What is the management for a 6-month-old infant presenting with three episodes of seizures?

Management of a 6-Month-Old Infant with Three Seizure Episodes

Immediate Emergency Actions

Activate emergency medical services immediately—a 6-month-old infant with seizures requires urgent hospital evaluation regardless of seizure characteristics, as this age falls below the typical febrile seizure threshold and mandates investigation for serious underlying pathology. 1, 2, 3

Critical First Steps During Active Seizure

• Position the infant on their side in the recovery position to prevent aspiration if vomiting occurs 1, 2, 3
• Clear the area around the infant of any objects that could cause injury 1, 3
• Stay with the infant continuously to monitor for complications 1, 3
• Never restrain the infant during seizure movements, as this causes musculoskeletal injuries without stopping seizure activity 2, 3
• Never place anything in the mouth—no fingers, bite blocks, or tongue blades, as this causes dental trauma and airway obstruction 2, 3
• Do not give oral medications, food, or liquids during or immediately after the seizure due to aspiration risk 2, 3

Acute Seizure Termination (If Seizure Lasts >5 Minutes)

• Administer IV diazepam 0.2-0.5 mg/kg (maximum 5 mg) slowly over 2 minutes, OR lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) 4, 5
• If IV access is unavailable, rectal diazepam 0.5 mg/kg (maximum 20 mg) is effective 3, 6
• Seizures lasting >5 minutes represent status epilepticus and require emergency anticonvulsant medications 1, 5, 7

Critical Differential Diagnosis in a 6-Month-Old

This age group requires aggressive workup because febrile seizures by definition do not occur in infants <6 months, making serious pathology more likely. 1, 4

Life-Threatening Conditions to Rule Out Immediately

• Bacterial meningitis is the primary concern due to potential for permanent neurological damage and death if diagnosis is delayed 4
• Hypoglycemia must be assessed immediately with glucose oxidase strips in any seizing or unarousable infant 4
• Sepsis can present with seizures without direct CNS infection 4
• Hypoxic-ischemic injury accounts for 46-65% of neonatal seizures and should be considered with any perinatal complications 4, 8
• Intracranial hemorrhage from birth trauma or child abuse must be excluded 4
• Encephalitis (including HSV) can have devastating consequences and may present without clear meningeal signs 4

Mandatory Diagnostic Workup

Immediate Laboratory Studies

• Bedside glucose measurement with glucose oxidase strips—do this first if infant is still seizing or unarousable 4
• Lumbar puncture is mandatory in infants <12 months with seizures and fever unless CNS infection can be clinically ruled out 4
• Blood cultures for bacteremia 4
• Complete metabolic panel to assess for electrolyte imbalances (hyponatremia, hypocalcemia, hypomagnesemia) 4
• Urinalysis and urine culture since UTIs can cause fever and lower seizure threshold 4

Neuroimaging

• MRI with diffusion-weighted imaging is the most sensitive modality for detecting hypoxic-ischemic injury and cortical malformations 1, 4
• CT head without contrast has a limited but specific role for detecting hemorrhagic lesions in infants with birth trauma history, low hematocrit, or coagulopathy 1, 4
• Neuroimaging is recommended at all levels of care for infants presenting with epilepsy 6

EEG Evaluation

• Video-EEG analysis is beneficial for infants with abnormal movements whose routine EEG is not diagnostic 6
• EEG evaluation is useful if status epilepticus is suspected 7

Hospital Admission and Management

Hospital admission is required for complete evaluation of CNS infection, close observation, and empirical antimicrobial therapy if meningitis/sepsis is suspected pending culture results 4

Empirical Treatment Considerations

• Start empirical antibiotics immediately if bacterial meningitis cannot be ruled out—do not delay for LP if infant is unstable 4
• Phenobarbital remains the first-choice antiepileptic drug for confirmed or suspected seizures in this age group 8, 6
• Benzodiazepines are used for refractory cases 8
• Levetiracetam has strong evidence for focal seizures and weak evidence for generalized seizures in infants 6

Critical Pitfalls to Avoid

• Do not assume febrile seizures in a 6-month-old—this age is at the lower boundary and requires full septic workup 1, 4
• Do not give antipyretics (acetaminophen, ibuprofen) expecting them to stop seizures or prevent recurrence—they are ineffective for this purpose 2, 3, 6
• Do not delay lumbar puncture in infants <12 months unless there are clear contraindications 4
• Do not discharge without complete evaluation—three seizure episodes in one presentation suggests either status epilepticus or recurrent seizures without return to baseline, both requiring intensive investigation 1, 2

Prognosis and Follow-Up

• Mortality from status epilepticus in children ranges from 3-10%, with morbidity twice that rate 5
• Outcome depends on underlying etiology, age, rapidity of treatment, and adequacy of care 5
• Adherence to a time-framed protocol in the emergency department improves final outcome 5