Managing Pediatric Seizures

Managing Pediatric Seizures

Structures the evaluation, classification, acute management, and long-term treatment of seizures in children using the ILAE 2017 classification framework, age-specific epilepsy syndrome recognition, evidence-based anticonvulsant selection, and status epilepticus protocols.

Why This Skill Exists

Seizures are the most common pediatric neurologic emergency, with febrile seizures affecting 2-5% of children and epilepsy affecting approximately 1% of the pediatric population. The ILAE 2017 three-tier classification system (seizure type → epilepsy type → epilepsy syndrome) replaced outdated terminology and drives treatment selection. Different epilepsy syndromes require different medications — some anticonvulsants worsen certain epilepsies (e.g., carbamazepine in absence epilepsy). This skill enforces proper classification, syndrome-directed therapy, and standardized status epilepticus management.

Checkpoint A — Intake Verification

Required Intake Questions

1. What is the child's age (determines likely seizure syndrome)?
2. Describe the event in detail: what was the child doing before, during (motor activity, eye deviation, cyanosis, duration), and after (postictal state)?
3. Was there witnessed loss of consciousness?
4. What is the total seizure duration? Was there clustering?
5. Has the child had fever? (if < 5 years, febrile seizure differential)
6. Is there a family history of seizures or epilepsy?
7. Are there developmental concerns or known neurologic conditions?
8. What medications is the child currently taking (including OTC and herbals)?
9. Was there any preceding head trauma?
10. If on anticonvulsants: current drug levels, recent dose changes, adherence?

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