Initial Treatment for Focal Seizures in Pediatric Patients
For acute focal seizures in pediatric patients, immediately administer lorazepam 0.1 mg/kg IV (maximum 2 mg per dose) as first-line therapy after ensuring airway protection and checking blood glucose, followed by levetiracetam 40 mg/kg IV (maximum 2,500 mg) if seizures persist. 1, 2
Immediate Stabilization
Before administering any antiepileptic medication, the following steps are critical:
- Assess circulation, airway, and breathing (CAB) and provide appropriate airway protection with high-flow oxygen to prevent hypoxia 1, 2
- Check bedside blood glucose immediately to identify and treat hypoglycemia, a rapidly reversible cause of seizures 1, 3
- Establish IV or intraosseous access for medication administration if not already present 1
- Monitor vital signs and oxygen saturation continuously throughout treatment 1, 3
First-Line Pharmacologic Treatment (0-5 Minutes)
Lorazepam is the preferred initial benzodiazepine:
- Administer lorazepam 0.1 mg/kg IV slowly (maximum 2 mg per dose) 1, 2
- May repeat once after at least 1 minute (maximum of 2 doses total) 1, 2
- This represents strong consensus from the American Academy of Pediatrics for active seizure management 1
Second-Line Treatment (5-20 Minutes)
If seizures continue after benzodiazepine administration:
- Immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1, 2, 3
- Alternative second-line option: Fosphenytoin 18-20 mg PE/kg IV at a maximum rate of 2 mg PE/kg/min (or 150 mg PE/min, whichever is slower) 1
- Levetiracetam is increasingly preferred over fosphenytoin due to better safety profile and ease of administration 1
Third-Line Treatment (20-40 Minutes)
For refractory seizures continuing beyond 20 minutes:
- Add phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) 1, 2
- Initiate continuous EEG monitoring to guide further management 1, 2
- Transfer to Pediatric Intensive Care Unit (PICU) for ongoing management 1, 2
Maintenance Therapy After Seizure Control
Once seizures are controlled, maintenance dosing prevents recurrence:
- Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1, 2, 3
- Levetiracetam 30 mg/kg IV every 12 hours or increase to 20 mg/kg IV every 12 hours (maximum 1,500 mg) 1, 2, 3
- Phenobarbital 1-3 mg/kg IV every 12 hours if used in acute management 2
Special Considerations for Simple Febrile Seizures
For simple febrile seizures specifically:
- No prophylactic anticonvulsant therapy is recommended by the American Academy of Pediatrics 1, 3
- Antipyretics (acetaminophen, ibuprofen) are ineffective in preventing febrile seizure recurrence 4, 1, 3
- Reassurance of caregivers is essential as these seizures are typically benign 1
Critical Pitfalls to Avoid
Inadequate respiratory monitoring is the most dangerous pitfall, as benzodiazepines cause respiratory depression, especially when combined with other sedative agents 1, 2, 3
Excessive fosphenytoin infusion rate can cause cardiovascular collapse; always adhere to maximum infusion rates 1
Failure to check glucose early leads to missed diagnosis of easily reversible hypoglycemia 1, 3
Delaying second-line therapy beyond 5-10 minutes significantly worsens seizure outcomes 1, 3
Using prophylactic anticonvulsants for simple febrile seizures causes unnecessary toxicity without benefit 4, 1, 3
Long-Term Management Considerations
Antiepileptic drugs should NOT be routinely prescribed after a first unprovoked seizure according to the American Academy of Pediatrics 3
For established epilepsy with focal seizures, carbamazepine and oxcarbazepine are considered first-line maintenance therapies:
- Carbamazepine: In children <12 years, over 95% respond at doses below 17.5 mg/kg/day; in children >12 years, over 95% respond below 15 mg/kg/day 5
- Oxcarbazepine: Start with 8-10 mg/kg/day in divided doses, with target maintenance doses of 30-46 mg/kg/day depending on weight 6, 7, 8
- Levetiracetam is increasingly used as first-line maintenance therapy due to favorable safety profile 9, 8