Management of Pediatric Seizure Disorders

Initial Assessment and Classification

The American Academy of Pediatrics recommends determining if the seizure is febrile (occurring in children 6-60 months with fever) or afebrile, and further classify febrile seizures as simple or complex 1, 2
For febrile seizures, classification as simple (brief <15 minutes, generalized, occurring once in 24 hours) or complex (>15 minutes, focal, or multiple in 24 hours) is recommended 1, 2

The American College of Emergency Physicians recommends emergent neuroimaging for patients with postictal focal deficit, altered mental status, or signs of increased intracranial pressure, and MRI is preferred over CT when neuroimaging is indicated 3
Routine neuroimaging is not necessary for simple febrile seizures, as recommended by the American Academy of Pediatrics 1, 2
EEG is recommended as part of the neurodiagnostic evaluation for first unprovoked seizure, according to the American College of Emergency Physicians 3

The American Academy of Pediatrics recommends ensuring patient safety during active seizures, including positioning the patient on their side, removing harmful objects, and protecting the head from injury 4, 5
For seizures lasting >5 minutes (Status Epilepticus), the American Academy of Pediatrics recommends first-line treatment with benzodiazepines, such as lorazepam 0.05-0.1 mg/kg IV (max 4 mg) 4
Valproic acid 20-40 mg/kg IV (max 3000 mg) is recommended as a second-line treatment for status epilepticus, according to the American Academy of Pediatrics 2

The American Academy of Pediatrics recommends monotherapy as the preferred initial approach for epilepsy management, with medications such as oxcarbazepine and topiramate 5
Regular neurological assessment, EEG monitoring, and monitoring for medication side effects are recommended for follow-up care, according to the American Academy of Pediatrics 5
Referral to a pediatric neurologist is recommended for medication management if the first medication fails, as suggested by the American Academy of Pediatrics 5

The American Academy of Pediatrics recommends considering syndrome-specific protocols for seizures associated with specific syndromes, such as cardio-facio-cutaneous syndrome 5
Prophylaxis with levetiracetam (10 mg/kg, max 500 mg per dose) every 12 hours for 30 days is recommended for patients receiving CAR T-cell therapy with seizure risk, according to the American Academy of Pediatrics 4

Regular follow-up with a neurologist for ongoing seizure management is recommended, according to the American Academy of Pediatrics 5
Early intervention services for developmental support and speech, physical, and occupational therapy as needed are recommended, as suggested by the American Academy of Pediatrics 5

The American Academy of Neurology recommends levetiracetam, fosphenytoin, and valproate as equivalent options for status epilepticus, with seizure cessation rates of 47%, 45%, and 46% respectively 6

The ESETT trial demonstrated no significant difference between levetiracetam, fosphenytoin, and valproate for status epilepticus, with seizure cessation rates of 47%, 45%, and 46% respectively 6