Managing Pediatric Seizures

---
name: managing-pediatric-seizures
language: en
description: Structures seizure evaluation with EEG interpretation and anticonvulsant selection for pediatric populations. Use when evaluating pediatric seizures, interpreting pediatric EEGs, or selecting anticonvulsants for children.
tags:
  - management
  - pediatrics
  - valuation
metadata:
  author: casemark
  practice_areas:
    - Pediatrics
    - Neonatology
    - Adolescent Medicine
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# 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 The ILAE 2017 three-tier classification system (seizure type → epilepsy type → epilepsy syndrome) replaced outdated terminology and drives treatment selection.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
| Category | Subtypes |
|----------|----------|
| **Focal onset** | Aware vs. impaired awareness; motor onset (automatisms, atonic, clonic, epileptic spasms, hyperkinetic, myoclonic, tonic) vs. non-motor onset (autonomic, behavior arrest, cognitive, emotional, sensory); focal to bilateral tonic-clonic |
| **Generalized onset** | Motor: tonic-clonic, clonic, tonic, myoclonic, myoclonic-tonic-clonic, myoclonic-atonic, atonic, epileptic spasms; Non-motor (absence): typical, atypical, myoclonic, eyelid myoclonia |
| **Unknown onset** | Motor: tonic-clonic, epileptic spasms; Non-motor: behavior arrest |

### 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
| Syndrome | Age of Onset | Key Features | EEG Pattern | First-Line Treatment |
|----------|-------------|--------------|-------------|---------------------|
| **Infantile spasms (West syndrome)** | 3-12 months | Clusters of flexion/extension spasms, developmental regression | Hypsarrhythmia | ACTH or vigabatrin (vigabatrin first-line if tuberous sclerosis) |
| **Dravet syndrome** | 5-8 months | Prolonged febrile seizures, later myoclonic/absence/focal; SCN1A mutation | Generalized spike-wave | Valproate, clobazam, stiripentol, fenfluramine; AVOID Na-channel blockers |
| **Childhood absence epilepsy (CAE)** | 4-10 years | Staring spells 10-30 sec with abrupt onset/offset, multiple per day | 3 Hz generalized spike-wave | Ethosuximide (first-line per SANAD II), valproate, lamotrigine |
| **Juvenile myoclonic epilepsy (JME)** | 12-18 years | Morning myoclonic jerks, GTC seizures; precipitated by sleep deprivation | 4-6 Hz generalized polyspike-wave | Valproate (males), levetiracetam or lamotrigine (females, due to VPA teratogenicity) |
| **Benign epilepsy with centrotemporal spikes (BECTS/Rolandic)** | 3-13 years | Focal motor seizures of face/mouth, often nocturnal; may not need treatment | Centrotemporal spikes activated by sleep | Observation if infrequent; levetiracetam or oxcarbazepine if treatment needed |
| **Lennox-Gastaut syndrome** | 2-8 years | Multiple seizure types (tonic, atonic, atypical absence), intellectual disability | Slow (< 2.5 Hz) spike-wave, paroxysmal fast activity in sleep | Valproate, clobazam, rufinamide, lamotrigine; consider VNS, dietary therapy |

### Medications to AVOID by Syndrome
| Syndrome | Avoid |
|----------|-------|
| Absence epilepsy | Carbamazepine, oxcarbazepine, phenytoin (worsen absences) |
| JME | Carbamazepine, oxcarbazepine, phenytoin (worsen myoclonus) |
| Dravet syndrome | Carbamazepine, oxcarbazepine, phenytoin, lamotrigine (worsen seizures via Na-channel blockade) |

---

## 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)
| Time Point | Action |
|------------|--------|
| **0-5 min** (stabilization) | ABCs, position, oxygen, suction, check glucose, monitor SpO2; if ≥ 5 min → treat |
| **5-20 min** (first-line) | **Benzodiazepine**: midazolam 0.2 mg/kg IM (max 10 mg) OR lorazepam 0.1 mg/kg IV (max 4 mg) OR diazepam 0.2-0.5 mg/kg rectal (max 20 mg); may repeat once at 5-10 min |
| **20-40 min** (second-line) | **Fosphenytoin** 20 mg PE/kg IV (max rate 3 mg PE/kg/min) OR **levetiracetam** 40-60 mg/kg IV (max 4500 mg) OR **valproate** 40 mg/kg IV (max 3000 mg) |
| **40-60 min** (refractory) | Repeat second-line agent if different from first OR begin continuous infusion: midazolam 0.2 mg/kg bolus → 0.05-2 mg/kg/hr |
| **> 60 min** (super-refractory) | ICU: pentobarbital, propofol (caution in children — propofol infusion syndrome), ketamine; continuous EEG monitoring |

---

## Step 5 — Chronic Anticonvulsant Selection and Monitoring

### First-Line Agents by Seizure Type
| Seizure Type | First-Line Options | Notes |
|----|----|----|
| Focal | Oxcarbazepine, levetiracetam, lamotrigine | Oxcarbazepine: watch for hyponatremia |
| Generalized tonic-clonic | Valproate, levetiracetam, lamotrigine | VPA: avoid in females of childbearing age if possible |
| Absence | Ethosuximide, valproate, lamotrigine | ESM for absence only; does not cover GTC |
| Infantile spasms | ACTH (high-dose, short course), vigabatrin | Vigabatrin first if tuberous sclerosis |

### 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

| Item | Requirement | Pass? |
|------|-------------|-------|
| ILAE classification | Three-tier classification documented | |
| Syndrome identification | Appropriate syndrome recognized or "unknown" stated | |
| Febrile seizure protocol | Correctly classified; inappropriate workup avoided | |
| EEG indication | Ordered when indicated; deferred with documented rationale | |
| MRI indication | Epilepsy protocol MRI obtained for appropriate indications | |
| Drug selection | Anticonvulsant matches seizure type; contraindicated drugs avoided | |
| Monitoring | Drug levels, CBC, LFTs ordered per medication requirements | |
| Status epilepticus | Timed protocol followed with appropriate escalation | |
| Rescue medication | Prescribed with training for home/school use | |
| No unexplained [VERIFY] tags | All flagged items resolved or escalated | |

---

## 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