What is the management and treatment of a seizure in a child?

Management and Treatment of Seizures in Children

Immediate Seizure Management

During an active seizure, position the child on their side in the recovery position, clear the surrounding area of harmful objects, and stay with the child—never restrain them or place anything in their mouth. 1

Critical First Aid Actions:

• Help the child to the ground safely to prevent fall-related injuries 1
• Place in recovery position (on their side) to reduce aspiration risk if vomiting occurs 1
• Remove nearby objects that could cause injury during seizure movements 1
• Do NOT restrain the child during seizure activity 1
• Do NOT place anything in the mouth or give food, liquids, or oral medications during or immediately after the seizure 1

When to Activate Emergency Medical Services:

Call 911 immediately for: 1

• First-time seizure in any child
• Seizure lasting >5 minutes (this is now considered status epilepticus requiring emergency anticonvulsant treatment) 1, 2
• Infant <6 months of age with seizure
• Multiple seizures without return to baseline between episodes
• Child does not return to baseline within 5-10 minutes after seizure stops 1
• Seizure with traumatic injury, choking, difficulty breathing, or occurring in water 1
• Seizure in a pregnant adolescent 1

Pharmacologic Treatment for Prolonged Seizures

For seizures lasting >5 minutes, first-line treatment is lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min. 3

Treatment Algorithm:

• Benzodiazepines are first-line for any seizure exceeding 5 minutes 3, 2
• Early treatment is critical: seizures persisting 5-10 minutes are unlikely to stop spontaneously and require immediate intervention 2
• Prehospital benzodiazepine administration significantly reduces seizure activity compared to waiting until emergency department arrival 2

Common Pitfall:

Emergency department personnel fail to recognize status epilepticus in children in 34% of cases—any seizure lasting ≥5 minutes should trigger immediate treatment protocols. 2

Febrile Seizures: A Distinct Category

Simple febrile seizures are benign, self-limited events that require NO anticonvulsant prophylaxis—neither continuous nor intermittent treatment is recommended. 1

Definition of Simple Febrile Seizures:

• Generalized seizure lasting <15 minutes 1, 4
• Occurs once in a 24-hour period 1, 4
• In febrile child (temperature ≥100.4°F/38°C) aged 6-60 months 1, 4
• No intracranial infection, metabolic disturbance, or history of afebrile seizures 1

What NOT to Do for Simple Febrile Seizures:

• Do NOT give antipyretics (acetaminophen, ibuprofen) to prevent seizures—they are completely ineffective at stopping or preventing febrile seizures 1, 3, 4
• Do NOT prescribe prophylactic anticonvulsants (phenobarbital, valproic acid, diazepam)—the potential toxicities clearly outweigh minimal risks 1, 3
• Do NOT order routine neuroimaging—it is not indicated for simple febrile seizures 3

Prognosis and Parent Education:

• Excellent long-term prognosis: no adverse effects on IQ, academic performance, neurocognitive function, or behavior 1, 3
• Risk of epilepsy is approximately 1%—identical to the general population 1, 3, 4
• No evidence of structural brain damage from simple febrile seizures 1, 3
• Recurrence risk varies by age: 50% if first seizure occurs before 12 months; 30% if after 12 months 1, 3, 4
• Even high-risk children (multiple seizures, age <12 months at first seizure, family history of epilepsy) have only 2.4% risk of developing epilepsy by age 25 1, 3

Critical Counseling Point:

Educate parents that simple febrile seizures are benign and that prophylactic treatment does not reduce epilepsy risk, as epilepsy development is due to genetic predisposition rather than seizure-induced brain damage. 1

Long-Term Epilepsy Management

For children diagnosed with epilepsy, monotherapy with medications such as oxcarbazepine, topiramate, or levetiracetam is the preferred initial approach. 3

Management Strategy:

• Start with single antiepileptic drug (monotherapy) 3
• Refer to pediatric neurology if first medication fails 3
• Regular monitoring required: neurological assessments, EEG monitoring, and medication side effect surveillance 3

Diagnostic Approach for Non-Febrile Seizures:

• MRI with diffusion-weighted imaging is most sensitive for detecting hypoxic-ischemic injury and cortical malformations 3
• Hypoxic-ischemic injury accounts for 46-65% of neonatal seizures 3
• Immediate assessment of airway, breathing, circulation, followed by age-specific classification and seizure type identification 3