LITERATURE REVIEW: Management of Seizures in Pediatrics: Criteria for Immediate Pharmacological Treatment, Clinical Monitoring, and Hospital Observation

Abstract

Introduction: Seizures are among the most common neurological emergencies in childhood. Accurately determining which patients require long-term antiseizure medication (ASM) therapy and which may be managed exclusively through clinical observation remains a significant clinical challenge. Objective: To analyze and standardize the clinical, electroencephalographic, and neuroimaging criteria used to distinguish pediatric patients with seizures who require pharmacological treatment from those who may be managed through observation. Methods: A systematic exploratory search was conducted in indexed databases, including PubMed, ScienceDirect, SciELO, and the Cochrane Library, using DeCS/MeSH terms. Clinical practice guidelines, meta-analyses, and clinical trials published between 2021 and 2026 were selected. Results: The available evidence indicates that a first unprovoked seizure is associated with a recurrence risk of approximately 40–50%; therefore, close clinical observation is generally the preferred management strategy. Long-term pharmacological treatment is indicated when the estimated risk of recurrence exceeds 60%, particularly in the presence of clear epileptiform discharges on electroencephalography, an abnormal baseline neurological examination, structural abnormalities on neuroimaging, or status epilepticus at presentation. Conclusion: In pediatric patients, the decision to initiate antiseizure therapy should not be determined by the dramatic clinical appearance of the first seizure. Instead, it should be based on an objective assessment of recurrence risk and a careful evaluation of the benefit–risk profile of antiseizure medications (American Academy of Pediatrics, 2022; Berg et al., 2022; National Institute for Health and Care Excellence, 2022).