What are the recommended medications for seizure control in children?

Recommended Seizure Medications for Children

For acute seizure management in children, lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) is the first-line treatment for seizures lasting >5 minutes, followed by levetiracetam, fosphenytoin, or valproate as second-line agents with equivalent efficacy. 1, 2 For chronic epilepsy management, levetiracetam and oxcarbazepine are preferred first-line monotherapy options due to superior tolerability profiles compared to older agents. 2, 3

Acute Seizure Management (Emergency/Status Epilepticus)

First-Line Treatment

• Benzodiazepines are the initial treatment: Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min for seizures lasting >5 minutes 2
• Position patient on side, protect head, remove harmful objects, and never restrain or place anything in the mouth 2

Second-Line Treatment (Refractory to Benzodiazepines)

All three agents show equivalent efficacy—choose based on patient-specific factors:

• Levetiracetam: 47% seizure cessation rate in children; associated with fewer intubations (8%) compared to fosphenytoin (33%) 1
• Fosphenytoin: 46% seizure cessation rate; higher intubation risk in children (33%) 1
• Valproate: 49% seizure cessation rate; no hypotension risk unlike phenytoin 1

Critical consideration: Children receiving levetiracetam at home who present with breakthrough seizures may respond better to alternative agents (fosphenytoin or valproate) rather than additional levetiracetam 1

Medications to Avoid in Acute Settings

• Phenytoin: Associated with significant hypotension (12% vs 0% with valproate) and unfavorable cardiotoxicity profile 1
• Lacosamide: Unfavorable cardiotoxicity profile; should be avoided when possible 1

Chronic Epilepsy Management (Long-Term Control)

First-Line Monotherapy Options

Preferred agents based on efficacy and tolerability:

• Levetiracetam:

  • Dosing: 20 mg/kg/day initially, titrate by 20 mg/kg/day increments every 2 weeks to target 60 mg/kg/day in two divided doses 4
  • 85% seizure control rate in recent pediatric studies 5
  • Superior tolerability: 31% of patients experience no side effects 5
  • Approved for children ≥1 month of age for partial onset seizures 4, 6
  • Caution: Behavioral changes and psychotic reactions occur more frequently in children <4 years, typically at doses <20 mg/kg/day, but are reversible upon discontinuation 7

• Oxcarbazepine: Recommended as first-line monotherapy with favorable efficacy and tolerability profile 2, 3

• Topiramate:

  • Pediatric dosing: 1-3 mg/kg/day initially, titrate by 1-3 mg/kg/day at 1-2 week intervals to target 5-9 mg/kg/day in two divided doses 8
  • Effective for partial seizures, primary generalized tonic-clonic seizures, and Lennox-Gastaut syndrome 8
  • Recommended as first-line option 2

Second-Line Options

• Valproic acid: Effective but carries significant risks in young children, particularly fatal hepatotoxicity in children <2 years (the age group at highest seizure risk) 1
• Carbamazepine: Still considered first-line by some guidelines but requires monitoring for bone marrow suppression, liver dysfunction, and multiple drug interactions 9, 3

Medications NOT Recommended

• Phenobarbital: Causes hyperactivity, irritability, lethargy, sleep disturbances in 20-40% of children—severe enough to necessitate discontinuation 1, 2
• Phenytoin: Not effective for preventing seizure recurrence even at therapeutic levels 1
• Carbamazepine: Not effective for simple febrile seizures (47% recurrence rate vs 10% with phenobarbital) 1

Special Considerations

Simple Febrile Seizures

No prophylactic anticonvulsant therapy is recommended: The American Academy of Pediatrics explicitly states that neither continuous nor intermittent anticonvulsant prophylaxis should be used, as potential toxicities clearly outweigh minimal risks 2

• Simple febrile seizures have excellent prognosis with no long-term effects on IQ, academic performance, or neurocognitive function 2
• Risk of developing epilepsy is approximately 1% (same as general population) 2
• Antipyretics do not prevent febrile seizures or reduce recurrence 1, 2

CAR T-Cell Therapy Recipients

• Levetiracetam prophylaxis: 10 mg/kg (maximum 500 mg) every 12 hours for 30 days following infusion for patients with CNS disease or seizure history 1
• Well-tolerated with minimal drug interactions and does not affect cytokine levels 1

Renal Impairment

• Levetiracetam and topiramate require dose adjustment: Use half the usual dose when creatinine clearance <70 mL/min/1.73m² 4, 8
• Supplemental dosing needed for patients on hemodialysis 8

Treatment Algorithm for Refractory Epilepsy

1. Start with monotherapy: Levetiracetam, oxcarbazepine, or topiramate 2
2. If first medication fails: Refer to pediatric neurology 2
3. Consider add-on therapy: Lamotrigine or gabapentin have sufficient data supporting adjunctive use 3
4. Reserve for refractory cases: Vigabatrin (limited by visual field constriction risk), ketogenic diet, or vagus nerve stimulation 3

Critical Pitfalls to Avoid

• Never delay benzodiazepines for prolonged seizures (>5 minutes) while obtaining IV access—consider intranasal or buccal routes 2
• Avoid phenytoin in children when alternatives exist due to higher intubation rates and cardiovascular toxicity 1
• Do not use prophylactic anticonvulsants for simple febrile seizures—harm exceeds benefit 2
• Monitor for behavioral changes in children <4 years on levetiracetam, particularly during titration phase 7
• Avoid valproate in children <2 years when possible due to hepatotoxicity risk 1