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    Approach and Management of Neonatal Seizures

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    G Venkatesh
    This document provides guidance on evaluating and managing neonatal seizures. It defines seizures and describes the various types seen in neonates. Common causes of neonatal seizures include hypoxic ischemic encephalopathy, intraventricular hemorrhage, metabolic disorders, infections, and genetic conditions. The approach involves obtaining a thorough history, conducting a full examination, and ordering appropriate tests like bloodwork, imaging, EEG. Initial treatment consists of identifying and treating any underlying metabolic abnormalities. If seizures continue, first line anticonvulsants like phenobarbital and phenytoin are administered. Second line drugs are considered if seizures remain refractory. The goal is to control seizures while determining the underlying etiology.

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    Approach and Management of Neonatal Seizures

    Uploaded by

    G Venkatesh
    727 views42 pages
    This document provides guidance on evaluating and managing neonatal seizures. It defines seizures and describes the various types seen in neonates. Common causes of neonatal seizures include hypoxic ischemic encephalopathy, intraventricular hemorrhage, metabolic disorders, infections, and genetic conditions. The approach involves obtaining a thorough history, conducting a full examination, and ordering appropriate tests like bloodwork, imaging, EEG. Initial treatment consists of identifying and treating any underlying metabolic abnormalities. If seizures continue, first line anticonvulsants like phenobarbital and phenytoin are administered. Second line drugs are considered if seizures remain refractory. The goal is to control seizures while determining the underlying etiology.

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    This document provides guidance on evaluating and managing neonatal seizures. It defines seizures and describes the various types seen in neonates. Common causes of neonatal seizures include hypoxic ischemic encephalopathy, intraventricular hemorrhage, metabolic disorders, infections, and genetic conditions. The approach involves obtaining a thorough history, conducting a full examination, and ordering appropriate tests like bloodwork, imaging, EEG. Initial treatment consists of identifying and treating any underlying metabolic abnormalities. If seizures continue, first line anticonvulsants like phenobarbital and phenytoin are administered. Second line drugs are considered if seizures remain refractory. The goal is to control seizures while determining the underlying etiology.

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    Download as pptx, pdf, or txt
    727 views42 pages

    Approach and Management of Neonatal Seizures

    Uploaded by

    G Venkatesh
    This document provides guidance on evaluating and managing neonatal seizures. It defines seizures and describes the various types seen in neonates. Common causes of neonatal seizures include hypoxic ischemic encephalopathy, intraventricular hemorrhage, metabolic disorders, infections, and genetic conditions. The approach involves obtaining a thorough history, conducting a full examination, and ordering appropriate tests like bloodwork, imaging, EEG. Initial treatment consists of identifying and treating any underlying metabolic abnormalities. If seizures continue, first line anticonvulsants like phenobarbital and phenytoin are administered. Second line drugs are considered if seizures remain refractory. The goal is to control seizures while determining the underlying etiology.

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    Some of the key takeaways from the document are that subtle seizures are the most common type of neonatal seizures, hypoxic ischemic encephalopathy is the most common cause, and phenobarbitone is usually the first line treatment for neonatal seizures.

    The main types of neonatal seizures discussed are subtle, clonic, tonic, myoclonic and spasms seizures.

    Common causes of neonatal seizures mentioned include hypoxic ischemic encephalopathy, hypoglycemia, hypocalcemia, cerebral malformations and bacterial meningitis.

    CASE

    OF
    NE0NATAL
    CONVULSIONS
    Dr. Balakrishna
    2nd year Postgraduate
    Dept of pediatrics
    OBJECTIVES
    To familiarize the varied presentations of
    neonatal seizures.
    To distinguish non seizure states from
    seizures.
    To recognize the unique etiology of neonatal
    seizures.
    To familiarize the algorithm of management
    specific to neonatal seizures.
    To be able to decide the duration of
    antiepileptic therapy and followup.
    OVERVIEW
    DEFINITION OF SEIZURE
    TYPES OF NEONATAL SEIZURES
    CAUSES OF NEONATAL SEIZURES
    SEIZURE MIMICS
    APPROACH TO NEONATAL SEIZURES
    DURATION OF ANTICONVULSANT THERAPY
    GUIDELINES
    PROGNOSIS
    SEIZURE is defined clinically as paroxysmal
    alteration in neurologic function ie., motor,
    behaviour and/or autonomic function.
    It includes
    1. Epileptic seizures - phenomenon associated
    with corresponding EEG seizure activity.
    Eg: clonic seizures.
    2. Nonepileptic seizures - clinical seizures
    without corresponding EEG correlate.
    Eg: subtle and generalised tonic seizures.
    3. EEG seizures - abnormal EEG activity with
    no clinical correlation.
    Why seizures are common in neonatal
    period ?

    Seizures are common in neonatal period than


    any other time in life due to decreased
    seizure threshold.

    Transient overdevelopment of excitatory


    system than inhibitory system.
    Why seizures are common in preterm
    neonates ?

    Incidence of Neonatal seizures is 2.8 per 1000


    in infants with birth weight >2.5kg. It is higher
    in preterm LBW neonates as high as 57.5 per
    1000.

    Myelination, dendritic processes, arborization


    starts to develop at term.
    Why generalised seizures are rare in
    neonates ?

    Neonatal brain has reduced connectivity,


    therefore electrical discharges spread
    incompletely, so generalised seizures are
    rare in neonates.
    TYPES OF NEONATAL
    SEIZURES
    There are 5 subtypes of neonatal seizures
    1. Subtle seizures
    2. Clonic seizures
    3. Tonic seizures
    4. Myoclonic seizures
    5. Spasms
    SUBTLE SEIZURES
    Most common form(>50%)
    It includes
    a) Ocular - tonic horizontal deviation of eyes or
    sustained eye opening with ocular fixation or
    cycled fluttering.
    b) Oral facial lingual movements - chewing, tongue
    thrusting, lip smacking etc.
    c) Limb movements - cycling, paddling, boxing etc.
    d) Autonomic phenomena-tachycardia or
    bradycardia.
    e) Apnea may be a rare manifestation of seizure.
    CLONIC SEIZURES
    Rhythmic movements of muscle groups.
    Have both fast and slow movements.
    Commonly associated with EEG changes.
    May be unifocal or multifocal.
    Focal clonic has good prognosis.
    TONIC SEIZURES
    Pattern is sustained posture of limbs or
    asymmetrical truncal postures.

    cause: diffuse neurological injury or IVH in


    preterm or postasphyxial.

    Prognosis is poor except for postasphyxial


    cases.
    MYOCLONIC SEIZURES
    Non rhythmic lightning fast contraction.

    Seen in diffuse brain damage as in perinatal


    asphyxia, inborn errors of metabolism,
    cerebral dysgenesis.

    Worst prognosis in terms of


    neurodevelopmental outcome and seizure
    recurrence.
    SPASMS
    Sudden generalised jerks lasting for 1-2sec.

    Distinguished from generalised tonic spells by


    their short duration and they are usually
    associated with single very brief generalised
    discharge.
    CAUSES OF NEONATAL SEIZURES
    AGES 1 - 4 DAYS

    HIE ( most common )

    IVH

    Acute metabolic disorder

    hypocalcemia
    hypoglycemia
    hypomagnesemia
    hypo/ hypernatremia
    Drug withdrawl maternal drug use of
    narcotics or barbiturates.

    Drug toxicity- lidocaine, penicillin.

    Inborn errors of metabolism


    galactosemia, hyperglycinemia, urea cycle
    disorders.

    Pyridoxine deficiency (must be considered


    at all ages).
    AGES 4 - 14 DAYS

    Infection meningitis (bacterial) , encephalitis


    (enteroviral, herpes simplex).
    Metabolic disorders hypocalcemia,
    hypoglycemia
    Drug withdrawal
    Kernicterus, hyperbilirubinemia
    Benign neonatal convulsions
    Developmental delay, epilepsy, neonatal
    diabetes syndrome- DEND syndrome
    AGES 2 - 8 WEEKS

    Infection
    Head injury subdural hematoma
    Inherited disorders of metabolism -
    aminoacidurias , organic aciduria, urea cycle
    defects
    Malformations of cortical developments
    lissencephaly, focal cortical dysgenesis.
    Tuberous sclerosis
    Sturge weber syndrome
    SPECIFIC ETIOLOGIES
    Hypoxic Ischemic Encephalopathy

    Most common cause of neonatal seizures


    usually in the first 24 hours.

    In perinatal asphyxia, seizures occur in


    context of history of difficulty during labour ,
    delivery with fetal HR alterations, low Apgar
    scores.
    Intra cranial hemorrhages

    Sub arachnoid hemorrhages cause


    seizures usually on second day and have a
    very good outcome.
    In preterm infant, seizures occur with
    extension of germinal matrix hemorrhage
    to parenchyma typically after 3 days of life
    and it is not assosciated with good
    outcome.
    Acute metabolic disorders

    Hypoglycemia : RBS level <40mg/dl in the first


    24 hours and <50mg/dl after 24 hours.

    Hypocalcemia : Whole blood ionized calcium is


    the best measure.
    ionised calcium < 1.1 mmol/lit in > 1500gm.
    ionised calcium < 1 mmol/lit in < 1500gm.
    Hypomagnesemia: Levels < 1.4mg/dl (0.6
    mmol/lit ) are considered low.
    Hypo/Hypernatremia
    Neonatal seizure syndromes

    Benign familial neonatal seizures


    Benign idiopathic neonatal seizures ( fifth day
    fits )
    Early infantile epileptic encephalopathy
    ( Ohtahara syndrome )
    Malignant migrating partial seizures ( Coppala
    syndrome )
    SEIZURE MIMICS
    1. Jitteriness suppress with passive flexion,
    increases with stimulation, not associated with
    autonomic accompaniments and eye
    movements.
    2.Epileptic apnea associated with
    tachycardia.
    3.Benign neonatal sleep myoclonus - occur
    as synchronus myoclonic jerks during REM
    sleep disappear when baby is awake, EEG is
    normal and seizures spontaneously resolve by
    2 months of age.
    CLINICAL CHARACTER SEIZURE
    JITTERINESS
    rare
    Increases with
    common
    stimulation
    Suppress with absent
    passive flexion present
    Autonomic
    accompanimen present
    ts absent
    Predominant
    movement clonic jerking
    tremor
    APPROACH TO NEONATAL
    SEIZURES
    HISTORY

    Seizure history regarding type of seizure ,


    associated movements , day of onset.

    Antenatal history - intrauterine infection ,


    maternal diabetes , narcotic addiction.

    Perinatal history - H/o fetal distress,


    instrumental delivery, need for resuscitation in
    labour room, apgar scores .
    Feeding history appearance of lethargy,
    poor activity and vomiting after initiation of
    breast feeding may be suggestive of IEM.

    Family history H/o consanguinity in


    parents , family h/o seizures or MR , early
    fetal or neonatal deaths would be suggestive
    of IEM.
    H/o seizures in either parent or sibling in
    neonatal period may be suggestive of benign
    familial neonatal convulsion.
    EXAMINATION

    Vitals HR, RR, CRT, Temp, BP.

    General examination gestation , birth wt


    and wt for age
    - Seizures in term well baby may be due to
    SAH.
    - Seizures in large for date babies may be due
    to
    hypoglycemia.
    CNS examination presence of bulging AF may
    be
    suggestive of meningitis or ICH
    - consciousness (alert /drowsy/comatose).
    - tone (hypo/hyper).
    - fundus examination for chorioretinitis.

    Systemic examination presence of


    hepatosplenomegaly or abnormal urine odour
    may
    be suggestive of IEM
    - skin should be examined for neurocutaneous
    markers .
    INVESTIGATIONS
    Essential
    - Blood sugar
    - Serum electrolytes
    - CSF examination
    - Cranial ultrasound
    - EEG
    Additional
    - Neuroimaging (CT, MRI)
    - Screen for congenital infections (TORCH)
    - Screen for IEM
    NSG - excellent tool for detection of IVH and
    parenchymal hemorrhage.

    CT - diagnostic in SAH and developmental


    malformations.

    MRI - diagnostic in cerebral dysgenesis,


    lissencephaly and other neuronal migration
    disorders.

    EEG - diagnostic and prognostic role in


    seizures and should be done in all neonates
    who need anticonvulsant treatment.
    Acute management of
    seizures
    Neonate with seizures

    Identify and characterize the seizure


    Secure airway and optimize breathing, circulation, and temperature
    Secure IV access and take samples for baseline investigations

    If hypoglycemic (blood sugar <40 mg/dl): administer 2 ml/kg


    of 10% dextrose as bolus followed by a continuous infusion
    of 6-8 mg/kg/min

    If serum calcium is abnormal, 2 ml/kg of calcium gluconate


    (10%) should be given IV under cardiac monitoring

    Seizures persist
    Administer phenobarbitone 20mg/kg IV stat
    over 20 minutes
    Seizures
    continue
    Repeat phenobarbitone in 10 mg/kg/dose
    aliquots until 40 mg/kg dose is reached
    Seizures continue

    Administer phenytoin 20 mg/kg IV slowly


    over 20 minutes under cardiac monitoring
    Seizures continue

    Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated


    Midazolam: 0.15 mg/kg IV bolus followed by infusion of 1-7 mcg/kg/min
    Clonazepam 0.1mg/kg;Consider ventilation.
    Seizures continue
    Second line drugs like
    Lidocaine[4mg/kg f/b 2mg/kg/hr]
    Paraldehyde[0.1-0.2ml/kg/dose IM]
    sodium valproate[20-25mg/kg f/b 5-10mg/kg/12h]
    Topiramate(20mg/kg/day)
    Levetiracetam(10-30mg/kg/day)
    Vigabatrin(50mg/kg/day) Pyridoxine(100mgIVtestdose)
    exchange transfusion[IEMs,drug toxicity,bilirubin encephalopathy ]

    Seizures controlled

    Wean AEDs slowly to maintenance


    phenobarbitone
    MAINTENANCE DOSES
    Phenobarbitone or phenytoin after
    loading dose maintenance dose 3-5
    mg/kg/day divided in bd .
    Start weaning if baby convulsion free
    for 72 hours .
    Wean slowly in a way, taper the last
    given anti convulsant first and first
    given phenobarbitone in last.
    DURATION OF ANTICONVULSANT
    THERAPY GUIDELINES
    Newborn on anticonvulsant therapy

    Wean all antiepileptic drugs except phenobarbitone once


    seizure controlled

    Perform neurological examination prior to discharge

    Normal Abnormal
    Stop
    phenobarbitone Continue phenobarbitone for 1 month
    prior to
    discharge
    Repeat neurological examination at 1 month

    Normal examination Abnormal examination

    Stop Evaluate EEG


    phenobarbiton Abnormal EEG
    e. Normal EEG Continue drug;
    Stop reassess at 3
    phenobarbitone
    PROGNOSIS
    Focal clonic seizures carry the best prognosis.
    Myoclonic seizures carry the worst prognosis
    in terms of neurodevelopmental outcome and
    seizure recurrence.
    Seizures due to SAH and late onset
    hypocalcemia carry best prognosis in terms of
    long term neurodevelopmental outcome.
    Seizures related to hypoglycemia,cerebral
    malformations and meningitis have adverse
    outcome.
    Neurological Disease Normal
    Development

    Hypoxic-ischemic encephalopathy 50%

    Primary subarachnoid hemorrhage 90%

    Hypocalcemia
    Early-onset 50%
    Later-onset
    100%

    Hypoglycemia 50%
    Bacterial meningitis 50%
    SUMMARY
    Seizures are common in neonatal period than any
    other period of life.
    Subtle seizures are the most common type of
    neonatal seizures.
    Hypoxic ischemic encephalopathy is the most
    common cause of neonatal seizures.
    Phenobarbitone is the drug of choice for neonatal
    seizures.
    Focal clonic seizures and seizures due to
    subarachnoid hemorrhage and late onset
    hypocalcemia carries best prognosis.
    REFERENCES
    AIIMS NICU PROTOCOL
    PGEI NICU PROTOCOL
    MANUAL OF NEONATAL CARE - CLOHERTY
    NELSON TEXTBOOK OF PEDIATRICS
    CARE OF THE NEWBORN MEHARBAN SINGH
    PRACTICAL PEDIATRIC NEUROLOGY VEENA
    KALRA
    IAP TEXT BOOK OF PEDIATRICS
    THANK YOU

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