Seizure in Children

Background

• A seizure is abnormal electrical activity of neurons in the brain and the resulting transient stereotypical signs and symptoms, such as involuntary movements and altered consciousness.
  • A provoked seizure is caused by an acute condition such as hypoglycemia, toxic ingestion, intracranial infection, trauma, or other precipitating factor. A febrile seizure is a common type of provoked seizure in children.
  • An unprovoked seizure may have a remote etiology (a preexisting brain abnormality or insult), be due to a genetic condition, or have no apparent cause.
• Seizures are generally classified as focal or generalized based on features at onset, and may be further classified based on additional characteristics.
  • Focal seizures may be subclassified as focal aware or focal impaired awareness seizures (previously called simple and complex partial seizures), and may be further classified as motor or nonmotor.
    • Motor symptoms may include automatisms or more stereotypical activity such as tonic or clonic movements.
    • Nonmotor manifestations may include autonomic changes, as well as sensory, cognitive, emotional, and behavioral symptoms.
    • Focal seizures can evolve to become generalized (focal to bilateral tonic-clonic seizures).
  • Generalized seizures may be subclassified as motor or nonmotor.
    • Motor symptoms may include tonic, clonic, myotonic, and/or atonic motor activity.
    • Generalized nonmotor seizures (also called absence seizures) typically manifest as an interruption of ongoing activity characterized by sudden onset, blank stare, unresponsiveness when spoken to, and rapid recovery within about 30 seconds.

Evaluation

• Suspect a seizure in a child presenting with a paroxysmal event, spell, or episode involving characteristic ictal motor or nonmotor symptoms.
• Diagnostic workup of status epilepticus should be completed as soon as possible and occur simultaneously and in parallel with treatment.
• After stabilizing children not in status epilepticus, perform testing based on clinical presentation.
  • Order laboratory tests based on individual history or clinical findings (Weak recommendation).
  • Consider toxicology screening for any question of drug exposure or substance abuse (Weak recommendation).
  • Perform lumbar puncture (LP) if concerned about possible meningitis or encephalitis, otherwise LP is of limited value (Weak recommendation).
  • Obtain an electroencephalogram (EEG) as part of neurodiagnostic evaluation for a child presenting with an apparent first unprovoked seizure (Strong recommendation).
  • Perform emergent or nonemergent neuroimaging as indicated.
    • Emergency neuroimaging:
      • should be performed in any child with prolonged postictal focal deficit (Todd paralysis) or failure to return to baseline within several hours of seizure (Weak recommendation)
      • should be considered in a child with an abnormal neurologic exam, predisposing history, or focal-onset seizure (Weak recommendation)
      • may be considered for infants < 6 months old, and in any child with a first seizure or AIDS (Weak recommendation)
  • Nonurgent magnetic resonance imaging should be considered in infants < 1 year old, and in any child with unexplained abnormalities on neurologic exam, focal-onset seizure, or an EEG that is not consistent with benign partial epilepsy of childhood or primary generalized epilepsy (Weak recommendation).

Management

• Acute seizure management
  • Initial management should include stabilization and monitoring , including:
    • assessing and supporting the airway, breathing, circulation, and performing a neurologic examination
    • for status epilepticus, obtaining IV access and diagnostic tests
  • In children with ongoing seizure activity:
    • Give benzodiazepines as first-line treatment for acute seizure cessation (Strong recommendation).
      • Preferred options include:
        • lorazepam (Strong recommendation) 0.1 mg/kg IV, may repeat dose once
        • midazolam (Strong recommendation) 5 mg intramuscularly if 13-40 kg (28.7-88.2 lbs), 10 mg intramuscularly if > 40 kg, or 0.2 mg/kg intramuscularly
        • diazepam (Strong recommendation) 0.15-0.2 mg/kg IV, may repeat dose once
      • Buccal and intranasal midazolam and rectal diazepam are alternatives if IV or intramuscular formulations are not feasible or available (Strong recommendation).
    • Second-line options for benzodiazepine-refractory seizures include:
      • IV valproic acid (Strong recommendation)
      • IV fosphenytoin, levetiracetam, phenobarbital, or phenytoin, or continuous-infusion midazolam (Weak recommendation)
    • Additional options for seizures refractory to first- and second-line antiseizure medications include lacosamide, topiramate, and anesthetic doses of midazolam, propofol, pentobarbital, or thiopental (Weak recommendation).
  • For provoked seizures, treat underlying cause if possible (for example, antibiotics for central nervous system infection).
• Antiseizure medication therapy to prevent seizure recurrence:
  • consider after ≥ 2 unprovoked seizures
  • may be considered after first unprovoked seizure if the benefits of reducing the risk of a second seizure outweigh the risks of pharmacologic and psychosocial side effects (Weak recommendation)
  • antiseizure medication selection should be based on the epilepsy syndrome, seizure type, adverse-effect profile, and patient/caregiver preferences.
• Options that may be considered for medication-refractory seizures include ketogenic diet, vagal stimulation, and neurosurgery.