Injectable Levetiracetam Dosing for Pediatric Patients
For status epilepticus in children, administer levetiracetam 30-40 mg/kg IV as a loading dose (maximum 2500-3000 mg), given over 5-15 minutes, followed by maintenance dosing of 30 mg/kg IV every 12 hours for convulsive status epilepticus or 15 mg/kg IV every 12 hours for non-convulsive status epilepticus.
Loading Dose for Status Epilepticus
The recommended loading dose is 30-40 mg/kg IV (maximum 2500-3000 mg) administered over 5-15 minutes 1, 2. This higher dosing range is critical because:
- 30 mg/kg achieves 68-73% efficacy in benzodiazepine-refractory status epilepticus 1, 2
- Lower doses of 20 mg/kg show significantly reduced efficacy (38-67%) and should not be used as first-line 2
- Doses up to 60 mg/kg have been safely tolerated in pediatric patients without serious adverse events 2, 3, 4
Administration Rate
- Administer over 5-15 minutes 1, 2, 5
- Rapid IV push (over 5 minutes) of undiluted levetiracetam (100 mg/mL) is safe in children and reduces time to medication delivery 6, 4
- Undiluted administration reduces time to drug delivery by approximately 27 minutes compared to diluted infusions (23 min vs 50 min) 6
Maintenance Dosing After Status Epilepticus
Convulsive Status Epilepticus
- 30 mg/kg IV every 12 hours (maximum 1500 mg per dose) 1
- Alternative: Increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours 1
Non-Convulsive Status Epilepticus
- 15 mg/kg IV every 12 hours (maximum 1500 mg per dose) 1
Age-Specific Considerations
Children require 30-40% higher weight-normalized doses than adults due to increased clearance 3. The pharmacokinetic data show:
- Apparent body clearance in children is 1.43 ± 0.36 ml/min/kg, approximately 30-40% higher than adults 3
- Half-life in children is 6.0 ± 1.1 hours (shorter than adults) 3
- Daily maintenance dosing should be 130-140% of adult weight-normalized doses 3
Safety Profile and Monitoring
Levetiracetam has minimal cardiovascular effects with approximately 0.7% hypotension risk and 20% intubation rate, making it safer than alternatives like fosphenytoin (12% hypotension, 26.4% intubation) 1. Common adverse effects include:
- Sleepiness, fatigue, and restlessness (minor and transient) 5
- Rarely: nausea or transient transaminitis 2
- No serious adverse reactions reported in pediatric safety studies 5, 6, 4
Critical Monitoring Parameters
- Monitor vital signs every 15 minutes during infusion and for 2 hours post-infusion 2
- Continue monitoring every 30 minutes for hours 2-8, then hourly until 24 hours 2
- Focus on seizure activity, blood pressure, and neurological status 2
- Continuous oxygen saturation monitoring with supplemental oxygen available 1
Practical Implementation
Undiluted levetiracetam (100 mg/mL) given as IV push over 5 minutes is the preferred method because:
- Similar adverse event incidence compared to diluted infusions (5.5% vs 7.5%) 6
- Significantly faster administration (median 18 min vs 36.5 min to drug delivery in status epilepticus) 4
- Reduces drug waste by 39% (18.7% undiluted vs 57.6% diluted) 4
- Safe for doses up to 4500 mg in pediatric patients 4
Renal Dose Adjustments
Adjust dosing based on creatinine clearance 1:
| CrCl | Dose | Frequency |
|---|---|---|
| >80 mL/min | 500-1500 mg | Every 12 hours |
| 50-80 mL/min | 500-1000 mg | Every 12 hours |
| 30-50 mL/min | 250-750 mg | Every 12 hours |
| <30 mL/min | 250-500 mg | Every 12 hours |
Common Pitfalls to Avoid
- Do not use 20 mg/kg loading doses—this achieves only 38% efficacy and is inadequate for status epilepticus 2
- Do not delay administration for dilution—undiluted IV push is equally safe and significantly faster 6, 4
- Do not skip loading dose in status epilepticus—maintenance dosing alone is insufficient for acute seizure control 1
- Do not underdose based on adult weight-normalized dosing—children require 30-40% higher mg/kg doses 3