Neonatal Seizures

2. Introduction
• Seizures are the most common manifestation of a
neurological disorder in the neonatal period and may
be the only clinical indication of neurological
dysfunction in this age group.
• Neonates have a greater tendency to develop seizures
than older infants and children due to the inherent
hyperexcitability of the immature brain and the
multiple risk factors found in this age group.
• Seizures in the neonate may be difficult to recognize
because they are brief, fragmentary and lack the
organization seen in older children.

3. • Nonepileptic phenomena like jitteriness,
benign sleep myoclonus and generalised tonic
posturing are often confused with epileptic
seizures.
• Neonatal seizures are rarely idiopathic and
are the single most major predictors of
adverse neurological outcome.

4. Clinical recognition of seizure activity
• For immediate management, diagnosis is based on the clinical
recognition of repetitive, stereotypic motor, behavioral or
autonomic phenomena that comprise the spectrum of neonatal
seizure activity. These are:
o Spontaneous, paroxysmal, repetitive, motor or autonomic
phenomena like lip smacking, sucking, chewing, respiratory
irregularities (tachypnoea or apnoea), cycling or peddling
movements. This group constitutes the most common type of
neonatal seizures, seen in 50 % of cases of neonatal seizures.
o Tonic posturing with or without abnormal gaze.
o Clonic movements which may be unifocal, multifocal or
generalised
o Myoclonic jerks

5. • True seizures are usually not stimulus sensitive, cannot be stopped
with restraint and are usually associated with altered sensorium or
autonomic or ocular phenomena.
• Most neonatal seizures may be categorised as symptomatic
seizures and are representative of a group of disorders with an
identified etiology.
• These events which occur in close association with EEG seizure
activity are referred to as epileptic neonatal seizures.
• When associated with other clinical signs that suggest CNS injury,
their etiology may be considered cryptogenic.
• When such seizures occur in otherwise normal infants, they may be
considered idiopathic.
• For clarification it has been proposed that clinical events first be
designed as seizures and then be referred to as either epileptic or
nonepileptic.

6. Nonepileptic Behaviors of Newborns

7. Etiology of neonatal seizures

8. Management
• Once a seizure is appreciated clinically in a
neonate it is taken as an emergency and warrants
the following actions:
I. Stabilization of the neonate and treatment of
the seizure
II. Detection and treatment of underlying cause
III. Long term planning and prognostication

9. Stabilization and treatment of the
seizure
• All neonate with seizures need to be admitted.
• Seizures can cause significant cardio respiratory and
metabolic disturbances and potentially aggravate brain
injury.
• Hence ongoing seizures must be treated energetically,
while simultaneously trying to determine the underlying
cause.
• Maintenance of airway and breathing, administration of
oxygen and ensuring adequate circulation are mandatory
during or immediately after a seizure. A good IV access and
facilities for intubation should be available.

10. • since hypoglycaemia is a common, treatable cause,
during a seizure of unconfirmed etiology the blood
glucose level should be checked with a bedside
glucometer and
• if levels are low (<40 mg%), a bolus of 200 mg (2ml)/Kg
of 10%D should be given immediately followed by a
glucose drip@ 7-8 mg/Kg/min (100 ml/Kg/day of 10%
D).
• Blood sugar should be repeated after 10-15 min and a
repeat bolus given if required.
• This step may be omitted in recurrent seizures of
known etiology other than hypoglycaemia.

11. • In cases of suspected hypocalaemia, especially if the
seizures are multifocal clonic, a bolus of Calcium
gluconate 10%, 2ml/Kg IV dilutes 1:1 in 5%D, may be
given slowly with heart rate monitoring, making sure
that the heart rate does not fall by more than 20
beats/min form the baseline during administration.
• It is not required to wait for the serum calcium report
to give Calcium gluconate in every case of seizures.
• In suspected or known cases of hypocalcaemia not
responding to adequate calcium, Inj Magnesium
sulphate (0.2ml/Kg of 50% solution) should be given
IM.

12. • If the seizure is not controlled with the above measures,
anticonvulsants should be given.
• The ideal anticonvulsant for the neonate is still controversial but till
further evidence is forthcoming,
• Phenobarbitone is the first line drug of choice in neonatal seizures.
• The loading dose is 20 mg/Kg slow IV, over 20 minutes, which can
be repeated @ 5mg/Kg, if there is no response to a maximum of
40mg/Kg.
• If ventilator is not available it is prudent not to exceed the loading
dose of 20 mg/Kg to prevent respiratory depression, specially in a
case of birth asphyxia with hypoxic ischaemic encephalopathy.
• If the seizures persist Phenytoin is the second line drug of choice
and is given as 20 mg/Kg as a bolus in normal saline over 20
minutes if the seizure continues or recurs. A repeat dose of 5
mg/Kg may be given if there is no response.

13. • Benzodiazepines like Midazolam, Lorazepam and
Clonazepam (any one) have all been used
effectively as third line drugs and they are given
as bolus doses which may be followed by a
continuous drips .
• While using these drugs too, ideally, there should
be back up of ventilator support in case the baby
develops respiratoy depression.
• Diazepam is avoided in neonates due to its short
anticonconvulasant action, long sedative action
and greater respiratory depressant action.

14. • Any seizure lasting > 1 minute or seizures occurring > 2/hr
should be treated to quiescence as far as possible.
• Fewer seizures or seizures of shorter duration (despite
multiple anticonvulsants) not causing cardiorespiratory
compromise may be ignored in certain conditions like HIE
Stage III as they tend to “burn out” spontaneously.
• However, in cases where the etiology is not established a
trial of Inj Pyridoxine or other anticonvulsants is warranted,
unless EEG is normal during these clinical events.
Pyridoxine is given IV @ 50-100 mg.
• Valproate, Carbamazepine, Lamotrigine and Vigabatrin
have been tried in refractory seizures in the newborn with
variable success.

15. Algorithm for acute therapy of
neonatal seizures
• Ensure the patency of airway, ( suction )
• Assess Respiration, Heart rate, Blood pressure,
colour, Pulse Oximeter.
• Start Oxygen.
• Secure IV line
• Check glucose by glucometer
• Collect blood for investigations depending on
clinical suspicion Hypoglycemia

16. CAUSE SPECIFIC THERAPY
1. Hypocalemia:
2. Hypomagnesemia
3. Pyridoxine deficiency
4. Correction of electrolyte imbalance
5. Sepsis / Meningitis : Antibiotics

17. Hypoglycemia
Consider Valproate / Carbamazepine/newer anticonvulsants (after consultation
with Neonatologist Pediatric neurologist)

18. Refractory seizures
• Trial of AED
• Failure to respond to 2 or more regimens
• Side effects seen at the cost of seizure control.
• Check - Right Drug + Dose + Duration +
Compliance + Drug vehicle + IV patency Is it a
pseudo-seizure ? Search for:
Metabolic
Epileptic
Structural Anomaly

19. Anti-convulsant used in neonatal
seizures

20. Alternative Drugs for Neonatal
Seizures

21. Detection and treatment of underlying
cause
• Identification of a single etiologic factor as the cause for
seizures is often difficult. For example hypocalcemia,
hypoglycemia and intracranial hemorrhage maybe
associated with hypoxic-ischemic encephalopathy and all
these can cause seizures.
 Maternal and neonatal history like fetal compromise, IUGR,
drugs taken by mother during pregnancy, consanguinity,
early deaths in the family may suggest a likely etiology.
 A detailed general and neurologic examination should be
performed. Look for dysmorphic features, neurocutaneous
markers, skin pigmentation, hair changes, abnormal body
and urine odors.

22.  Hb/PCV, blood glucose, calcium and magnesium and
electrolytes should be done.
 Other metabolic parameters like pH, lactate, ammonia,
aminoacids, organic acids, fatty acids and urinary
ketones are individualised and not recommended in all
cases but restricted to those cases of suspected Inborn
Errors of Metabolism (IEMs).
 Septic workup, when clinical situation is not clear or
sepsis is strongly suspected is mandatory. This includes
complete blood count, peripheral smear, CRP, lumbar
puncture, blood and urine cultures.

23. • EEG: This is indicated in all cases of neonatal seizures,
which are recurrent, resistant, associated with abnormal
neurological findings or where no definite etiology is
forthcoming. Interpretation of the findings in the neonatal
age group is gestational age dependant and requires special
expertise.
• EEG helps both to detect an acute episode by continuous
monitoring wherever possible and to look at the
background tracing for prognostication in the interictal
stage.
• The EEG is analysed for ictal activity (focal or multifocal
spikes or sharp waves and focal monorhythmic discharges)
and for background activity.

24. • Neuroimaging: This has more value in prognostication
rather in acute management. Early neuroimaging is advised
when structural malformations are suspected.
• Head USG is available for bed side diagnosis and is good for
ventricular pathology like intraventricular hemorrhage.
• Neurosonography cannot detect subarachnoid and
subdural hemorrhage CT scan brain can be done faster than
MRI and is especially good for hemorrhages and
calcifications.
• MRI provides better resolution of anatomy and details of
function and perfusion with Diffusion Weighted MRI, MR
Spectroscopy and MR angiography.

25. Clinical points
• Not all seizures may warrant anti epileptic drug (AED) treatment
because they may not be epileptic in character. When the seizures
are epileptic, they may be too brief or infrequent to justify
treatment.
• Phenobarbital is almost universally accepted as the first-line AED
and phenytoin as the second-line AED. However studies have found
no significant difference between them and neither proved as
efficacious as generally believed. Phenytoin is not compatible with
concomitant dopamine use.
• Acute administration of anti convulsants may carry some risk of
adverse reactions, such as CNS depression, hypotension,
bradycardia, and respiratory depression (all of which may be
associated with phenobarbital, diazepam, and lorazepam) and
cardiac arrhythmia (associated with phenytoin). Thus, appropriate
monitoring of infant’s vital parameters is indicated.

26. • Dosage titration should be based primarily on clinical
endpoints (seizure control or the development of side
effects) rather than serum drug concentrations.
• Keep resuscitation apparatus ready by the side of baby.
• Major determinant of prognosis is most likely the
underlying etiology.
• Response to the first AED is the most powerful
predictor of long-term prognosis.

27. • Infants with metabolic disorders usually are lethargic
and feed poorly even prior to seizures. Alteration in
mental status far outweighs other signs early on, and a
child is more likely to present comatose, but with a
preserved blood pressure.
• Unresolved issues :
a) Optimal maintenance doses of Anti-convulsant.
b) Importance of eliminating electrographic seizures.
c) Optimal duration of anticonvulsant therapy.
d) Whether AED or seizure adversely affect the
immature brain.

28. Long-term management
• Long term management of neonatal seizures
depends on the etiology and neurological
status of the neonate including the EEG.
• A neonate is considered to be neurologically
normal if there is no paucity of movements,
cry, tone and neonatal reflexes are normal and
suckling has started.

30. Prognostication
• These depend upon the type of clinical seizure, etiology, associated
problems, effect of intervention and EEG changes.
• Focal clonic seizures are invariably benign while persistent tonic
seizures have poor outcome.
• Among the underlying causes, hypocalcemia and primary
subarachnoid hemorrhage have the best prognosis and cerebral
dysgenesis the worst.
• Hypoglycaemia, intracranial hemorrhage, infection and infarcts if
extensive or prolonged have a poor prognosis but otherwise
prognosis may be better.
• Refractory seizures or seizures in preterms have a poor prognosis.
• Interictal burst suppression pattern and isoelectric EEG patterns
indicate poor neurological outcome.

31. Key points
• Neonatal seizures are rarely idiopathic. A thorough search for the
aetiology is warranted.
• Most of the neonatal seizures are self limited and rarely lead to
chronic post neonatal convulsive disorder. The term epilepsy,
therefore is rarely applied in neonatal period.
• Seizure syndromes are typically characterised by a cluster of clinical
signs, symptoms, and laboratory findings. The EEG is characteristic
and is an important diagnostic criterion for the syndromes.
• Long-term prognostication is guarded in recurrent or resistant
seizures or those with EEG abnormalities.
• There is increasing evidence that neonatal seizures have an adverse
effect on neurodevelopment and may predispose to cognitive,
behavioral, or epileptic complications later in life.

32. THANKS FOR YOUR
Attention