ORIGINAL RESEARCH www.ijcmr.

com Section: Pediatrics

Profile and Short Term Outcome of Seizures in Term Neonates

Chandan Kumar Abhishek1, Girijanand Jha2, Binod Kumar Singh3, Saroj Kumar4

Seizures in newborn are different from those in older

ABSTRACT children.3 Common causes of neonatal seizures include
Introduction: Neonatal seizures are common neurological hypoxic-ischemic encephalopathy, intracranial hemorrhage,
problem and they are often the first sign of neurological meningitis, hypoglycemia, hypocalcemia, congenital
dysfunction. Neonatal seizure carries a high risk of mortality malformation etc. Neonatal seizure carries a high risk of
as well as neurological impairment/epilepsy in later life. mortality as well as neurological impairment/epilepsy
Common causes include hypoxic-ischemic encephalopathy, disorders in later life.4 With advances in neonatology,
meningitis, hypoglycemia, hypocalcemia etc. Study aimed to
mortality from NS has decreased considerably from 40%
study the clinico-aetiological profile & short term outcome of
to about 20% over the years, but occurrence of long-term
neonatal seizure in term neonates.
Material and methods: We conducted this observational
neurodevelopment problems hasn’t changed much and
study in NICU of NMCH, Patna over 1 year period from June hovers around 30%.5 This can be partly due to delay in
2019 to May 2020 including term neonates of less than 1 diagnosis as well as improper and inadequate management
month age with seizure who stayed for >24 hours. Parameters of seizures.
studied were risk factors, seizure type, time of onset of seizure Based on this background and considering the frequent
& short term outcome. occurrence of this entity at our tertiary care level teaching
Results: Of the 81 neonates studied, male: female ratio was hospital, we intended to conduct this study for better
1.25:1. Mean gestational age was 38.9±1.3 weeks and mean understanding of the clinico- etiological profile of neonatal
admission weight was 3.12 ±0.52 Kg. Perinatal asphyxia was seizures. As we cater to sick term neonates referred from
the commonest risk factor (46.9%) followed by septicemia- nearby districts, we decided to include only term neonates
meningitis (32.1%) and metabolic disturbances (32.1%).
in the present study.
Subtle seizure was the commonest seizure type (37.2%)
Study aimed to study the clinico-aetiological profile & short
followed by clonic seizures (36.1%). 66% of the events were
reported before 72 hours of age. In neonates with seizure, term outcome of neonatal seizure in term neonates with
mortality was 28.4% and mean duration of hospital stay was the objectives to study clinical profile and risk factors for
8.4± 2.7 days. There was a significant increase in duration seizures in term neonates, to characterize the type of seizures
of hospital stay and delay in commencement of oral feeds in them and to study time of onset of seizures and short term
without increase in mortality, need of ventilator support outcome of seizures in these neonates.
or inotrope support in such neonates as compared to term
MATERIAL AND METHODS
neonates without seizures.
Conclusion: HIE and sepsis-meningitis was accountable for Hospital based prospective observational study was done
approximately 75% of neonatal seizure cases. Subtle seizures in N.I.C.U of deptt of Pediatrics N.M.C.H Patna for 1 year,
were the commonest seizure type. Majority of seizures from June 2019 to May 2020.
occurred within 72 hours of life. Occurrence of seizure in term Hospital based prospective observational study.
neonate significantly increases duration of hospital stay and Inclusion criteria: We included consecutively admitted
delays the commencement of oral feeds without increasing term babies of less than 1 month age with neonatal seizure at
mortality.
our NICU who stayed for >24 hours.
Keywords: Hypoxic Ischemic Encephalopathy, Neonatal Exclusion criteria: babies born preterm, seizures occurring
Seizure, Term Neonates, Seizure Type. after 1 month of age, neonatal tetanus cases and obvious

1
2nd Year M.D Student, Department of Pediatrics, N.M.C.H, Patna,
INTRODUCTION 2
Senior Resident, Department of Pediatrics, N.M.C.H, Patna,
3
Professor & HOD, Department of Pediatrics, N.M.C.H, Patna,
Neonatal seizure (NS) is defined as a paroxysmal alteration 4
Assistant Professor, Department of Pediatrics, N.M.C.H, Patna,
in neurological function i.e. motor, behavior and/or India
autonomic function1 in infants less than 4 weeks of age.
Neonatal seizure is a common neurological problem, infact Corresponding author: Dr Girijanand Jha, Children Ward,
seizures occur more frequently in neonatal period than at any N.M.C.H, Agamkuan, Patna-800007, Bihar, India
other time of life. The reported incidence in India is about
How to cite this article: Abhishek CK, Jha G, Singh BK,
10.3/1000 live births.2 However, as its clinical recognition Kumar S. Profile and short term outcome of seizures in term
is difficult, the true incidence of neonatal seizures is neonates. International Journal of Contemporary Medical Research
difficult to determine. Though they are often the first sign of 2020;7(12):L1-L4.
neurological dysfunction, their clinical expression at this age
is quite variable, poorly organized and often subtle. DOI: http://dx.doi.org/10.21276/ijcmr.2020.7.12.4

International Journal of Contemporary Medical Research Section: Pediatrics L1

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 12 | December 2020
Abhishek, et al. Short Term Outcome of Seizures in Term Neonates

congenital malformation were excluded from the present STATISTICAL ANALYSIS

study. Pertaining data was first entered in Microsoft excel sheet
Study technique: After obtaining written informed consent, and then analyzed by SPSS version 20 software. Results
we enrolled cases in this study. All cases were subjected to were presented as mean, standard deviation, percentage
thorough physical and neurological examination and focused as appropriate. Dichotomous events were compared by
history taking from guardians. Information so obtained and Chi-Square test and continuous variables were compared
data regarding baseline characteristics, admission diagnosis by Student t-test. P value less than 0.05 was considered
and lab investigation reports was recorded in a structured significant.
proforma. HIE staging was done using Sarnat and Sarnat
RESULTS
classification. Blood sample was sent for detection of
sepsis, metabolic disturbances including hypoglycemia Incidence of NS was 18.6% in term neonates admitted in our
(serum glucose<45mg/dl), hypocalcemia (total serum NICU. Out of the 81 neonates in the study, 36 (44.4%) were
Calcium <7mg/dl), hypomagnesemia (serum magnesium female and 45(55.5%) were male. Mean GA was 38.9 weeks,
levels < 1.5 mg/dl), hypernatremia (serum sodium >150 SD 1.3 weeks and mean admission weight was 3.12 Kg, S.D
meq/dl), hyponatremia (serum sodium <130 meq/dl), 0.52 Kg. Out of them 48 (59.25%) were referred to us from
hypokalemia (serum potassium <3.5 meq/dl), hyperkalemia peripheral institutions (outborn), while 33(40.7%) neonates
(serum potassium >5.5 meq/dl), hyperphosphatemia were born in our institution (inborn).
(serum phosphorus >8 mg/dl) etc. X-ray chest, X-ray Among the 81 neonates studied, perinatal asphyxia was the
skull, USG cranium, thyroid profile was done whenever commonest risk factor for neonatal seizure (n=38, 46.9%
required. Lumber puncture was done for CSF analysis of neonates). Among these HIE neonates, HIE stage -2 was
in all cases with suspected meningitis. Blood culture seen in 37.1% (n =30) and HIE stage-3 was seen in 9.8%
and septic screen was done in all cases with suspected (n=8). Second to HIE was septicemia- meningitis (n=26,
sepsis. 32.1%). Other causes include- hypocalcemia (n=11, 13.6%),
hypoglycemia (n=9, 11.1%), hyponatremia (n=6, 7.4%),
Etiology of seizures Number of Percentage
hyperbilirubinemia kernicterus (n=2, 2.5%) and unknown
patients
HIE 2 30 37.1
Type of seizure Number of Percentage
HIE 3 8 9.8
events
Septicemia and meningitis 26 32.1
Subtle seizures 35 37.2%
Hypocalcemia 11 13.6
Focal clonic seizures 19 20.2%
Hypoglycemia 9 11.1 Multifocal clonic seizure 15 15.9%
Hyponatremia 6 7.4 Myoclonic seizures 14 14.9%
Hyperbilirubenemia kernicterus 2 2.5 tonic seizures 11 11.7%
Unknown 2 2.5 (9 neonates had more than 1 clinical type of seizure during
(13 neonates had more than 1 risk factor for their seizures) their hospital stay)
Table-1: Profile of risk factors for neonatal seizures: Table-2: Clinical type of neonatal seizure:

Age of onset of Seizure Etiology of Seizure Number Percentage

Less than 12 hr of life HIE 21 22.3%
(Total no. of events=27) Hypoglycemia 3 3.2%
Hypocalcemia 3 3.2%
12 to 24 hr of life HIE 14 14.9%
(Total no. of events= 23) Septicemia- Meningitis 2 2.1%
Hypoglycemia 2 2.1%
Hypocalcemia 3 3.2%
Hyponatremia 2 2.1%
24 to 72 hr of life HIE 3 3.2%
(Total no. of events= 12) Septicemia- Meningitis 6 6.4%
Hypoglycemia 1 1.1%
Hyponatremia 1 1.1%
Hypocalcemia 1 1.1%
More than 72 hrs Hypocalcemia 4 4.2%
(Total no. of events= 32) Hyponatremia 3 3.2%
Hypoglycemia 3 3.2%
Septicemia- meningitis 18 19.1%
Kernicterus/Bilirubin encephalopathy 2 2.1%
Unknown cause-2 2 2.1%
Table-3: Age of occurrence and the risk factor for neonatal seizure

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Section: Pediatrics International Journal of Contemporary Medical Research
Volume 7 | Issue 12 | December 2020 | ISSN (Online): 2393-915X; (Print): 2454-7379
Abhishek, et al. Short Term Outcome of Seizures in Term Neonates

Sl No. Parameter studied Term neonates with seizure Term neonates without seizure P value
(n=81) (n=354)
01 Mortality 28.4% 23.1% 0.31
02 Hospital stay (days) Mean 8.4, SD 2.7 Mean 7.5, SD 2.4 0.003
03 Ventilator support 15.1% 21.6% 0.19
04 Inotrope support 12.5% 14.1% 0.70
05 Enteral feeds starting after admission (days) Mean 6.1, SD 2.3 Mean 5.2, SD 1.9 0.0003
Table-4: Univariate analysis of short term outcome

(n=2, 2.5%) (table-1). 72 hours of life and most of them could be attributed to birth
asphyxia (61.3% of these events). Rose et al10 also found early
Clinical type of neonatal seizures: Overall, there were 94
onset seizures in 50.33% babies whereas Coen RW et al11
instances of neonatal seizures. The most common type of
found that 81% of babies had early onset seizures. In a study
seizure was subtle seizures (n=35, 37.2%), followed by focal
done by Ajay at New Delhi, 52 neonates developed seizures
clonic seizures (n=19, 20.2%), multifocal clonic seizures
within 48 hours of life, out of which 20 neonates had seizure
(n=15, 15.9%) and myoclonic seizure (n= 14, 14.9%). The
in less than 12 hours of life.12 Theses are in agreement to our
least common type of seizures was tonic seizures (n= 11,
findings and emphasizes the need to be more vigilant during
11.7%) (table-2).
the early hours of life of a neonate, more so when dealing
Time of presentation of seizures: Of the 94 events of with sick neonates.
neonatal seizures studied in these 81 neonates, 27(28.7%) In our study most common risk factor for neonatal seizure
events of NS occurred before 12 hours of life, 23(24.5%) was perinatal asphyxia (46.9% neonates), followed by
between 12 hours to 24 hours of life, 12(12.8%) between 24 sepsis-meningitis in 32.1% neonates. Metabolic disturbances
hours to 72 hours of life and 32(34%) after 72 hours of life. (hypoglycemia, hyponatremia, hypocalcemia) were also
Overall, 62 events (66.%) were reported before 72 hours of seen in 32.1% neonates. In a study done by Sahana et al13 on
age and the rest 32 (34%) were reported after 72 hours of clinical profile of neonatal seizures in 109 neonates, 63 had
age (table-3). perinatal asphyxia as the major common etiology (57.80%),
Outcome: In neonates with seizure, mortality was 23 second major common etiology was infection (14.67%). In
(28.4%), mean duration of hospital stay was 8.4 days (SD= another study, Shah et al14 showed that the major etiology
2.7 days). In univariate analysis, neonatal seizure in term of seizures were birth asphyxia(44%), septicemia (11%),
neonates was associated with a significantly higher duration meningitis (11%), hypocalcemia (11%), and hypoglycemia
of hospital stay and delay in commencement of oral feeds (22%). These figures correlate with our findings and
but there was no significant increase in mortality, need of reiterate the high burden of neonatal seizures in asphyxiated
ventilator support or inotrope support in such neonates as neonates which require prompt recognition and management
compared to term neonates without seizures (table-4). of seizures to improve the outcome of these unfortunate
neonates.
DISCUSSION We also studied the short term outcome of such neonates
Seizures are usually the first indicators of metabolic or and compared it with term neonates without seizures. In
neurological disorder .They are powerful predictors of long univariate analysis, neonates with seizures were found to
term cognitive and developmental impairment. The time have a significant longer duration of hospital stay as well
of onset of seizures has a correlation with the etiology of as significant delay in starting oral feeds. However, there
seizures and prognosis. Biochemical disturbances occur was no increase in mortality, need of ventilator support or
frequently in neonatal seizures either as an underlying cause inotrope support in such neonates. This however may be
or as associated abnormalities and are often underdiagnosed.6 explained by the higher proportion of asphyxiated neonates
This study attempts to determine etiology, biochemical in seizure group who require more interventions owing to
abnormalities and short term outcome in neonatal seizures their perinatal depression.
which would help in early recognition and treatment and Limitations
hence better prognosis in neonatal seizures. First limitation is inherent in the study design, this is a single
In our study subtle seizures was the commonest seizure type centre study. Second, EEG correlation with the seizures was
(37.2%) followed closely by clonic seizures (36.1%) while not done and so it is likely that the true incidence of seizures
tonic seizures were the least common (11.7%). Silverstein couldn’t be reported. Third, we couldn’t do long term follow
et al.7 showed subtle seizures as the commonest type of fits up of these neonates.
occurring in approx 50% of neonates which is only slightly
higher than our findings. Moreover, the comprehensive work CONCLUSION
of Mizrahi et al8 and Scher et al9 also reports subtle seizures Hypoxic ischemic encephalopathy was the commonest
as the most common type of neonatal seizures. etiology in our study, followed by sepsis-meningitis. Together,
In our study 62 (66%) of seizures presented within the first these two problems are accountable for approximately 75%

International Journal of Contemporary Medical Research Section: Pediatrics L3

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 12 | December 2020
Abhishek, et al. Short Term Outcome of Seizures in Term Neonates

of total neonatal seizure cases. Subtle seizures were the

commonest clinical type of seizure which can be easily Source of Support: Nil; Conflict of Interest: None
missed by untrained eyes. Most of the neonates developed Submitted: 14-10-2020; Accepted: 26-11-2020; Published: 22-12-2020
seizure within 72 hours of life. Relatively earlier presentation
and a high burden of asphyxia indicate that there is a pressing
need to improve the quality of care these neonates receive
during their prenatal period. Occurrence of neonatal seizure
in term neonate seems to significantly increase duration of
hospital stay and delay the commencement of oral feeds
without increasing mortality.
Abbreviations
GA: Gestational age; HIE: Hypoxic ischemic encephalopathy; NS:
neonatal seizure; NICU: neonatal intensive care unit; SD: standard
deviation;
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Section: Pediatrics International Journal of Contemporary Medical Research
Volume 7 | Issue 12 | December 2020 | ISSN (Online): 2393-915X; (Print): 2454-7379