Seizures in Children: Diagnostic Evaluation & Management Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with seizures or seizure-like events

Physical Examination Guide

Systematic approach to examining a child with seizures or seizure-like events

Diagnostic Approach

Initial Assessment

For a child presenting with seizure or seizure-like activity, the initial assessment should include:

• Detailed history focusing on event description, duration, and associated symptoms
• Complete neurological and physical examination
• Determination of seizure vs. non-seizure event
• Immediate stabilization if actively seizing

Diagnostic Criteria and Classification

The International League Against Epilepsy (ILAE) classification system helps categorize seizures:

Seizure Type	Clinical Features	Key Characteristics
Focal Seizures	Start in one area of the brain	May have preserved or impaired awareness; can evolve to bilateral tonic-clonic
Generalized Seizures	Engage bilateral networks from onset	Include absence, tonic, clonic, tonic-clonic, myoclonic, atonic types
Unknown Onset	Unclear where seizure begins	Insufficient information to categorize; includes epileptic spasms

Epilepsy Syndromes in Children

Syndrome	Age of Onset	Key Features	Prognosis
Infantile Spasms (West Syndrome)	3-12 months	- Clusters of spasms - Hypsarrhythmia on EEG - Developmental regression	Variable; depends on etiology and treatment timing
Childhood Absence Epilepsy	4-10 years	- Brief staring spells - 3 Hz spike-wave on EEG - Multiple daily episodes	Good; many outgrow by adolescence
Juvenile Myoclonic Epilepsy	12-18 years	- Morning myoclonic jerks - Tonic-clonic seizures - Photosensitivity	Good control with medication; lifelong treatment often required
Benign Rolandic Epilepsy (BECTS)	3-13 years	- Nocturnal focal seizures - Orofacial involvement - Centrotemporal spikes on EEG	Excellent; typically resolves by age 16
Lennox-Gastaut Syndrome	1-8 years	- Multiple seizure types - Intellectual disability - Slow spike-wave on EEG	Poor; refractory seizures, cognitive impacts
Dravet Syndrome	First year of life	- Prolonged febrile seizures initially - Multiple seizure types evolve - SCN1A mutations common	Poor; developmental impairment, refractory seizures

Differential Diagnosis

Category	Conditions	Distinguishing Features
Non-Epileptic Paroxysmal Events	- Breath-holding spells - Syncope - Night terrors - Tics - Pseudoseizures	- Precipitating factor often present - Preserved consciousness in many - Different pattern from typical seizures - Normal EEG during events
Acute Symptomatic Seizures	- Febrile seizures - Electrolyte abnormalities - Intoxication/poisoning - CNS infection - Traumatic brain injury	- Clear temporal relationship to acute illness - Systemic symptoms often present - Fever (febrile seizures) - Normal prior development - Resolves with treatment of underlying cause
Metabolic Disorders	- Hypoglycemia - Inborn errors of metabolism - Pyridoxine dependency - Mitochondrial disorders - Neurometabolic diseases	- Other systemic manifestations - Developmental regression - Episodic decompensation - Specific biochemical abnormalities - Family history sometimes present
Movement Disorders	- Infantile torticollis - Chorea - Dystonia - Benign myoclonus - Jitteriness	- Can be suppressed or modified - No alteration of consciousness - Preserved awareness - Different EEG characteristics - Different pattern than typical seizures

Laboratory Studies

Consider these studies based on clinical presentation:

Investigation	Clinical Utility	When to Consider
Basic Metabolic Panel	Assess for electrolyte abnormalities, glucose, calcium	All first seizures, acute presentation
Complete Blood Count	Evaluate for infection, anemia	Fever, signs of infection, abnormal exam
Toxicology Screen	Identify drug ingestion or exposure	Unexplained seizure, altered mental status, adolescents
Lumbar Puncture	Evaluate for CNS infection	Fever, meningeal signs, infants, immunocompromised
Electroencephalogram (EEG)	Identify epileptiform activity, classify seizure type	All children with suspected epilepsy, unprovoked seizures

Advanced Studies

Reserve for specific clinical scenarios:

Investigation	Clinical Utility	When to Consider
Neuroimaging (MRI/CT)	Identify structural abnormalities	- Focal seizures - Focal neurological deficits - Developmental delay - Suspected neurocutaneous disorder - Age <1 year
Video EEG Monitoring	Correlate clinical events with EEG activity	- Diagnostic uncertainty - Characterization of seizure type - Pre-surgical evaluation - Suspected non-epileptic events
Genetic Testing	Identify genetic causes of epilepsy	- Infantile/early-onset epilepsy - Drug-resistant epilepsy - Developmental delay/regression - Family history of seizures - Specific epilepsy syndromes
Metabolic Studies	Evaluate for inborn errors of metabolism	- Infants - Developmental regression - Refractory seizures - Other systemic features - Episodic decompensation

Status Epilepticus Assessment

Rapid assessment for prolonged or clustered seizures:

1. Immediate stabilization (ABCs, secure airway, oxygen, consider intubation if necessary)
2. Assess for hypoglycemia (check bedside glucose, administer dextrose if low)
3. Establish IV access for medication administration
4. Rapid history from witnesses (prior seizures, medications, recent illness)
5. Bedside examination between seizures if possible
6. Laboratory studies (electrolytes, toxicology, calcium, magnesium)
7. Neuroimaging once stabilized (CT or MRI based on setting)
8. EEG monitoring if available, especially if mental status doesn't improve

Management Strategies

General Approach to Management

Key principles in managing seizures in children:

• Accurate diagnosis: Confirm seizure vs. non-seizure event
• Identify and treat underlying cause: When possible
• Education and counseling: Empower family with seizure first aid
• Individualized treatment plan: Based on seizure type, syndrome, age
• Regular follow-up: Monitor seizure control and medication effects

Acute Seizure Management

Time Point	Intervention	Dosing/Details
0-5 minutes	- Stabilize patient - Position safely - Oxygen if needed - Check glucose	- Lateral decubitus position - Avoid restraint - Clear airway - Administer glucose if hypoglycemic
5-10 minutes	- First-line antiseizure medication - Benzodiazepine - Establish IV access	- Midazolam: 0.2 mg/kg IN/IM (max 10 mg) - Diazepam: 0.5 mg/kg PR (max 10 mg) - Lorazepam: 0.1 mg/kg IV (max 4 mg)
10-20 minutes	- Second-line therapy if seizure continues - Additional benzodiazepine dose - Consider second-line agent	- Repeat benzodiazepine once - Fosphenytoin: 20 mg PE/kg IV - Valproate: 40 mg/kg IV - Levetiracetam: 60 mg/kg IV
20-40 minutes	- Refractory status treatment - Third-line agent - Consider intubation - ICU transfer	- Phenobarbital: 20 mg/kg IV - Additional levetiracetam or valproate - Prepare for possible intubation - EEG monitoring if available
40+ minutes	- Super-refractory status management - Continuous infusion therapy - Anesthesia - Intubation and ventilation	- Midazolam infusion: 0.1-0.4 mg/kg/hr - Pentobarbital: 1-5 mg/kg/hr - Propofol: 1-4 mg/kg/hr (caution in children) - EEG burst suppression target

Long-Term Antiseizure Medications

Medication	Primary Seizure Types	Dosing Information	Monitoring/Side Effects
Levetiracetam (Keppra)	- Focal seizures - Generalized seizures - Broad spectrum	- Initial: 10 mg/kg/day in 2 doses - Maintenance: 20-60 mg/kg/day - Max: 3000 mg/day	- Behavioral changes/irritability - No routine lab monitoring - Somnolence - May need pyridoxine
Valproic Acid (Depakote)	- Generalized seizures - Absence seizures - Myoclonic seizures - Broad spectrum	- Initial: 10-15 mg/kg/day in 2-3 doses - Maintenance: 30-60 mg/kg/day - Target level: 50-100 μg/mL	- LFTs, CBC, platelets - Weight gain - Hyperammonemia - Avoid in young females, mitochondrial disorders
Oxcarbazepine (Trileptal)	- Focal seizures - Focal to bilateral tonic-clonic	- Initial: 8-10 mg/kg/day in 2 doses - Maintenance: 30-60 mg/kg/day - Max: 2400 mg/day	- Hyponatremia - Rash (cross-reactivity with carbamazepine) - Somnolence, dizziness - Monitor sodium in first 3 months
Ethosuximide (Zarontin)	- Absence seizures (first-line) - Not effective for other types	- Initial: 10-15 mg/kg/day in 1-2 doses - Maintenance: 15-40 mg/kg/day - Target level: 40-100 μg/mL	- GI upset - Behavioral changes - Blood dyscrasias (rare) - CBC monitoring
Lamotrigine (Lamictal)	- Focal seizures - Generalized seizures - Absence seizures - Broad spectrum	- Complex titration schedule - Slower with valproate - Maintenance: 5-15 mg/kg/day - Max: 600 mg/day	- Rash (including SJS/TEN) - Very slow titration required - Interactions with many medications - Dizziness, headache

Syndrome-Specific Management

Syndrome	First-Line Treatment	Alternative Options	Special Considerations
Infantile Spasms	- ACTH - Vigabatrin (especially for TSC)	- Oral steroids - Ketogenic diet - Topiramate	- Urgent treatment essential - Developmental outcomes tied to time to treatment - Vision monitoring with vigabatrin - EEG response critical to assess
Absence Epilepsy	- Ethosuximide - Valproic acid	- Lamotrigine - Levetiracetam - Combination therapy	- Avoid carbamazepine/oxcarbazepine (may worsen) - Hyperventilation may help diagnosis - Good prognosis if treated appropriately - May need EEG to confirm resolution
Benign Rolandic Epilepsy	- Often no treatment needed - Levetiracetam if treated	- Oxcarbazepine - Carbamazepine - Gabapentin	- Self-limited syndrome - Nocturnal seizures predominate - Good developmental outcomes - Treatment decisions based on frequency, impact
Juvenile Myoclonic Epilepsy	- Valproic acid - Levetiracetam	- Lamotrigine - Topiramate - Zonisamide	- Lifelong treatment often needed - Avoid triggers (sleep deprivation, alcohol) - Valproate risk in young women - Good seizure control with treatment
Lennox-Gastaut Syndrome	- Valproic acid - Clobazam - Rufinamide	- Lamotrigine - Topiramate - Ketogenic diet - Vagus nerve stimulation - Cannabidiol (Epidiolex)	- Often requires polytherapy - Developmental support crucial - High risk of status epilepticus - Rescue medication plan essential - Consider genetic testing

Non-Pharmacological Interventions

Intervention	Description	Evidence Level
Ketogenic Diet	- High fat, low carbohydrate, adequate protein - Multiple formulations (classic, MCT, modified Atkins) - Mimics fasting state with ketosis	- Strong evidence for refractory epilepsy - First-line for certain metabolic disorders - Most effective in GLUT-1 deficiency, infantile spasms
Vagus Nerve Stimulation	- Implanted device that stimulates vagus nerve - Programmed stimulation plus magnet activation - Adjunctive therapy for refractory epilepsy	- Moderate evidence for long-term benefit - 50% reduction in 30-40% of patients - Greater benefit with longer use
Epilepsy Surgery	- Resection of epileptogenic focus - Disconnection procedures (corpus callosotomy) - Requires precise localization	- Strong evidence for focal lesional epilepsy - Can be curative in selected cases - Best outcomes with clear structural lesions
Responsive Neurostimulation	- Implanted device that detects and responds to seizure activity - Delivers stimulation to abort seizures - Used when seizure focus cannot be resected	- Emerging evidence in pediatrics - More established in adults - Option for refractory focal epilepsy
Lifestyle Management	- Regular sleep schedule - Stress reduction - Avoidance of known triggers - Regular medication schedule	- Moderate evidence for seizure reduction - Important adjunct to all therapies - Particularly important in reflex epilepsies

Febrile Seizure Management

Specific approach for this common childhood condition:

• Simple febrile seizures: Reassurance, education, fever management
• Complex febrile seizures: Consider EEG, further evaluation based on features
• Recurrent febrile seizures: Rescue benzodiazepine for prolonged events
• Prophylaxis: Generally not recommended for most children
• Follow-up: Routine for simple febrile seizures, closer monitoring for complex

Family Education and Support

• Seizure first aid training: What to do during a seizure, when to call emergency services
• Medication education: Importance of adherence, side effects to monitor
• Safety counseling: Home safety, activity restrictions, water safety
• School planning: Seizure action plan, staff education, academic accommodations
• Resources: Support groups, epilepsy foundations, financial assistance programs

When to Refer

• Pediatric Neurologist: All children with epilepsy or recurrent unprovoked seizures
• Pediatric Epileptologist: Refractory epilepsy, epilepsy syndromes, surgical candidates
• Genetic Counseling: Known or suspected genetic epilepsy syndromes
• Developmental Specialists: Children with developmental delays or regression
• Psychiatry/Psychology: Comorbid mood, behavior, or learning issues