If an event occurs that is most likely to be a seizure: [Sansevere: 2017]

• Rule out acute symptomatic causes, e.g., meningitis or toxic ingestion. If no acute etiologies are found, the seizure is said to be unprovoked. This type of seizure includes idiopathic seizures (thought to be genetic in origin), remote symptomatic seizures (e.g., in a child with known long-standing cerebral palsy), and cryptogenic seizures (no obvious cause).
• Obtain a detailed history and physical (see Seizure Assessment Tool (AAN) ( 41 KB) for an assessment algorithm).
• Consider laboratory studies such as blood glucose, toxicology, blood chemistries, but only as suggested by clinical history or physical exam in a child older than 6 months.
• Consider performing a lumbar puncture if the child has altered mental status, meningeal signs, or is very young; otherwise, it is usually not necessary.
• Schedule an EEG to be performed on an outpatient basis sometime after the seizure because it may help determine seizure type and epilepsy syndrome - and hence recurrence risk. EEGs performed very soon after the seizure are often abnormal and might be difficult to interpret.
• Consider brain imaging, preferably an MRI. This can usually be done on an outpatient basis. Imaging may be helpful in determining seizure etiology, especially if the seizure had a focal onset (eye deviation to one side, 1 side of the body, etc.).

• Since only a small percentage of children with a first unprovoked seizure have another seizure, most providers will wait for a second seizure before starting medication. However, this decision will depend on seizure length, results of EEG and brain MRI, family preference, etc.
• When considering whether or not to treat a child with antiepileptic drugs after a first seizure, weigh the risks of having a second seizure against the side effects and possible psychosocial aspects of being on daily medication. Waiting to treat until a second seizure allows a better clarification of events and allows the event frequency to be determined.
• There is no evidence that treatment with ASMs prevents future seizures or the development of epilepsy or that not treating increases the risk of developing epilepsy.
• Levetiracetam is a possible drug of first choice in this situation because it has few side effects, few drug interactions, and it is effective in both generalized and focal seizures. Levels and screening laboratory testing are not performed with this medication. If levetiracetam is not successful at the maximum dose, another medication will usually be necessary. The prescribing physician should familiarize themselves with all prescribing information.

Before the child is discharged from the clinic, emergency department, or hospital, the following information should be covered with the family:

Discuss seizure activity restrictions with the child and family as appropriate:

• Care around water (baths, pools, lakes/ocean): A child with seizures should be supervised 1 to 1 by an adult while swimming
• Care around heights (climbing trees, playground equipment, mountains)
• Caution in/on moving conveyances (bikes, boards, skis)
• Caution around fire/equipment that may cause a burning injury (water heaters, cooking equipment)
• Education of caregivers, such as babysitters, on what to do if a seizure occurs.
• State laws concerning driving with epilepsy vary by state; consult the Division of Motor Vehicles for each state.
• Follow-up should be arranged with the child's medical home clinician or a pediatric neurologist.
• Develop a seizure action plan with the family that includes what to do if there is another seizure, and if the seizure was prolonged, directions for rescue medication in case of another prolonged seizure. Either rectal diazepam (Diastat), nasal diazepam (Valtoco), or nasal midazolam (Versed, Nayzilam) can be prescribed if seizures last longer than 5 minutes.