Pediatric Seizures


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Author: Danielle Cassidy, Pharm.D., BCPS
Audience: Third year pharmacy students at University of Colorado School of Pharmacy
Background: describes common causes of seizures, differentiates dosing of antiepileptic drugs in pediatrics vs. adults, common risk factors associated with febrile seizures, treatment of febrile seizures, treatment of status epilepticus (inpatient & outpatient), & how to dispense/counsel parents on the administration of Diastat.

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Pediatric Seizures

  1. 1. Danielle Cassidy, Pharm.D. Clinical March 24, 2009
  2. 2.  Define common causes of seizures. Differentiate dosing of antiepileptic drugs in kids as compared to adults. List risk factors associated with febrile seizures. Define the American Academy of Pediatrics (AAP) Guidelines for treatment of febrile seizures. Identify appropriate treatment of status epilepticus in kids (inpatient and outpatient). Describe how to dispense and counsel a parent on the administration of Diastat.
  3. 3.  Adults & Kids  Kids  Partial seizures  Infantile spasms/ West  Complex syndrome  Simple  Febrile seizures  Secondarily  Lennox-Gastaut generalized syndrome  Generalized seizures  Juvenile absence  Absence  Myoclonic absence  Myoclonic  Benign partial epilepsy  Clonic of childhood  Tonic  Juvenile myoclonic  Tonic-clonic epilepsy  Atonic
  4. 4.  Neonatal asphyxia Intraventricular hemorrhage Hypoglycemia/hypocalcemia Infection (meningitis, fever) Genetics Medications/ingestion Trauma Metabolic disorders Cranial Tumors Idiopathic
  5. 5.  Kids versus Adults  Similarities  Selection based on seizure type  Measure serum drug levels  Monitor for response to therapy and side effects  Differences  Higher doses due to increased hepatic metabolism and volume of distribution  Dosing is based on mg/kg  Multiple formulations available
  6. 6.  Sprinkle capsules  Valproic acid  Topiramate Chewable tablets  Carbamazepine  Phenytoin  Lamotrigine
  7. 7.  Liquid  Carbamazepine  Ethosuximide  Gabapentin  Levetiracetam  Oxcarbazepine  Phenytoin  Valproic acid  Diazepam /lorazepam /midazolam /clonazepam  Phenobarbital  Felbamate
  8. 8.  How is dosing of pediatric antiepileptic medications different as compared to adults?  A) Children are given 50% of the adult dose  B) Children are dosed on mg/m2  C) Children are dosed on mg/kg
  9. 9.  Generalized seizure occurring during febrile illness  Ages 6 months to 5 years  Exclusion criteria  Intracranial infections  Severe metabolic disturbances Incidence ~3%
  10. 10.  Risk Factors  Winter months  Family history  Daycare attendance  Neurodevelopmental abnormality  Rapid elevation of temperature
  11. 11.  Simple  Less than 15 minutes  Generalized features  Single occurrence in 24 hour period Complex  Greater than 15 minutes  Focal features  More than one occurrence in 24 hours
  12. 12.  Treatment not recommended for simple febrile seziures Risk vs. Benefit  High potential for medication related side effects  Phenobarbital  Valproic acid  Diazepam  No evidence demonstrating improved long-term outcomes  Very low risk of adverse outcomes
  13. 13.  Old/Classic  Single seizure lasting greater than 30 minutes OR  Recurrent seizures lasting more than 30 minutes without full recovery Revised  Single seizure lasting more than 5 minutes OR  Two or more seizures with incomplete recovery of consciousness
  14. 14.  Incidence ~1.3-16% Risk Factors  Metabolic abnormalities  Trauma  CNS infections  Hypoxic events  Intracranial tumors  Cerebrovascular diseases  Noncompliance
  15. 15.  Initial management  Maintaining vitals  Adequate oxygenation of the brain  Termination of seizure activity  Prevention of seizure reoccurrence
  16. 16. Lorazepam IV 0.1 mg/kg 3-10 mins Fosphenytoin IV 20 PE/kg or Phenytoin IV 20mg/kg 20-30 mins Phenobarbital IV 20 mg/kg 60 mins Midazolam, propofol, thiopental, Keppra, or pentobarbital
  17. 17.  Infants  Second line therapy: Phenobarbital Out-patient  Rectal diazepam
  18. 18.  What is the correct order of medication administration for status epilepticus?  A) Lorazepam, propofol, leviteracitam  B) Fosphenytoin, phenobarbital, leviteracitam  C) Lorazepam, phenobarbital, fosphenytoin  D) Lorazepam, fosphenytoin, phenobarbital
  19. 19.  SB is a 3 year old female presenting with new onset seizure activity. POC report SB began having tactile fevers and HA 3 days PTA. Over the weekend, SB was treated with IBU, which would help periodically, but symptoms would return. On day of admit, she went to her PCP, was dx with a viral illness, and sent home.
  20. 20.  When SB arrived home, FOC noticed eye deviation to the left, jerking head movements, and teeth gritting. He took her inside and laid her down at which point she was breathing hard and then stopped breathing for 1 minute. He administered 2 rescue breaths which caused her to cough and resume breathing.
  21. 21.  SB then started having left arm and left leg jerking. At this point the paramedics arrived and administered diazepam 2 mg x 2 doses. The entire episode lasted for about 5-10 minutes.
  22. 22.  What is SB’s likely diagnosis? Upon arrival to TCH the patient is still seizing and the MD asks your advice about what medication to give next. What is your recommendation? Why? Should SB be sent home with abortive therapy? Why?
  23. 23.  MK is a 4 year old female (20 kg) with a hx of Lennox-Gastaut syndrome presenting in status epilepticus . MOC reports antiepileptic medication changes by a pediatric neurologist 2 months PTA. MK was well controlled during this time without any breakthroughs seizures. 7 days PTA, MK began experiencing 1 breakthrough seizure per day.
  24. 24.  The pediatric neurologist initiated oxcarbazepine with a rapid dose titration schedule. On day of admission MK had 4-5 seizures in the morning, with none lasting more than 5 minutes. In the afternoon, MK continued to experience multiple seizures and POC took her to the ED. She experienced another seizure in the ED, lasting for more than 5 minutes.
  25. 25.  MD administered lorazepam 2mg IV. Was the dose of lorazepam appropriate? MK continues seizing despite a second doses of lorazepam. What medication would you recommend next? Why? MK is still seizing after 30 minutes and the MD is considering phenobarbital. What serious side effect(s) are we worried about with this medication?
  26. 26.  Conway EE Jr. (2008). Management of seizures and status epilepticus in the PICU. In T. Shanley & J. Zimmerman (Eds.), Current Concepts in Pediatric Critical Care (pp. 59-67). Society of Critical Care Medicine, Mount Prospect, IL. Epilepsy in children. First Consult®. Elsevier Inc., St Louis, MO. 18 February 2008. Available at: Accessed on March 1, 2008. American Academy of Pediatrics: Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice Parameter: long- term treatment of the child with simple febrile seizures. Pediatrics 1999;103(6):1307-1039. Status epilepticus in children. First Consult®. Elsevier Inc., St Louis, MO. 18 February 2008. Available at: Accessed on March 1, 2008. Behera MK, Rana KS, et al. Status epilepticus in children. MJAFI 2005;61:174-178. American Medical Association: Working Group on status epilepticus. Treatment of convulsive status epilepticus: recommendations of the epilepsy foundation of American’s Working Group on status epilepticus.