What is the appropriate management for an infant experiencing a seizure?

Management of Infant Seizures

For an infant experiencing a seizure, immediately ensure airway protection and oxygenation, activate emergency medical services (EMS) for any seizure in an infant <6 months of age, and administer lorazepam 0.1 mg/kg IV/IO as first-line treatment if the seizure is active, followed by levetiracetam or phenobarbital if seizures persist. 1, 2, 3

Immediate Stabilization and Emergency Activation

Activate EMS immediately for any seizure in an infant <6 months of age, as this represents a critical indication requiring emergency evaluation regardless of seizure duration or characteristics. 1 Additional reasons to activate EMS include seizures lasting >5 minutes, multiple seizures without return to baseline, seizures with traumatic injuries or difficulty breathing, or failure to return to baseline within 5-10 minutes after seizure cessation. 1

Critical First Actions

• Position the infant on their side in the recovery position to reduce aspiration risk if vomiting occurs during or after the seizure. 1, 2
• Ensure high-flow oxygen is administered to maintain adequate oxygenation and prevent hypoxia. 2
• Check blood glucose immediately using point-of-care testing to rule out hypoglycemia as the underlying cause. 2, 4
• Maintain a patent airway by positioning the baby in a "sniffing" position and having airway equipment immediately available. 2, 3
• Maintain normal body temperature using a radiant heat source, avoiding both hypothermia and hyperthermia. 2

Critical Pitfalls to Avoid

• Never restrain the infant during seizure activity. 1
• Never place anything in the infant's mouth during or immediately after the seizure. 1, 2
• Never give oral medications, food, or liquids to an infant experiencing a seizure or with decreased responsiveness post-seizure. 1

Acute Seizure Management Protocol

First-Line Treatment

• Establish IV or intraosseous access immediately to facilitate medication administration. 2
• Administer lorazepam 0.1 mg/kg IV/IO (maximum 4 mg) given slowly at 2 mg/min for active seizures. 2, 3
• If seizures persist after 5 minutes, repeat lorazepam 0.1 mg/kg (maximum of 2 doses total). 2, 3

Second-Line Treatment

• Administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) as a slow infusion over 5-10 minutes if seizures continue after lorazepam. 2, 5
• Alternatively, administer phenobarbital 15-20 mg/kg IV loading dose (maximum 1,000 mg), which achieves therapeutic levels within minutes and controls 77% of neonatal seizures. 2, 4, 5

The choice between levetiracetam and phenobarbital as second-line depends on clinical context. Phenobarbital remains the evidence-based first choice for neonatal seizures (age 0-29 days) per ILAE guidelines 5, while levetiracetam has strong evidence for focal seizures in older infants and may be preferred if cardiac disorders are present. 6, 5

Maintenance Therapy After Seizure Control

• Lorazepam 0.05 mg/kg IV every 8 hours for 3 doses to prevent recurrence. 2
• Levetiracetam 15 mg/kg IV every 12 hours for ongoing seizure control. 2
• Phenobarbital 1-3 mg/kg IV every 12 hours if used as second-line agent. 2

Age-Specific Diagnostic Considerations

Neonates (0-29 days)

The most common cause is hypoxic-ischemic encephalopathy (46-65% of cases), with 90% of HIE-related seizures occurring within the first 2 days of life. 1, 4 Other etiologies include intracranial hemorrhage (10-12%), perinatal stroke, infection, metabolic disorders, and genetic conditions. 1, 4

Diagnostic workup for neonates:

• Perform head ultrasound immediately if the infant is unstable or MRI unavailable, which identifies intraventricular hemorrhage, hydrocephalus, and white matter changes in 38% of cases. 1, 4
• Obtain MRI with diffusion-weighted imaging when stable, as this identifies the etiology in 39.8% more cases than ultrasound alone and is most sensitive for hypoxic-ischemic injury. 1, 4
• Check blood glucose, calcium, magnesium, and sodium immediately, as metabolic derangements must be corrected urgently. 2, 4
• Perform lumbar puncture if meningism is present, after complex seizures, or if the infant is excessively drowsy or systemically ill—but never in comatose infants due to herniation risk. 2, 4

Infants 1-12 Months

For infants with febrile seizures (fever ≥38.0°C), lumbar puncture is almost always indicated in those <12 months of age to exclude meningitis, particularly if there are signs of meningismus, complex seizure features, excessive drowsiness, or incomplete recovery within 1 hour. 7, 4

For febrile seizures specifically:

• Treat fever with acetaminophen for comfort and to prevent dehydration, but understand this does not prevent seizure recurrence. 1, 7
• Do not initiate continuous or intermittent anticonvulsant therapy for simple febrile seizures, as there is Class 1 evidence showing no benefit. 1, 6
• Obtain urine testing given the high prevalence (5-7%) of urinary tract infection as the source of fever in this age group. 7

Ongoing Monitoring and Specialized Care

• Monitor oxygen saturation continuously to ensure adequate oxygenation. 2
• Assess neurological status using the AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) or pediatric Glasgow Coma Scale. 2
• Check pupillary size and reaction, as unilateral sluggish or absent responses are the most reliable signs of raised intracranial pressure. 4
• Consider elective intubation if the infant remains unconscious (Glasgow Coma Score ≤8) to ensure adequate ventilation. 2

When to Consult Pediatric Neurology

• After failure of one antiseizure medication at the standard care level, or optimally after any first seizure presentation. 6
• For suspected infantile spasms or epileptic encephalopathies, where rapid drug introduction and dose escalation are required. 6
• If considering epilepsy surgery candidacy, which should be part of standard practice even at primary care level. 6

Special Considerations

For suspected channelopathies (e.g., family history of genetic epilepsy), use phenytoin or carbamazepine instead of phenobarbital as first-line treatment. 5

For withdrawal-associated seizures (maternal substance use), pharmacologic therapy is indicated with oral morphine solution or methadone, though other causes must still be evaluated. 4

For vitamin B6-dependent epilepsy, attempt a trial of pyridoxine in neonates with seizures unresponsive to second-line medications. 5

Premature infants <32 weeks gestation respond significantly better to phenobarbital than term infants. 4