for detecting hypoxic-ischemic injury and cortical malformations 1
• Neuroimaging is recommended at all levels of care for infants presenting with epilepsy, with MRI as the standard investigation at tertiary level 6

EEG Evaluation

• Infants with abnormal movements whose routine EEG is not diagnostic benefit from video-EEG analysis or home video to capture events 6
• Prolonged EEG is ideally recommended for suspected epileptic spasms 6

Genetic Testing

• Genetic evaluation for Dravet syndrome and other infantile-onset epileptic encephalopathies should be available in tertiary care 6
• Genetic screening should not be undertaken at primary or secondary level care 6

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Critical Pitfalls to Avoid

• Do not prescribe prophylactic anticonvulsants for simple febrile seizures - this is the most common error, as the risks clearly outweigh benefits 4, 2
• Do not rely on antipyretics to prevent febrile seizure recurrence 2
• Do not perform routine neuroimaging for simple febrile seizures 1
• Avoid IM diazepam due to erratic absorption when treating active seizures 2
• Do not delay referral to tertiary care - refer after failure of one antiepileptic drug at standard care level 6