Unprovoked Seizure in Children

Aka: Unprovoked Seizure in Children, Pediatric Afebrile Seizure, First Time Seizure in Children

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II. Precautions

  1. Evaluation described here is for unprovoked first-time Seizure
  2. See Seizure Disorder for full general evaluation

III. Diagnosis: Seizure

  1. See Seizure Disorder
  2. See Single Seizure Evaluation
  3. Recurrent Seizure activity
    1. Seizures appear similar each time they recur
  4. Awareness
    1. Decreased awareness occurs with most Seizure types
    2. Distraction from Seizure activity by external events suggests a Seizure mimic
      1. Attempt to interact with child during Seizure-like activity in ways that they would ignore
  5. Motor activity
    1. Record the movements that occur with each episode (capture on video if possible)
  6. Incontinence and Tongue biting are not uniformly present in Seizures
    1. Often occur in Generalized Seizures, but not with Focal Seizures

IV. Differential Diagnosis

  1. Benign Seizure Mimics (esp. young children)
    1. See Seizure Differential Diagnosis
    2. Breath Holding Spells
    3. Motor Tic
      1. Child can often voluntarily suppress Motor Tics (contrast with Seizures)
  2. Atypical presentations or prolonged postictal period
    1. Closed Head Injury
    2. CNS Infection
    3. Electrolyte disturbance
    4. Inborn Errors of Metabolism

V. Labs

  1. See Single Seizure Evaluation
  2. Fingerstick Glucose (all patients)

VI. Diagnostics

  1. Lumbar Puncture Indications
    1. Indicated in age <6 months (exam unreliable to exclude CNS Infection)
    2. Consider in age 6 to 12 months
    3. Perform if specifically indicated for age >12 months (similar indications for any age)
      1. Example: Altered Mental Status with fever (Meningitis or Encephalitis)
  2. Electroencephalogram (EEG)
    1. Only emergently indicated in suspected Status Epilepticus, or frequent, recurrent Seizures
    2. Defer to outpatient evaluation in most other cases
    3. EEG is typically delayed for 1-2 weeks after last Seizure (to allow non-specific slowing to clear)

VII. Imaging

  1. See Neuroimaging after First Seizure
  2. MRI Brain
    1. Evaluate for CNS mass
    2. MRI in young children requires Procedural Sedation and increased resource use
      1. Defer for oupatient imaging in a well-appearing child with normal Neurologic Exam
      2. Consult pediatric neurology if imaging may be deferred to follow-up or tertiary transfer
      3. Larger, tertiary facilities have T3 MRI allowing rapid sequences and shorter MRI time
      4. See Neuroimaging after First Seizure for anxiolysis protocol (may be sufficient in some children)
  3. CT Head
    1. MRI is preferred (CT is lower yield for CNS Lesions, MRI avoids radiation exposure)
    2. Emergent CT Head indications
      1. See Head Injury CT Indications in Children (PECARN)
      2. Consider in Non-accidental Trauma
      3. Consider for concerns of Increased Intracranial Pressure

VIII. Management

  1. See Status Epilepticus
  2. See Single Seizure Evaluation
  3. See Seizure Disorder
  4. See Febrile Seizure
  5. Pediatric neurology referral
  6. Disposition
    1. Evaluation with imaging and EEG can often be deferred to outpatient evaluation
    2. However, admit all patients who have not returned to baseline following Seizure activity
  7. Discharge Instructions
    1. See Seizure Disorder
    2. Avoid swimming pools unless under very close 1:1 observation
    3. Wear helmets for activities at risk of Head Injury (e.g. biking)
    4. Showers are preferred over baths
      1. If baths are taken, they should be supervised continuously
  8. Seizure Prophylaxis
    1. Not recommended for single Seizure
    2. Recommended to start if more than one Seizure has occurred
    3. Rescue medication may be considered for discharge medication
      1. Parent may administer if Seizure lasts >5 minutes (and call 911)
      2. Options include Intranasal Midazolam and rectal Diazepam

IX. Prognosis

  1. See Single Seizure Evaluation
  2. Seizure risk recurrence in children
    1. After single first Seizure: 40-45%
    2. After second Seizure: 80%

X. References

  1. Woods, Martin, Mason in Swadron (2022) EM:Rap 22(1): 6-8

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