Management of Seizures in Children
Immediate Seizure Management
For any active seizure lasting >5 minutes, administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) at 2 mg/min as first-line treatment. 1
Acute Intervention Steps:
- Position the child on their side, remove dangerous objects, and protect the head from injury 1
- Never restrain the patient or place anything in the mouth during active seizure activity 1
- Assess airway, breathing, and circulation immediately 1
- Activate emergency services for first-time seizures, seizures >5 minutes, multiple seizures without return to baseline, or seizures with breathing difficulties 2
Febrile Seizures: The Most Common Pediatric Seizure Disorder
Classification and Risk Stratification
Simple febrile seizures are defined as generalized seizures lasting <15 minutes, occurring once in 24 hours, in children 6-60 months with fever ≥100.4°F (38°C) without intracranial infection 1, 3
Complex febrile seizures have duration ≥15 minutes, focal features, or recurrence within 24 hours 1, 2
Diagnostic Evaluation: What to Do and What to Avoid
For simple febrile seizures, do NOT order routine neuroimaging, EEG, or laboratory tests - the only evaluation needed is to identify the fever source 1, 2
Critical age-specific exception: In children <12 months with febrile seizure, lumbar puncture is almost always indicated to exclude meningitis, as meningeal signs may be absent in up to one-third of cases 1, 3
For children with simple febrile seizures who are well-appearing:
- Focus on identifying fever source, particularly urinary tract infection (5-7% prevalence, higher in males) 3
- Obtain urine testing given the high UTI prevalence in this age group 3
- EEG is explicitly listed as an inappropriate investigation that should not be performed 1
For complex febrile seizures: Neuroimaging is generally NOT indicated unless specific concerning features exist (postictal focal deficits, febrile status epilepticus, suspected underlying pathology) 1, 2. Analysis of 161 children with complex febrile seizures showed head CT revealed no findings requiring intervention 2
Long-Term Management: The Evidence is Unequivocal
Do NOT prescribe continuous or intermittent anticonvulsant prophylaxis for children with simple febrile seizures - the potential toxicities clearly outweigh the minimal risks. 4, 1
This recommendation is based on high-quality randomized controlled trials and represents the strongest consensus in pediatric seizure management 1. The harm-benefit analysis clearly favors no treatment 1, 3.
Why Prophylaxis is Contraindicated:
- Rare fatal hepatotoxicity (especially in children <2 years, who are at greatest risk of febrile seizures)
- Thrombocytopenia
- Weight changes
- Gastrointestinal disturbances
- Pancreatitis
- Behavioral adverse effects in 20-40% of patients (hyperactivity, irritability, lethargy, sleep disturbances)
- Mean IQ reduction of 7 points during treatment, persisting 5.2 points lower even 6 months after discontinuation 1
- Hypersensitivity reactions
Intermittent diazepam risks: 1
- Lethargy, drowsiness, ataxia
- May mask evolving CNS infection
Carbamazepine and phenytoin are ineffective - studies show 47% recurrence with carbamazepine versus 10% with phenobarbital, and phenytoin shows no benefit even at therapeutic levels 4
The Role of Antipyretics: A Common Misconception
Antipyretics (acetaminophen, ibuprofen) do NOT prevent febrile seizures or reduce recurrence risk 4, 1, 3, 2. Use them only for the child's comfort and to prevent dehydration, not for seizure prevention 1, 3
Randomized controlled trials definitively showed that administering prophylactic acetaminophen during febrile episodes was ineffective in preventing fever or febrile seizure recurrence 4
Prognosis and Parent Education: Reassurance Based on Evidence
Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, neurocognitive function, or behavior 1
The risk of developing epilepsy is approximately 1% - identical to the general population 1. Even children with multiple simple febrile seizures, first seizure before 12 months, and family history of epilepsy have only 2.4% risk of developing epilepsy by age 25 1
Simple febrile seizures do not cause structural brain damage 1. Pre-existing neurological abnormalities predict epilepsy development, not the febrile seizures themselves 1
Recurrence Risk Counseling:
- Overall recurrence risk: ~30% 1, 3, 2
- Children <12 months at first seizure: ~50% recurrence probability 1, 3
- Children >12 months at first seizure: ~30% recurrence probability 1
- Of those with a second febrile seizure, 50% have at least one additional recurrence 1
Provide practical home management instructions: position child on side during seizure, do not place anything in mouth, seek emergency care if seizure lasts >5 minutes or child does not return to baseline 3
Epilepsy Management in Children
When to Initiate Antiepileptic Drug Therapy
Monotherapy is the preferred initial approach for epilepsy management 1. AED therapy leads to seizure freedom in about 70% of all children with epilepsy 5
AED initiation can be delayed until a second seizure in most children and may be avoided altogether in many children with self-limited childhood focal epilepsies 5
First-Line Medication Selection by Seizure Type
For partial/focal seizures: Oxcarbazepine, topiramate, or levetiracetam are recommended as first-line monotherapy 1, 5, 6
Levetiracetam is FDA-approved as adjunctive treatment for partial onset seizures in children from 1 month of age 7, 8. Dosing is initiated at 20 mg/kg/day in two divided doses, with adjustments in 20 mg/kg/day increments at 2-week intervals to target dose of 60 mg/kg/day 7
For absence seizures: Ethosuximide and valproic acid are superior to lamotrigine 5
For generalized epilepsies: Valproic acid remains the most effective drug for a broad range of seizure types 5
For epileptic spasms: Steroids and vigabatrin are the most effective treatment options 5
For myoclonic seizures in juvenile myoclonic epilepsy (≥12 years): Levetiracetam is effective, with target dose of 3000 mg/day given in 2 divided doses 7
Medication Efficacy Data
Levetiracetam studies demonstrate:
- 17.1% reduction in partial seizure frequency over placebo at 1000 mg/day 7
- 21.4% reduction at 2000 mg/day 7
- 23.0% reduction at 3000 mg/day 7
- In pediatric patients (4-16 years): 26.8% reduction in partial seizure frequency over placebo at 60 mg/kg/day 7
When to Refer to Pediatric Neurology
Refer to pediatric neurology if the first antiepileptic medication fails 1
Also refer for:
- Prolonged febrile seizures 1
- Repetitive focal febrile seizures 1
- Abnormal neurological exam or development 1
Ongoing Management Requirements
- Regular neurological assessment 1
- EEG monitoring 1
- Medication side effect surveillance 1
- When treatment with two or more AEDs fails, consider epilepsy surgery, vagal nerve stimulation, or dietary therapies 5
Discontinuation of Antiepileptic Drugs
After 2 years or more of seizure freedom, if recurrence risk is acceptable, slow weaning of AEDs should occur over 6 weeks or longer 5. After discontinuation, about 70% of patients remain seizure free, and of those with recurrence, the majority achieve seizure control with restarting an AED 5
Critical Pitfalls to Avoid
Never prescribe prophylactic anticonvulsants for simple febrile seizures - this is the most common error and directly contradicts AAP guidelines 1
Do not tell parents that antipyretics prevent seizures - this creates false expectations and is not evidence-based 4, 1, 2
Do not order routine neuroimaging or EEG for simple febrile seizures - these are explicitly inappropriate investigations 1, 2
Do not miss meningitis in infants <12 months - maintain a low threshold for lumbar puncture in this age group 1, 3
If phenobarbital was inappropriately started for simple febrile seizures, taper and discontinue it - it provides no benefit in preventing epilepsy development and causes cognitive impairment 1
Avoid carbamazepine for febrile seizure prophylaxis - it is ineffective and may increase recurrence rates 4