How to manage a 3-year-old child with developmental delay and a seizure disorder who has developed vomiting and breakthrough seizures?

Management of a 3-Year-Old with Developmental Delay, Seizure Disorder, Vomiting, and Breakthrough Seizures

Activate emergency medical services immediately and administer benzodiazepines for active seizures, then investigate for acute precipitants including infection, metabolic derangements, and medication non-adherence while avoiding valproate due to this child's high-risk profile.

Immediate Emergency Actions

Seizure Management

• Position the child on their side in the recovery position to reduce aspiration risk, especially critical given the vomiting 1
• Administer lorazepam 0.1 mg/kg IV/IO (maximum 4 mg) slowly at 2 mg/min if seizures are ongoing 2
• If seizures persist after lorazepam, give levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) as a slow infusion over 5-10 minutes 2
• Alternatively, phenobarbital 15-20 mg/kg IV loading dose (maximum 1,000 mg) can be used as second-line therapy 2
• Activate EMS if seizures last >5 minutes, if multiple seizures occur without return to baseline, or if the child does not return to baseline within 5-10 minutes after seizure cessation 1, 2

Supportive Care

• Ensure high-flow oxygen to maintain adequate oxygenation and prevent hypoxia 2
• Check blood glucose immediately using point-of-care testing to rule out hypoglycemia 2
• Monitor oxygen saturation continuously 2
• Assess neurological status using AVPU scale or pediatric Glasgow Coma Scale 2
• Check pupillary size and reaction for signs of raised intracranial pressure 2

Critical Diagnostic Evaluation

Rule Out Acute Precipitants

Infection Assessment:

• Perform lumbar puncture if there is concern for meningitis or encephalitis, particularly if the child has meningismus, excessive drowsiness, or incomplete recovery within 1 hour 2, 3
• This is especially important given the vomiting, which could indicate CNS infection 1
• Check for fever and treat with acetaminophen for comfort, though this will not prevent seizure recurrence 1

Metabolic Evaluation:

• Order laboratory tests selectively based on clinical circumstances: electrolytes (sodium, calcium, magnesium), glucose, and liver function tests 1, 3
• Vomiting increases risk for dehydration and electrolyte abnormalities that can lower seizure threshold 1
• Ensure adequate hydration and correct any electrolyte abnormalities identified 1

Medication Review:

• Verify antiepileptic drug (AED) adherence and check serum drug levels if applicable 4
• Vomiting may have prevented adequate absorption of maintenance AEDs, precipitating breakthrough seizures 4
• Review for recent medication changes or drug interactions, particularly with carbapenem antibiotics which can reduce valproate levels to subtherapeutic ranges 5

Neuroimaging Considerations

• Perform emergent neuroimaging (CT or MRI) if the child exhibits a postictal focal deficit that does not quickly resolve or has not returned to baseline within several hours 3
• MRI is the preferred modality when neuroimaging is obtained 3
• Given the developmental delay, consider non-urgent MRI if not previously performed to evaluate for structural abnormalities or malformations of cortical development 3

Antiemetic Management

For Ongoing Vomiting:

• Administer ondansetron (oral or IV) as first-line antiemetic 1
• Consider adding dexamethasone 4 mg if vomiting persists, though effect is modest 1
• Use rectal or intravenous routes if oral administration is not feasible due to ongoing vomiting 1
• Metoclopramide or haloperidol can be used as alternative agents from different drug classes 1
• Ensure adequate hydration and assess for electrolyte abnormalities 1

Long-Term AED Adjustment Considerations

Critical Warning About Valproate

This child is at extremely high risk for fatal hepatotoxicity from valproate and should NOT receive this medication 5. Children under age 2 years with developmental delay, severe seizure disorders accompanied by mental retardation, and those on multiple anticonvulsants have considerably increased risk of developing fatal hepatotoxicity 5. If valproate is currently prescribed, consult neurology urgently about alternative agents 5.

Safer AED Options for This Population

• Levetiracetam is effective for focal seizures with strong evidence and has favorable cognitive/behavioral profile 6
• Children with developmental disabilities experience antiepileptic drug cognitive and behavioral adverse effects more frequently, requiring careful medication selection 7
• Phenobarbital is highly effective in young children, particularly those <32 weeks gestation at birth, controlling 77% of neonatal seizures 2

Disposition and Follow-Up

Admission Criteria

• Admit if seizures are prolonged, multiple without return to baseline, or if the child has not returned to baseline mental status 1
• Admit if metabolic abnormalities require correction or if CNS infection is suspected 1
• Admit if vomiting prevents oral medication administration and IV AED loading is required 1

Outpatient Management (if stable)

• Discharge only if the child has returned to baseline, has normal neurologic examination, vomiting is controlled, and no concerning features exist 8
• Schedule urgent neurology follow-up within 24-48 hours to reassess AED regimen 4
• Ensure the primary care physician and neurologist are notified of all ED visit details 4
• Provide clear instructions about when to return (seizure >5 minutes, recurrent seizures, persistent vomiting, altered mental status) 1

Common Pitfalls to Avoid

• Do not assume vomiting is unrelated to seizures—it may indicate increased intracranial pressure, CNS infection, or metabolic derangement requiring urgent evaluation 1
• Do not use or continue valproate in this high-risk child (age 3, developmental delay, seizure disorder) due to extreme risk of fatal hepatotoxicity 5
• Do not delay lumbar puncture if CNS infection is suspected—developmental delay does not exclude meningitis/encephalitis 2, 3
• Do not assume breakthrough seizures are simply due to "epilepsy"—actively search for acute precipitants including infection, metabolic abnormalities, and medication issues 1, 4
• Do not discharge without ensuring vomiting is controlled and oral medications can be tolerated, as this will perpetuate the cycle of inadequate AED levels and breakthrough seizures 1, 4