Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Seizures, Febrile Convulsions & Status Epilepticus

Comprehensive emergency protocol for pediatric seizures and status epilepticus. Covers diagnostic criteria and benign reassurance for simple febrile seizures vs. complex features, the rapid point-of-care glucose rule, the 2025/2026 pediatric status epilepticus pharmacotherapy timeline (Benzodiazepines -> Levetiracetam/Fosphenytoin -> Anesthetic infusions), and neonatal phenobarbital and pyridoxine trials.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Check Blood Glucose First

Stat POC glucose: Neonates < 40-45 mg/dL treat with D10W 2-5 mL/kg IV; Children < 60 mg/dL treat with D25W 2 mL/kg IV

First-Line Benzodiazepines

Lorazepam 0.1 mg/kg IV (max 4 mg) OR Intranasal/IM Midazolam 0.2 mg/kg (max 10 mg); repeat once at 5-10 min

Second-Line Non-Sedating AED

Levetiracetam (Keppra) 60 mg/kg IV (max 4,500 mg) OR Fosphenytoin 20 mg PE/kg IV over 10-15 min

Simple Febrile Seizure Rule

Age 6mo-5yr, generalized, < 15 min, 1 in 24h: Zero routine workup (no LP, no EEG, no neuroimaging); antipyretics for comfort

Neonatal Phenobarbital First-Line

Phenobarbital 20 mg/kg IV slow push; neonates have immature GABA receptors where benzodiazepines can cause paradoxical excitation

Bottom-Line Clinical Pearl

In pediatric status epilepticus (seizure duration > 5 minutes), rapid first-line administration of weight-based Benzodiazepines (IV Lorazepam 0.1 mg/kg or Intranasal Midazolam 0.2 mg/kg) within the 5 to 10 minute window halts progression to pharmacoresistant status. Always check point-of-care glucose immediately; pediatric glycogen stores are minimal, and unrecognized hypoglycemia causes permanent brain injury. In neonates (< 28 days), Phenobarbital is the preferred first-line anticonvulsant over benzodiazepines.

1. Simple vs. Complex Febrile Seizures: Triage & Workup

Febrile seizures are the most common convulsive event in childhood, occurring in 2-5% of children between 6 months and 5 years of age (peaking at 18 months). They represent a benign, age-dependent heightened neuronal sensitivity to rapid core temperature elevation in the setting of normal neurodevelopment:

Feature	Simple Febrile Seizure (90% of Cases)	Complex Febrile Seizure (10% of Cases)
Clinical Criteria	Must meet ALL three criteria: 1. Generalized (tonic-clonic, bilateral symmetrical) 2. Duration < 15 minutes (usually < 2-3 minutes) 3. Single episode in a 24-hour period (does not recur during same illness).	Meets ANY of the following: 1. Focal features (focal onset, asymmetric twitching, gaze deviation) 2. Prolonged duration >= 15 minutes 3. Recurrent (>= 2 episodes within 24 hours).
Post-Ictal State	Rapid recovery to normal baseline alertness within 30 to 60 minutes. Normal age-appropriate neurological examination.	Prolonged post-ictal depression or focal neurologic deficit (Todd's Paresis: transient unilateral weakness lasting up to 24 hours).
Recommended Emergency Workup	ZERO ROUTINE DIAGNOSTIC TESTING: - No Lumbar Puncture (unless signs of meningitis present) - No Blood cultures or CBC - No Serum electrolytes - No Neuroimaging (CT or MRI contraindicated) - No Electroencephalogram (EEG).	Targeted diagnostic investigation: - Lumbar puncture strongly considered if age < 12 months, incomplete Hib/Pneumococcal immunization, or pre-treated with antibiotics. - Urgent neuroimaging (MRI preferred or non-contrast CT) if focal deficits persist.
Prognosis & Family Education	Recurrence risk is ~30% (50% if first seizure occurred < 12 months). Risk of developing future unprovoked epilepsy is ~1-2% (virtually identical to the general population). Reassure parents that simple febrile seizures do not cause brain damage or cognitive delay.	Slightly increased risk of future epilepsy (4-8%). Outpatient neurology follow-up recommended.

2. Pediatric Status Epilepticus Resuscitation Timeline

Status epilepticus is defined as continuous seizure activity lasting >= 5 minutes (Phase T1), or recurrent seizures without return to baseline mental status. Immediate protocolized escalation terminates convulsions before irreversible neuronal necrosis occurs (Phase T2 at 30 minutes):

Timeline Window	Immediate Action & First-Line Pharmacotherapy	Clinical Pearl & Route Considerations
0 to 5 Minutes: Stabilization & Glucose	1. ABCs: High-flow 100% O2 via non-rebreather; gentle jaw thrust, position in lateral decubitus. 2. STAT POINT-OF-CARE GLUCOSE CHECK. - If Hypoglycemic: - Neonates (< 28 days): 10% Dextrose (D10W) 2 to 5 mL/kg IV - Infants/Children: 25% Dextrose (D25W) 2 mL/kg IV (or D10W 5 mL/kg IV).	Do NOT administer concentrated D50W to infants or neonates: extreme hyperosmolality causes osmotic fluid shifts, intracranial hemorrhage, and cerebral edema.
5 to 10 Minutes: First-Line Benzodiazepines	Administer First-Line Benzodiazepine Immediately: - IV Access Present: Lorazepam 0.1 mg/kg IV (max 4 mg) over 1-2 min. - No IV Access (Rapid Non-Vascular Routes): - Intranasal (IN) Midazolam: 0.2 mg/kg (using mucosal atomizer device, max 10 mg; 5 mg/mL formulation divided between nares). - Intramuscular (IM) Midazolam: 0.2 mg/kg (max 10 mg). - Rectal Diazepam: 0.2 to 0.5 mg/kg PR (Diastat gel). May repeat dose ONCE at 5-10 minutes if seizure persists.	Intranasal Midazolam achieves faster seizure cessation than attempting to establish difficult intravenous access in a convulsing child. Avoid under-dosing.
10 to 20 Minutes: Second-Line Non-Sedating Antiepileptics	If seizure persists beyond 10-15 minutes, infuse non-sedating AED: 1. Levetiracetam (Keppra): 60 mg/kg IV (max 4,500 mg) infused over 5-10 minutes (preferred first-line in modern pediatric protocols). OR 2. Fosphenytoin: 20 mg PE/kg IV (max 1,500 mg PE) at 150 mg PE/min with continuous cardiac monitoring. OR 3. Sodium Valproate: 40 mg/kg IV (max 3,000 mg; avoid in children < 2 years with suspected metabolic/mitochondrial disorders).	The landmark EcLiPSE and ConSEPT trials confirmed equivalent efficacy (~50-60% cessation) between Levetiracetam and Fosphenytoin, with Levetiracetam demonstrating fewer cardiac dysrhythmias and faster administration.
20 to 30 Minutes: Refractory Status Epilepticus	1. Prepare for Rapid Sequence Intubation with video laryngoscopy and continuous end-tidal capnography. 2. Continuous Anesthetic Infusions: - Midazolam: 0.2 mg/kg IV load, then 0.1 to 2.0 mg/kg/hr infusion. - Propofol (in children > 16 years; avoid prolonged infusion due to Propofol Infusion Syndrome). - Ketamine: 1-2 mg/kg IV load, then 0.5 to 5 mg/kg/hr infusion. 3. Continuous bedside EEG monitoring.	Refractory status epilepticus represents severe GABA-receptor downregulation and NMDA-receptor upregulation; anesthetic infusions and NMDA antagonists (ketamine) are required to suppress epileptiform discharges.

3. Neonatal Seizures & Inborn Errors of Metabolism

Seizures in neonates (< 28 days of age) are clinically distinct: they are predominantly focal, subtle (bicycling, tongue thrusting, apnea, sustained tonic eye deviation), and rarely generalized tonic-clonic. The developing neonatal brain possesses an immature chloride gradient (high intracellular chloride mediated by the NKCC1 cotransporter), causing GABA-A receptor activation to be depolarizing and excitatory rather than hyperpolarizing:

First-Line Anticonvulsant: Phenobarbital: Administer Phenobarbital 20 mg/kg IV slow push over 10-15 minutes (may repeat 10-20 mg/kg up to 40 mg/kg total). Phenobarbital remains the first-line drug for neonatal seizures worldwide, significantly more effective than benzodiazepines.
Second-Line: Levetiracetam: Levetiracetam 40-60 mg/kg IV is increasingly utilized as a safe second-line agent with minimal cardiorespiratory depression.
Refractory Neonatal Seizures & The Pyridoxine Trial: In any neonate with intractable, pharmacoresistant status epilepticus unresponsive to phenobarbital, suspect Pyridoxine-Dependent Epilepsy (mutations in ALDH7A1). Administer an immediate diagnostic and therapeutic trial of Pyridoxine (Vitamin B6) 100 mg IV under continuous EEG and cardiorespiratory monitoring (causes immediate seizure cessation within minutes, but prepare for transient profound hypotonia and apnea).

Pediatric Status Epilepticus: Time to Second-Line AED Escalation

The greatest pitfall in managing pediatric status epilepticus is giving multiple repeated doses of benzodiazepines while delaying the initiation of a second-line antiepileptic drug (Levetiracetam or Fosphenytoin). Administering more than two doses of benzodiazepines rarely terminates refractory seizures, but dramatically surges the incidence of severe hypoventilation, respiratory depression, and laryngospasm. If convulsions continue after two appropriate doses of Lorazepam or Midazolam, immediately start intravenous Levetiracetam (60 mg/kg IV) or Fosphenytoin (20 mg PE/kg IV). Always maintain immediate airway rescue equipment (bag-valve-mask with appropriate size mask, suction, endotracheal tubes) at the bedside.

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