Synopsis
Recognise a likely first unprovoked seizure, separate it from common childhood mimics, identify acute symptomatic causes and organise urgent specialist assessment without prematurely diagnosing epilepsy.
- A first afebrile event is not automatically epilepsy; reconstruct exactly what happened before, during and after the episode from the child, witnesses and any video.
- Stabilise first and check capillary glucose promptly when the child is still unwell, has not recovered or an acute metabolic cause is plausible.
- NICE recommends urgent specialist assessment, usually within two weeks, after a first suspected seizure in a child or young person.
- Obtain a 12-lead ECG after a first suspected seizure because arrhythmic syncope can produce stiffening and jerks that mimic epilepsy.
- If the history supports epilepsy, EEG may support seizure classification but must not be used to exclude epilepsy; when requested after a first seizure, perform it as soon as possible, ideally within 72 hours.
- MRI with an epilepsy protocol is the preferred structural study when indicated; emergency CT is reserved for an acute question such as trauma, haemorrhage or raised intracranial pressure.
- Do not routinely start long-term antiseizure medicine after a single unprovoked seizure; specialist treatment depends on recurrence risk, EEG, neurological findings, imaging and family preference.
- Teach seizure first aid: time the event, protect from hazards, cushion the head, do not put anything in the mouth, place in recovery position when movements stop and call emergency help at five minutes.
- Document driving implications only when age-relevant, but address bathing, swimming, heights, cycling and school supervision immediately and proportionately.
- A normal examination and normal routine EEG reduce neither the importance of a convincing witness history nor the need for specialist review.
Key red flags
A seizure continuing for five minutes or more should be treated as convulsive status epilepticus rather than observed for spontaneous resolution.
Failure to recover progressively, persistent unilateral weakness, new speech loss or unequal pupils raises intracranial infection, haemorrhage, stroke or mass effect.
Fever with neck stiffness, non-blanching rash, bulging fontanelle, marked irritability or encephalopathy requires an urgent meningitis or encephalitis pathway.
Exertional collapse, palpitations, family sudden death or a seizure-like event with little postictal confusion may represent a dangerous cardiac syncope.
Possible ingestion, diabetes, electrolyte loss, adrenal disease or metabolic disorder changes immediate glucose, blood and toxicology assessment.
A first seizure in an infant, a child with developmental regression or a child with a known brain lesion merits accelerated paediatric neurology review.
Investigation priorities
Establish whether the event was epileptic and classify its likely onset before ordering tests.
Management branches
The event continues for five minutes or recovery is unsafe.
- Use ABCDE, time the seizure, protect the child and check glucose without delaying treatment.
- Follow the paediatric status algorithm and treat infection, toxin, trauma or metabolic disturbance in parallel.
- Escalate persistent altered consciousness, focal deficit or cardiorespiratory compromise for urgent imaging and critical care.