What is the recommended acute and long‑term management for a child presenting with a seizure?

Management of Seizures in Children

Acute Management of Active Seizures

For any child with a seizure lasting more than 5 minutes, immediately administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min as first-line treatment. 1

Immediate Safety Measures

• Position the child on their side in the recovery position, help them to the ground if still standing, clear the area of harmful objects, and protect the head from injury 2, 1
• Stay with the child throughout the seizure and do not restrain them 2
• Never place anything in the mouth or give food, liquids, or oral medications during the seizure or immediately after when responsiveness is decreased 2

When to Activate Emergency Medical Services

Activate EMS immediately for: 2

• First-time seizure in any child
• Seizure lasting >5 minutes
• Multiple seizures without return to baseline between episodes
• Seizure in an infant <6 months of age
• Seizure in water, with traumatic injury, difficulty breathing, or choking
• Child does not return to baseline within 5-10 minutes after seizure stops

Escalation for Prolonged Seizures (Status Epilepticus)

If seizures persist after initial lorazepam dose(s): 1

• Second-line: Administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) concurrently with benzodiazepine protocol
• Third-line: If still refractory, add phenobarbital IV loading dose 10-20 mg/kg (maximum 1,000 mg)
• Transfer promptly to pediatric intensive care unit and initiate continuous EEG monitoring 1

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Febrile Seizures: Specific Management

Definition and Classification

Simple febrile seizures are generalized seizures lasting <15 minutes, occurring once in 24 hours, in febrile children (temperature ≥38°C/100.4°F) aged 6-60 months without intracranial infection. 1, 3 Complex febrile seizures last ≥15 minutes, have focal features, or recur within 24 hours. 1

Critical Management Principle

Do NOT prescribe continuous or intermittent anticonvulsant prophylaxis (including phenobarbital, valproic acid, diazepam, or clobazam) for children with simple febrile seizures—the potential toxicities clearly outweigh the minimal risks. 1, 3 This is a Class 1, Level B recommendation based on randomized controlled trials. 1

Why No Prophylaxis?

• Simple febrile seizures cause no structural brain damage, no decline in IQ, academic performance, or neurocognitive function 1, 3
• Risk of developing epilepsy is approximately 1% (identical to general population); even high-risk children have only 2.4% risk by age 25 1, 3
• Anticonvulsant prophylaxis does not prevent epilepsy development 1
• Medications carry significant risks: valproic acid causes rare fatal hepatotoxicity; phenobarbital causes hyperactivity, irritability, and mean IQ reduction of 7 points during treatment; diazepam causes lethargy and may mask evolving CNS infection 1

Role of Antipyretics

Antipyretics (acetaminophen, ibuprofen, paracetamol) do NOT prevent febrile seizures or reduce recurrence risk—use them only for comfort and to prevent dehydration, not for seizure prevention. 2, 1, 3 This is a Class 3: No Benefit recommendation. 2

Diagnostic Evaluation for Febrile Seizures

• No routine neuroimaging, EEG, or laboratory tests are indicated for simple febrile seizures 1, 3
• Evaluation should focus on identifying the source of fever 1
• For infants <12 months with fever and seizure, strongly consider lumbar puncture because meningeal signs may be absent in up to one-third of meningitis cases 1
• For complex febrile seizures, neuroimaging may be considered only when postictal focal neurological deficits are present, underlying pathology is suspected, or febrile status epilepticus occurred 1

Parent Education and Prognosis

Counsel parents that: 1, 3

• Simple febrile seizures are benign with excellent prognosis
• Recurrence risk is approximately 30% overall; 50% in children <12 months at first seizure, 30% in those >12 months
• No long-term adverse effects on development, intelligence, or behavior
• Risk of epilepsy is extremely low and not prevented by medication

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Afebrile (Unprovoked) Seizures: Long-Term Management

Initial Evaluation

For a child ≥6 months with a first afebrile seizure who returns to neurologic baseline: 4

• Assess for return to baseline—this is the critical decision point
• Check serum glucose and sodium 2
• Obtain pregnancy test if female of childbearing age 2
• EEG during wakefulness and sleep is recommended 5

Neuroimaging Decisions

Emergent neuroimaging is NOT required for well-appearing children who return to baseline after a first unprovoked seizure. 4 Defer imaging to outpatient settings when the child: 4

• Is ≥6 months old
• Has no high-risk historical features
• Has normal neurologic examination
• Returns to neurologic baseline

Perform emergent neuroimaging when: 4

• Status epilepticus presentation
• Failure to return to neurologic baseline
• Neurologic deficits on examination
• Predisposing conditions (immunocompromise, malignancy, head trauma, anticoagulation)

For focal seizures or status epilepticus, MRI is the preferred imaging modality. 5

Disposition

• Admit children who have not returned to baseline, have concerning neurologic findings, or require ongoing seizure management 4
• Well-appearing children who return to baseline may be discharged with close outpatient follow-up 4

Antiepileptic Drug Initiation

Prophylactic anticonvulsant therapy is NOT recommended after a first afebrile seizure. 4 Most children will have only a single seizure. 5

If epilepsy is diagnosed after appropriate evaluation (typically requiring ≥2 unprovoked seizures): 1, 4

• Monotherapy is the preferred initial approach using levetiracetam, oxcarbazepine, or topiramate
• Refer to pediatric neurology if the first antiepileptic medication fails
• Regular neurological assessment, EEG monitoring, and medication side effect surveillance are essential

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Special Considerations

Distinguishing Seizure Types

• Febrile seizures are generalized tonic-clonic with fever, followed by postictal drowsiness 1, 3
• Absence seizures present as brief staring spells (seconds) with impaired awareness, eye blinking, or lip smacking, WITHOUT fever and WITHOUT postictal confusion 1, 3
• If a child exhibits staring episodes during fever, evaluate for absence epilepsy or CNS infection rather than dismissing as febrile seizure—obtain EEG to identify typical 2.5-4 Hz spike-wave pattern 1

Neonatal Seizures

For neonates with seizures: 6

• Phenobarbital should be first-line ASM regardless of etiology (unless channelopathy suspected, then use phenytoin or carbamazepine)
• Second-line options include phenytoin, levetiracetam, midazolam, or lidocaine
• Discontinue ASMs before discharge if acute provoked seizures have ceased without evidence of neonatal-onset epilepsy

Stroke Patients

In children with acute stroke: 2

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting
• A single self-limiting seizure within 24 hours of ischemic stroke should NOT be treated with long-term anticonvulsants
• Prophylactic anticonvulsants are not recommended and may negatively affect neurological recovery

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Common Pitfalls to Avoid

1. Do not prescribe prophylactic anticonvulsants for simple febrile seizures—this is explicitly contraindicated by high-quality evidence 1, 3

2. Do not rely on antipyretics to prevent febrile seizures—they provide comfort but have no effect on seizure occurrence 2, 1, 3

3. Do not routinely image children with simple febrile seizures—imaging findings do not alter management 1, 3

4. Do not start long-term anticonvulsants after a single afebrile seizure—wait for epilepsy diagnosis 4

5. Do not restrain or place objects in the mouth during seizures—this causes harm 2, 1

6. Do not dismiss staring spells during fever as febrile seizures—evaluate for absence epilepsy 1