What to do when a child with a history of seizures presents with a seizure?

Management of a Child Presenting with Seizure

When a child with a history of seizures presents with an active seizure, immediately protect them from injury by helping them to the ground, placing them on their side in the recovery position, clearing the area around them, and staying with them throughout the episode. 1, 2

Immediate Safety Measures During Active Seizure

Protective positioning is critical:

• Help the child to the ground immediately to prevent fall-related injuries, which are a major source of morbidity in seizure patients 1, 2
• Place the child on their side in the recovery position to reduce aspiration risk if vomiting occurs during the seizure or postictal period 1, 2
• Clear the area of any objects that could cause injury during seizure movements 1, 2
• Stay with the child throughout the entire episode to monitor for complications 1, 2

Critical actions to avoid:

• Never restrain the child during seizure movements, as this can cause musculoskeletal injuries and does not stop seizure activity 1, 2
• Never put anything in the child's mouth (fingers, bite blocks, tongue blades, spoons), as this can cause dental trauma, airway obstruction, or injury to the rescuer 1, 2
• Never give food, liquids, or oral medicines during the seizure or when the child has decreased responsiveness afterward due to high aspiration risk 1, 2

When to Activate Emergency Medical Services

Call 911 immediately if:

• The seizure lasts >5 minutes, as these may not stop spontaneously and require emergency anticonvulsant medications 1, 2, 3
• Multiple seizures occur without return to baseline mental status between episodes 1, 2
• The child does not return to baseline within 5-10 minutes after the seizure stops 1, 2
• The seizure is accompanied by traumatic injury, difficulty breathing, or choking 1, 2
• The seizure occurs in water 1, 2
• The child is an infant <6 months of age 1, 2

Most seizures are self-limited and resolve spontaneously within 1-2 minutes 1, 2. However, seizures lasting >5 minutes represent status epilepticus, a critical medical emergency that requires immediate intervention, as they are unlikely to stop on their own and carry serious risk of subsequent prolonged seizure activity, epileptogenesis, memory deficits, and learning difficulties 1, 3.

Post-Seizure Assessment

After the seizure stops:

• Monitor the child during the postictal period, when they will appear tired and confused for several minutes 1
• Check temperature immediately to determine if the seizure is febrile or afebrile, as this changes the diagnostic and therapeutic approach in children aged 6-60 months 4
• Assess for any injuries sustained during the seizure 1
• Ensure the child returns to baseline mental status within 5-10 minutes; if not, activate EMS 1, 2

Special Considerations for Febrile Seizures

Antipyretics are NOT effective for seizure management:

• Do not give acetaminophen, ibuprofen, or paracetamol to stop a seizure or prevent subsequent febrile seizures 1, 2
• Fever treatment may help the child feel better later but will not prevent seizures 1, 2
• Antipyretics should be used for comfort, not seizure prevention 4

Common Pitfalls to Avoid

Critical errors in seizure management:

• Attempting to restrain the child or force objects into their mouth, which causes harm without benefit 1, 2
• Giving oral medications during or immediately after a seizure when consciousness is impaired, risking aspiration 1, 2
• Delaying EMS activation for prolonged seizures (>5 minutes), as early treatment is essential to prevent status epilepticus 1, 3, 5
• Assuming antipyretics will prevent febrile seizure recurrence, when evidence shows no benefit 1, 4

Considerations for Known Seizure Disorder

For children with established epilepsy:

• If the family has been prescribed rescue benzodiazepines (such as rectal diazepam at 0.5 mg/kg up to maximum 20 mg), these should be administered if the seizure lasts >5 minutes 6
• Consider correctable acute causes such as hypoglycemia, hyponatremia, or other metabolic derangements, as these require specific metabolic correction rather than anticonvulsants 2, 7
• The recurrence risk for febrile seizures is approximately 30% overall, but increases to 50% in children younger than 12 months at first seizure 4