Pediatric emergency care · public guidelines · reviewed October 2026
Pediatric Seizure Pathway
Weight-based doses, a status epilepticus clock, and the febrile and first-unprovoked seizure branches. Built from the AES status epilepticus guideline, the AAP febrile seizure guidelines and the AAN first-seizure practice parameter.
Education and decision support, not medical advice. Confirm every dose against your own order set and pharmacy.
Convulsive status epilepticus
A seizure lasting 5 minutes or more, or repeated seizures without return to baseline between them. Time the seizure from its true onset and count any benzodiazepine already given before arrival.
Seizure time
00:00
Now
Phases follow the American Epilepsy Society algorithm (0–5, 5–20, 20–40, 40–60 minutes). At each phase: if the seizure has stopped and the child is at baseline, move to symptomatic care.
Pathway navigator
Answer from the bedside. Each branch ends in the workup, disposition and family counseling the guidelines support.
Weight-based doses
Calculated from the weight above and capped at each source's maximum. Red means the cap is setting the dose rather than the mg/kg. Dashed rows have no dose in the AES algorithm and show common practice: check them locally.
Reference
What each guideline says, summarized.
Status epilepticus (AES 2016)
Initial therapy
A benzodiazepine is the initial therapy of choice. IM midazolam, IV lorazepam and IV diazepam are equivalent first-line options. Give an adequate single full dose; only lorazepam and diazepam may be repeated once.
If none of those are available
IV phenobarbital, rectal diazepam, or intranasal or buccal midazolam.
Second therapy
No evidence-based preferred agent: fosphenytoin, valproic acid or levetiracetam, each as a single dose. Phenobarbital if none of these are available. ESETT later found the three about equally effective, stopping seizures in roughly half of patients.
Third therapy
No clear evidence. Repeat second-line therapy, or anesthetic doses of thiopental, midazolam, pentobarbital or propofol, all with continuous EEG.
Glucose
If finger-stick glucose is under 60 mg/dL: 2 mL/kg D25W IV at 2 years and over, 4 mL/kg D12.5W IV under 2 years (both 0.5 g/kg).
Neonates
Seizures in the first month follow neonatal seizure guidance, where phenobarbital is the usual first-line drug.
Simple febrile seizure (AAP 2011)
Definition
Age 6–60 months, temperature 38.0 °C or higher, generalized, under 15 minutes, no recurrence within 24 hours, in a child without CNS infection, metabolic disturbance or prior afebrile seizure.
Lumbar puncture
Perform if there are meningeal signs or anything suggesting meningitis or intracranial infection. It is an option at 6–12 months if Hib or pneumococcal immunization is incomplete or unknown, and an option if the child was pretreated with antibiotics.
Not recommended
Routine EEG, routine labs (electrolytes, calcium, phosphorus, magnesium, CBC, glucose) and neuroimaging should not be done to find the cause of a simple febrile seizure.
Complex febrile seizure
Focal, 15 minutes or longer, or recurring within 24 hours. Not covered by the AAP guideline: evaluate individually.
Febrile seizure counseling (AAP 2008)
Common: 2–5% of children have one
About one third have another; recurrence is more likely when the first seizure is before 12 months
Epilepsy risk after a simple febrile seizure is about 1%, close to the general population
No effect on intelligence, learning or behavior
Neither continuous nor intermittent anticonvulsant therapy is recommended for simple febrile seizures
Fever medicines add comfort but do not prevent febrile seizures
Teach seizure first aid and when to call emergency services
First unprovoked afebrile seizure (AAN practice parameter)
EEG
Recommended as part of the evaluation. It does not have to be done in the ED.
Labs
Based on the clinical picture (vomiting, diarrhea, dehydration, failure to return to baseline), not routinely. Toxicology screen if drug exposure is possible. LP if meningitis or encephalitis is suspected.
Emergent imaging
A postictal focal deficit (Todd's paralysis) that doesn't resolve quickly, or failure to return to baseline within several hours.
Non-urgent MRI
Significant cognitive or motor impairment of unknown cause, unexplained abnormal neurologic exam, focal-onset seizure, an EEG not typical of benign focal or primary generalized epilepsy, or age under 1 year.
Sources
Glauser T et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults. American Epilepsy Society. Epilepsy Currents 2016;16(1):48–61, and its treatment algorithm
Kapur J et al. Randomized trial of three anticonvulsant medications for status epilepticus (ESETT). N Engl J Med 2019;381:2103–2113
American Academy of Pediatrics. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011;127(2):389–394
American Academy of Pediatrics. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics 2008;121(6):1281–1286
Hirtz D et al. Practice parameter: evaluating a first nonfebrile seizure in children. Neurology 2000;55(5):616–623
Brophy GM et al. Guidelines for the evaluation and management of status epilepticus. Neurocritical Care Society. Neurocrit Care 2012;17(1):3–23 (anesthetic infusion ranges)
US FDA prescribing information for diazepam rectal gel (age-based rectal dosing)