What is the first-line treatment for pediatric patients experiencing focal seizures?

First-Line Treatment for Pediatric Focal Seizures

For acute focal seizures in children, IV lorazepam 0.05-0.1 mg/kg (maximum 4 mg) at 2 mg/min is the preferred first-line treatment, with 65% efficacy in terminating status epilepticus. 1

Acute Management of Active Focal Seizures

Immediate Stabilization

• Establish airway, breathing, and circulation while providing high-flow oxygen and appropriate airway management. 2
• Check fingerstick glucose immediately to rule out hypoglycemia as the underlying cause. 1, 2
• Position the patient on their side in recovery position to prevent aspiration. 2
• Establish IV or intraosseous access for medication administration. 2

First-Line Benzodiazepine Therapy

When IV access is available:

• Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) at 2 mg/min is preferred over diazepam due to longer duration of action. 1, 3
• Alternatively, diazepam 0.2-0.5 mg/kg IV (maximum 5 mg for children <5 years, 10 mg for older children) over 2 minutes is equally effective. 1
• Have airway equipment immediately available before administering benzodiazepines, as respiratory depression can occur. 1

When IV access is unavailable or delayed:

• Intramuscular midazolam 0.2 mg/kg is equally efficacious to IV lorazepam in prehospital settings. 1
• Intranasal or buccal midazolam demonstrates 88-93% efficacy in stopping seizures within 10 minutes. 1
• Rectal diazepam can be administered when IV access is not possible. 2

Second-Line Therapy for Refractory Seizures

If seizures persist after benzodiazepines (>5 minutes or consecutive seizures without recovery):

• Valproate 30 mg/kg IV over 5-20 minutes (at 6 mg/kg/hour) achieves 88% seizure cessation within 20 minutes and has lower hypotension risk (1.6%) compared to fosphenytoin (3.2%). 1, 2
• Levetiracetam 30 mg/kg IV over 5 minutes (at 5 mg/kg/minute) demonstrates 68-73% efficacy with the lowest probability of respiratory depression, making it preferable for patients with cardiac concerns. 1, 2, 3
• Fosphenytoin 20 mg PE/kg IV at maximum rate of 50 mg/min has 84% efficacy but carries 12% hypotension risk. 1

Common pitfall: Do not delay second-line treatment—status epilepticus increases mortality with prolonged duration. 2

Long-Term Maintenance Therapy for Chronic Focal Epilepsy

First-Line Monotherapy Options

For children with recurrent focal seizures requiring chronic antiepileptic therapy:

• Carbamazepine or oxcarbazepine are recommended as first-line treatments for pediatric focal seizures. 3, 4, 5, 6
• Lamotrigine and levetiracetam are equally appropriate first-line alternatives. 3, 4
• Oxcarbazepine is initiated at 8-10 mg/kg/day (generally not exceeding 600 mg/day) given twice daily, with target maintenance doses of 900-1,800 mg/day depending on weight (20-70 kg range). 7

Evidence Supporting Specific Agents

• Levetiracetam demonstrates lower frequency of seizures and fewer dermatological adverse events compared to carbamazepine, though both achieve equal seizure freedom rates. 8
• Topiramate has demonstrated efficacy in controlled trials, with 58% of patients achieving maximal dose of 400 mg/day for ≥2 weeks in monotherapy trials. 9
• Phenobarbital and phenytoin are considered last-choice drugs due to adverse event profiles. 6

Key Principles for Chronic Management

• Always use monotherapy when possible—never use polytherapy if monotherapy achieves seizure control. 3
• Monotherapy minimizes adverse effects, drug interactions, and improves compliance. 3
• Do not routinely prescribe antiepileptic drugs after a first unprovoked seizure. 2, 3
• Consider discontinuing antiepileptic drugs after 2 seizure-free years, taking into account clinical, social, and personal factors. 2, 3, 4

When to Consider Alternative Therapies

If two or more appropriate antiepileptic medications at therapeutic doses fail:

• Consider epilepsy surgery, vagus nerve stimulation, or ketogenic diet for drug-resistant epilepsy. 4, 5
• Approximately 30% of pediatric patients do not respond to two antiseizure medications and are considered drug-resistant. 10

Critical caveat: Document the direction of head turning and eye deviation during focal seizures, as these often indicate the seizure origin is contralateral to the direction of head/eye movement. 2