What is the recommended treatment for convulsions in a 6-12 month old, 6 kg infant with LEVITERACETAM (Levetiracetam)?

Management of Convulsions in a 6 kg Infant with Levetiracetam

For acute convulsions in a 6 kg infant, administer levetiracetam 40 mg/kg IV (240 mg total) as a loading dose over 5 minutes, followed by maintenance dosing of 30 mg/kg IV every 12 hours (180 mg every 12 hours) for convulsive seizures. 1, 2

Immediate Treatment Protocol

First-Line Benzodiazepine Therapy

• Administer lorazepam 0.1 mg/kg IV (0.6 mg for this 6 kg infant) immediately for any actively seizing infant, which can be repeated after at least 1 minute up to a maximum of 2 doses 1, 3
• If IV access is challenging, consider intramuscular midazolam 0.2 mg/kg (1.2 mg for this infant) 1
• Have airway equipment immediately available, as respiratory depression can occur with benzodiazepines 1

Second-Line Levetiracetam Therapy

If seizures persist after adequate benzodiazepine dosing, immediately escalate to levetiracetam:

• Loading dose: 40 mg/kg IV (240 mg for this 6 kg infant) administered over 5 minutes 1, 2
• This loading dose should be given in addition to the maintenance dose, not instead of it 1
• Levetiracetam demonstrates 68-73% efficacy in benzodiazepine-refractory status epilepticus with minimal cardiovascular effects 3

Maintenance Dosing Strategy

After seizure control is achieved:

• For convulsive status epilepticus: 30 mg/kg IV every 12 hours (180 mg every 12 hours for this 6 kg infant), maximum 1,500 mg per dose 1, 3, 2
• For non-convulsive status epilepticus: 15 mg/kg IV every 12 hours (90 mg every 12 hours), maximum 1,500 mg per dose 1, 3
• Continue maintenance dosing for at least 3 doses after seizure termination 2

Critical Monitoring Requirements

During acute treatment:

• Continuous oxygen saturation monitoring with supplemental oxygen available 1
• Assess circulation, airway, and breathing continuously 1
• Check blood glucose immediately, as hypoglycemia is a rapidly reversible cause of seizures 3
• Monitor for respiratory depression, particularly when combining benzodiazepines with other anticonvulsants 1

Refractory Seizure Management

If seizures persist despite benzodiazepines and levetiracetam:

• Transfer to pediatric intensive care unit 1
• Add phenobarbital 10-20 mg/kg IV over 10 minutes (60-120 mg for this 6 kg infant), maximum 1,000 mg 1, 3
• Administer corticosteroids as indicated 1
• Consider continuous EEG monitoring if seizures are refractory 1

For super-refractory status epilepticus:

• Midazolam infusion: 0.15-0.20 mg/kg IV load (0.9-1.2 mg for this infant), then 1 mg/kg/min continuous infusion, titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 3

High-Dose Levetiracetam Considerations

If standard dosing fails to control seizures:

• Escalation to 80-100 mg/kg/day (480-600 mg/day divided every 12 hours for this 6 kg infant) may be considered 4
• High-dose levetiracetam (up to 275 mg/kg/day) has been shown to be well-tolerated in pediatric patients, with 44% achieving >50% seizure reduction 5
• In neonates not responding to standard doses, incremental increases to 80-100 mg/kg/day achieved complete seizure cessation in 4 out of 5 patients when used in combination therapy 4
• No adverse effects were noted with high-dose regimens in neonatal studies 4

Alternative Formulation for Resource-Limited Settings

If IV levetiracetam is unavailable:

• Crushed immediate-release levetiracetam tablets (diluted in saline) can be administered orally or via nasogastric tube 6
• This formulation demonstrated comparable pharmacokinetics to IV preparations, with 90% seizure termination by day 3 and 100% by day 4 in neonates 6
• No pharmacokinetic differences were observed between oral versus nasogastric administration 6

Safety Profile and Adverse Effects

Levetiracetam has a favorable safety profile in infants:

• Minimal cardiovascular effects with no significant hypotension risk (0% compared to 12% with phenytoin) 3
• No requirement for cardiac monitoring during administration 3
• Most common adverse effects in pediatric populations include irritability (67%), hyperactivity (8%), and somnolence (6%) 7
• Behavioral adverse effects occurred in only 12% of pediatric patients receiving high doses 5

Common Pitfalls to Avoid

• Do not underdose in status epilepticus—use the full 40 mg/kg loading dose rather than lower prophylactic doses of 10 mg/kg 2
• Do not skip second-line agents—levetiracetam should be administered immediately after adequate benzodiazepine therapy, not delayed for neuroimaging 3
• Do not use neuromuscular blockers alone, as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 3
• Do not attribute altered mental status solely to post-ictal state—obtain urgent EEG if the infant does not awaken within expected timeframe, as nonconvulsive status epilepticus occurs in >50% of cases 3

Simultaneous Evaluation for Underlying Causes

While administering anticonvulsant therapy, search for and treat reversible causes:

• Hypoglycemia (check fingerstick glucose immediately) 3
• Hyponatremia 3
• Hypoxia 3
• CNS infection (consider lumbar puncture if infant is <12 months old, systemically ill, or has signs of meningism) 1
• Drug toxicity or withdrawal syndromes 3