NEONATAL

SEIZURES
Dr.VENKATESH
Postgraduate
DeptofPediatrics
SVmedicalcollege

OBJECTIVES
Tofamiliarizethevariedpresentationsof
neonatalseizures.
Todistinguishnonseizurestatesfromseizures.

Torecognizetheuniqueetiologyofneonatal
seizures.
Tofamiliarizethealgorithmofmanagement
specifictoneonatalseizures.
Tobeabletodecidethedurationofantiepileptic
therapyandfollowup.
OVERVIEW

DEFINITIONOFSEIZURE
TYPESOFNEONATALSEIZURES

CAUSESOFNEONATALSEIZURES

SEIZUREMIMICS

APPROACHTONEONATALSEIZURES

DURATIONOFANTICONVULSANTTHERAPY
GUIDELINES
PROGNOSIS
 SEIZUREisdefinedclinicallyasparoxysmal
alterationinneurologicfunctionie.,motor,behaviour
and/orautonomicfunction.
Itincludes
1.Epilepticseizuresphenomenonassociatedwith
correspondingEEGseizureactivity.
Eg:clonicseizures.
2.Nonepilepticseizuresclinicalseizureswithout
correspondingEEGcorrelate.
Eg:subtleandgeneralisedtonicseizures.
3.EEGseizuresabnormalEEGactivitywithno
clinicalcorrelation.
EPIDEMIOLOGYINDIA(NNPD;200203)
Incidence:10.3per1000livebirths

TheincidenceishighinPRETERM
neonates(2fold),VLBW(4fold)compared
toTERMneonates.
Termneonates8.4
Pretermneonates20.8
VLBW36.1
Whyseizuresarecommoninneonatal
period?

Seizuresarecommoninneonatalperiodthanany
othertimeinlifeduetodecreasedseizurethreshold.

Transientoverdevelopmentofexcitatorysystemthan
inhibitorysystem.
Whygeneralisedseizuresarerarein
neonates?

Neonatalbrainhasreducedconnectivitydue
toincompletemyelination,soelectrical
dischargesspreadincompletely.
TYPESOFNEONATALSEIZURES

Fourtypesofneonatalseizures
1.Subtleseizures
2.Clonicseizures
3.Tonicseizures
4.Myoclonicseizures
SUBTLESEIZURES
Mostcommonform(>50%)
Itincludes

a)Oculartonichorizontaldeviationofeyesor
sustainedeyeopeningwithocularfixationorcycled
fluttering.
b)Oralfaciallingualmovementschewing,tongue
thrusting,lipsmackingetc.
c)Limbmovementscycling,paddling,boxingetc.
d)Autonomicphenomenatachycardiaorbradycardia.
e)Apneamaybeararemanifestationofseizure.
CLONICSEIZURES

Rhythmicmovementsofmusclegroups.
Havebothfastandslowmovementswithfrequencyof
13jerkspersecond.
CommonlyassociatedwithEEGchanges.

Maybeunifocalormultifocal.

Focalclonichasgoodprognosis.
TONICSEIZURES
Patternissustainedpostureoflimbsor
asymmetricaltruncalpostures.

cause:diffuseneurologicalinjuryorIVHin
pretermorpostasphyxial.
UsuallynoEEGchanges.

Prognosisispoorexceptforpostasphyxialcases.
MYOCLONICSEIZURES
Nonrhythmiclightningfastcontraction.

Seenindiffusebraindamageasinperinatal
asphyxia,inbornerrorsofmetabolism,cerebral
dysgenesis.

Worstprognosisintermsofneurodevelopmental
outcomeandseizurerecurrence.
ETIOLOGY
1.Perinatalevents:
Hypoxicischemicencephalopathy

Intracranialhemorrhage:Germinal
matrixintraventricularhemorrhage,
subduralhemorrhage,primary
subarachnoidhemorrhage(wellbaby
seizures)
ETIOLOGY
2.METABOLIC
Hypoglycemia
Hypocalcemia
Early:preterm,asphyxia,IDM
Late:Topfeeding

Hypomagnesemia
Hyponatremia/hypernatremia
Pyridoxinedeficiency
IEM:nonketotichyperglycinemia,ureacycle
defects,maplesyrupdisease,glutaricaciduria,
propionicaciduria,methylmalanoicaciduria,
mitochondrialdisease.
ETIOLOGY
3.INFECTIONS:
Bacterialmeningitis
Nonbacterialinfections:
toxoplasmosis,herpessimplex,
rubella,cytomegalovirus
4.DEVELOPMENTALPROBLEMS:
Cerebralcorticaldysgenesis
Neuronalmigrationdisorders
Pachygyria,polymicrogyria
ETIOLOGY
5.MISCELLANEOUS
Passivedrugwithdrawl
Accidentalinjectionoflocalanesthetic
intofetalscalp.
Neonatalepilepticsyndromes
Benignfamilialneonatalconvulsions
Benignidiopathicneonatalconvulsions

(fifthdayfits)
Earlymyoclonicencephalopathy

Earlyinfantileepilepticencephalopathy

(Ohtaharassyndrome)
Malignantmigratingpartialseizuresin

infancy(coppolasyndrome)
 NEONATALSEIZURESTIMEOF
ONSET
Timeof Etiology
onset
<24hrs HIE,severebirthtrauma,hypoglycemia,
hypocalcemia,drugwithdrawl,congenitalCNS
anomalies,intracranialhemorrhage

13days Allabove,subarachnoidhemorrhage,IEM,benign
familialneonatalseizures

>3days sepsis,meningitis,progressivehydrocephalus,
epilepticsyndromes,herpesencephalitis,IEM
SPECIFICETIOLOGIES
HypoxicIschemicEncephalopathy

Mostcommoncauseofneonatalseizuresusually
inthefirst24hours.

Inperinatalasphyxia,seizuresoccurincontext
ofhistoryofdifficultyduringlabour,delivery
withfetalHRalterations,lowApgarscores.
Intracranialhemorrhages

Subarachnoidhemorrhagescauseseizures
usuallyonseconddayandhaveaverygood
outcome.
Inpreterminfant,seizuresoccurwith
extensionofgerminalmatrixhemorrhageto
parenchymatypicallyafter3daysoflifeandit
isnotassosciatedwithgoodoutcome.
Acutemetabolicdisorders

Hypoglycemia

Hypocalcemia:Wholebloodionizedcalciumisthe
bestmeasure.
ionisedcalcium<1.1mmol/litin>1500gm.
ionisedcalcium<1mmol/litin<1500gm.
Hypomagnesemia:Levels<1.4mg/dl(0.6mmol/lit)
areconsideredlow.
Hypo/Hypernatremia
Neonatalseizuresyndromes

Benignfamilialneonatalseizures
Benignidiopathicneonatalseizures(fifthdayfits)

Earlyinfantileepilepticencephalopathy(Ohtahara
syndrome)
Malignantmigratingpartialseizures(Coppala
syndrome)
SEIZUREMIMICS
1.Jitterinesssuppresswithpassiveflexion,
increaseswithstimulation,notassociatedwith
autonomicaccompanimentsandeyemovements.
2.Epilepticapneaassociatedwithtachycardia.
3.Benignneonatalsleepmyoclonusoccuras
synchronusmyoclonicjerksduringnonREM
sleepdisappearwhenbabyisawake,EEGis
normalandspontaneouslyresolveby2monthsof
age.
Clinical seizures jitteriness
character
Increaseswith rare common
stimulation
Suppresswith absent present
passiveflexion
Autonomic present absent
phenomena
Eyeorfacial present absent
movements
Rateof Clonicseizuresshow Rateofmovement
movement rapidalterationoffast isidenticalin
andslowphaseof eitherdirection.
movements
EEG Yes No
APPROACHTONEONATAL
SEIZURES
HISTORY

Seizurehistoryregardingtypeofseizure,
associatedmovements,dayofonset.

Antenatalhistoryintrauterineinfection,maternal
diabetes,narcoticaddiction.

PerinatalhistoryH/ofetaldistress,instrumental
delivery,needforresuscitationinlabourroom,apgar
scores.
 Feedinghistoryappearanceoflethargy,poor
activityandvomitingafterinitiationofbreastfeeding
maybesuggestiveofIEM.

FamilyhistoryH/oconsanguinityinparents,
familyh/oseizuresorMR,earlyfetalorneonatal
deathswouldbesuggestiveofIEM.
H/oseizuresineitherparentorsiblinginneonatal
periodmaybesuggestiveofbenignfamilialneonatal
convulsion.
EXAMINATION

VitalsHR,RR,CRT,Temp,BP.

Generalexaminationgestation,birthwtandwt
forage
SeizuresintermwellbabymaybeduetoSAH.
Seizuresinlargefordatebabiesmaybedueto
hypoglycemia.
 CNSexaminationpresenceofbulgingAFmaybe
suggestiveofmeningitisorICH
consciousness(alert/drowsy/comatose).
tone(hypo/hyper).
fundusexaminationforchorioretinitis.

Systemicexaminationpresenceof
hepatosplenomegalyorabnormalurineodourmay
besuggestiveofIEM
skinshouldbeexaminedforneurocutaneous
markers.
INVESTIGATIONS
Essential
Bloodsugar
Serumelectrolytes
CSFexamination
Cranialultrasound
EEG
 Additional
Hematocrit(ifplethoricand/oratriskfor
polycythemia)
Serumbilirubin(ificteric)
Serummagnesium
Arterialbloodgasandaniongap(lethargy,
vomiting,familyhistory,etc.)
Imaging:CTand/orMRI(ifnoetiologyfound
afteressentialinvestigations)
TORCHscreenforcongenitalinfections
Workupforinbornerrorsofmetabolism
 NSGexcellenttoolfordetectionofIVHand
parenchymalhemorrhage.

CTdiagnosticinSAHanddevelopmental
malformations.

MRIdiagnosticincerebraldysgenesis,lissencephaly
andotherneuronalmigrationdisorders.

EEGdiagnosticandprognosticroleinseizuresand
shouldbedoneinallneonateswhoneed
anticonvulsanttreatment.
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 : 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
MAINTENANCEDOSE
Phenobarbitoneorphenytoinafter
loadingdosemaintenancedose35
mg/kg/dayintwodivideddoses.
Weanslowlyinaway,taperthelast
givenanticonvulsantfirstandfirst
givenphenobarbitoneinlast.
DURATIONOF
ANTICONVULSANT
THERAPYGUIDELINES
 Newbornonanticonvulsanttherapy

Weanallantiepilepticdrugsexceptphenobarbitoneonceseizure
controlled

Performneurologicalexaminationpriortodischarge

Normal Abnormal

Stop Continuephenobarbitonefor1month
phenobarbitone
priorto
Repeatneurologicalexaminationat1month
discharge

Normalexamination Abnormalexamination

EvaluateEEG
Taperdrugs AbnormalEEG
NormalEEG Continuedrug;
over2weeks Taperdrugsover reassessat3
2weeks
PROGNOSIS
Focalclonicseizurescarrythebestprognosis.
Myoclonicseizurescarrytheworstprognosisin
termsofneurodevelopmentaloutcomeand
seizurerecurrence.
SeizuresduetoSAHandlateonsethypocalcemia
carrybestprognosisintermsoflongterm
neurodevelopmentaloutcome.
Seizuresrelatedtohypoglycemia,cerebral
malformationsandmeningitishaveadverse
outcome.
NeurologicalDiseaseNormal
Development

Hypoxicischemicencephalopathy50%

Primarysubarachnoidhemorrhage90%

Hypocalcemia
Earlyonset50%
Lateronset100%

Hypoglycemia50%
Bacterialmeningitis50%
SUMMARY
Seizuresarecommoninneonatalperiodthanany
otherperiodoflife.
Subtleseizuresarethemostcommontypeof
neonatalseizures.
Hypoxicischemicencephalopathyisthemost
commoncauseofneonatalseizures.
Phenobarbitoneisthedrugofchoiceforneonatal
seizures.
Focalclonicseizuresandseizuresdueto
subarachnoidhemorrhageandlateonset
hypocalcemiacarriesbestprognosis.
REFERENCES
AIIMSNICUPROTOCOL2014
MANUALOFNEONATALCARECLOHERTY

NELSONTEXTBOOKOFPEDIATRICS

CAREOFTHENEWBORNMEHARBAN
SINGH
IAPTEXTBOOKOFPEDIATRICS
THANKYOU