Managing Pediatric Seizures

Required Documents

• Detailed event description (from witness/caregiver)
• Vital signs including temperature at time of event
• Neurologic examination findings
• EEG results (if previously obtained)
• Neuroimaging results (MRI preferred over CT for epilepsy workup)
• Current anticonvulsant levels (if applicable)
• Developmental history

Step 1 — Seizure Classification (ILAE 2017)

Level 1: Seizure Type

Level 2: Epilepsy Type

• Focal epilepsy
• Generalized epilepsy
• Combined generalized and focal epilepsy
• Unknown

Level 3: Epilepsy Syndrome

Match age of onset and seizure semiology to recognized syndromes (see Step 2).

Step 2 — Common Pediatric Epilepsy Syndromes

Age-Based Syndrome Recognition

Medications to AVOID by Syndrome

Step 3 — Febrile Seizures (Special Category)

Simple Febrile Seizure

• Age 6 months to 5 years
• Generalized tonic-clonic, duration < 15 minutes, does not recur within 24 hours
• Temperature ≥ 38°C (100.4°F)
• Normal neurologic exam after postictal period resolves
• Management: no workup needed (no EEG, no imaging, no labs routinely); reassurance and antipyretic education

Complex Febrile Seizure

• Focal features, duration > 15 minutes, recurrence within 24 hours, or abnormal postictal exam
• Warrants: LP consideration (especially < 12 months or if meningitis suspected), EEG, possible MRI

AAP Febrile Seizure Guidance

• EEG is NOT recommended after a simple febrile seizure (does not predict recurrence or epilepsy risk)
• LP: perform if < 12 months with incomplete Hib/PCV vaccination; strongly consider if 12-18 months; consider if > 18 months with meningeal signs
• Daily anticonvulsant prophylaxis is NOT recommended for simple febrile seizures
• Recurrence risk: approximately 30% after first febrile seizure; risk factors: age < 18 months, lower temperature at seizure onset, family history

Step 4 — Acute Seizure / Status Epilepticus Protocol

Definition

• Status epilepticus: seizure lasting > 5 minutes, or ≥ 2 seizures without return to baseline between episodes

Timed Protocol (Aligned with AES/NCS Guidelines)

Step 5 — Chronic Anticonvulsant Selection and Monitoring

First-Line Agents by Seizure Type

Monitoring Requirements

• Drug levels: phenytoin, phenobarbital, valproate, carbamazepine (others rarely needed)
• CBC and LFTs at baseline and periodically for VPA, carbamazepine, phenytoin
• VPA: monitor ammonia if lethargy develops; check for polycystic ovarian syndrome in adolescent females
• Lamotrigine: titrate slowly (risk of Stevens-Johnson syndrome; increased risk with VPA co-therapy)
• Levetiracetam: monitor for behavioral side effects (irritability, aggression) — common in children

Discontinuation Criteria

• Consider discontinuation after 2 years seizure-free (most syndromes)
• EEG before taper: normal EEG supports successful withdrawal
• BECTS: may remit by mid-teens; trial off medication reasonable
• JME: lifelong treatment typically required (high relapse rate off medication)

Step 6 — Diagnostic Workup

EEG

• Obtain routine EEG for all new-onset unprovoked seizures (except simple febrile seizures)
• Sleep-deprived EEG increases yield for generalized epilepsies (JME, CAE)
• Prolonged EEG monitoring (24-72 hours) for: frequent events, diagnostic uncertainty, pre-surgical evaluation

Neuroimaging

• MRI brain (epilepsy protocol with thin coronal cuts through hippocampi) for: focal seizures, abnormal neurologic exam, developmental delay, age < 1 year, refractory epilepsy
• CT: only for acute presentations where MRI not immediately available (trauma, stroke, hemorrhage concern)
• MRI NOT routinely needed for: simple febrile seizures, typical CAE with classic EEG, typical BECTS

Laboratory

• Glucose (at time of seizure)
• Electrolytes (sodium, calcium, magnesium) for first seizure
• Toxicology screen if suspicion for ingestion
• Genetic testing: epilepsy gene panels for refractory epilepsy, infantile-onset seizures, or syndromic features

Checkpoint B — Seizure Management Review

• Seizure described in detail with duration, semiology, and postictal state
• ILAE classification applied: seizure type → epilepsy type → syndrome (if identifiable)
• Febrile seizure classified as simple or complex (if applicable)
• EEG obtained or scheduled (with rationale if deferred)
• MRI obtained or scheduled (with rationale if deferred)
• Anticonvulsant selected appropriate for seizure type/syndrome
• Medications to avoid for this syndrome identified and documented
• Drug levels and labs current
• Seizure action plan provided (school, home, emergency)
• Driving/activity restrictions discussed (if adolescent)
• Rescue medication prescribed (rectal diazepam or intranasal midazolam) with training
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow ILAE 2017 Classification of Seizures and Epilepsies for terminology and classification
• Apply AAP 2011 guideline for simple febrile seizures (no routine EEG, imaging, or labs)
• Follow AES/NCS 2016 guidelines for status epilepticus treatment protocol
• SANAD II trial data: ethosuximide first-line for childhood absence; lamotrigine and valproate as alternatives
• Infantile spasms: follow ICISS/UKISS protocols (ACTH vs. vigabatrin)
• Dravet syndrome: avoid sodium-channel blockers per ILAE recommendation
• Valproate: FDA teratogenicity warning — avoid in females of childbearing potential when alternatives exist
• Lamotrigine: follow slow titration schedule (slower with VPA co-therapy) to reduce SJS risk
• Epilepsy surgery: refer to comprehensive epilepsy center if 2 appropriate medications fail (drug-resistant epilepsy per ILAE definition)
• Ketogenic diet: effective for drug-resistant epilepsy, particularly Lennox-Gastaut, GLUT1 deficiency, and tuberous sclerosis
• This skill produces clinical documentation; it does not replace clinical judgment