Neurotherapeutics

https://doi.org/10.1007/s13311-021-01085-8

REVIEW

Novel Therapeutics for Neonatal Seizures

Julie M. Ziobro1 · Krista Eschbach2 · Renée A. Shellhaas1

Accepted: 26 June 2021

© The American Society for Experimental NeuroTherapeutics, Inc. 2021

Abstract
Neonatal seizures are a common neurologic emergency for which therapies have not significantly changed in decades.
Improvements in diagnosis and pathophysiologic understanding of the distinct features of acute symptomatic seizures and
neonatal-onset epilepsies present exceptional opportunities for development of precision therapies with potential to improve
outcomes. Herein, we discuss the pathophysiology of neonatal seizures and review the evidence for currently available treat-
ment. We present emerging therapies in clinical and preclinical development for the treatment of acute symptomatic neonatal
seizures. Lastly, we discuss the role of precision therapies for genetic neonatal-onset epilepsies and address barriers and
goals for developing new therapies for clinical care.

Keywords  Antiseizure medication · Hypoxic-ischemic encephalopathy · KCNQ2 · Phenobarbital · Levetiracetam ·

Bumetanide

Introduction
Neonatal seizures are a common emergency with an inci-
dence up to 0.95 to 2.8 per 1000 live births [1–3]. The
reported incidence of seizures in preterm infants varies with
the method of ascertainment, although in population-based
and unselected cohorts incidence is estimated to be as high
as 5% [4]. The most common causes of neonatal seizures—
hypoxic–ischemic encephalopathy, stroke, and intracranial
hemorrhage—are similar for both term and preterm infants
[5]. Less common etiologies of neonatal seizures include
infection, electrolyte disturbances (e.g., hypoglycemia or
hypocalcemia), as well as metabolic causes. Therefore, most
neonatal seizures are acute symptomatic seizures rather than
a manifestation of neonatal-onset epilepsy [6].
The therapeutic approach to neonatal seizures can be
tailored according to the key distinction between acute
symptomatic seizures or neonatal-onset epilepsy. However,
* Julie M. Ziobro
ziobroj@med.umich.edu
1
Department of Pediatrics, Michigan Medicine, C.S. Mott
Children’s Hospital, University of Michigan, 1540 E.
Hospital Dr, Ann Arbor, MI, USA
2
Department of Pediatrics, Section of Neurology, Denver
Anschutz School of Medicine, Children’s Hospital Colorado,
University of Colorado, Aurora, CO 80045, USA
this distinction may not be clear at seizure onset and some
neonates with epilepsy also have super-imposed acute brain
injury [6]. Acute symptomatic seizures arise within the first
week after an acquired brain injury and are usually self-
limited in the neonatal period (though post-neonatal epilepsy
can occur in up to ~ 20%) [7]. Neonatal-onset epilepsies are
often secondary to underlying genetic or metabolic disor-
ders; methods to assist with early diagnosis and potential
for precision therapy will be discussed.
Key challenges surround the incomplete efficacy of
antiseizure medications for neonatal seizures; despite
standard treatments, more than half of neonates experience
continued seizures after initial loading doses of antiseizure
medications [8, 9]. This is likely, in part, due to immature
neonatal neurophysiology which leads to excess excitation
and reduced inhibition. Compared to mature adult neurons,
intracellular chloride concentration is about 20–40  mM
higher in immature neonatal neurons, a difference which
is sufficient to shift the action of gamma-aminobutyric acid
(GABA) from inhibition to excitation [10]. In mature neu-
rons, activation of ­GABAA receptors by binding of GABA
causes an influx of chloride; this results in neuronal mem-
brane hyperpolarization and inhibition of action poten-
tials. In immature neurons, ­GABAA receptor activation
leads to an efflux of chloride, which effectively increases
the likelihood of firing an action potential. Reversal of
this chloride gradient is mediated by the expression of the

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sodium–potassium-chloride cotransporter 1 (NKCC1),
which imports chloride, and the potassium-chloride cotrans-
porter 2 (KCC2), which exports chloride [11, 12]. In the
immature brain, expression of NKCC1 is higher than KCC2
which leads to the relatively high intracellular chloride con-
centration in immature neurons. This results in chloride
efflux and cell depolarization when GABA binds to the post-
synaptic receptor [11] and triggers inward calcium currents
and the removal of the voltage-dependent magnesium block
from the N-methyl-D-aspartate (NMDA) receptors. The net
effect is promotion of calcium entry and activation of second
messengers that increase brain excitability and seizure risk
[13, 14]. Recurrent seizures further increase the intracel-
lular chloride concentration, resulting in a more depolar-
ized reversal potential of GABA [15]. Additional develop-
mentally related expression changes in excitatory receptors
that allow the brain to form appropriate activity-dependent
developmental processes also leave the immature brain sus-
ceptible to hyperexcitability and seizures [13, 14, 16, 17].
Yet, despite these differences in neonatal physiology as
compared to adults, current treatment practices include first-
line antiseizure medications that act through the ­GABAA
receptor (i.e., phenobarbital and benzodiazepines), which
offers a potential explanation for the high risk of incomplete
treatment response. However, prescription of other antisei-
zure medications, including fosphenytoin or levetiracetam,
has not yielded superior results. Below, we discuss in detail
the data for each of the current available medications, as well
as emerging treatment options for neonatal seizures (Fig. 1).
Evaluating Data and Clinical Trial Design
The available data to guide medication selection for the
treatment of neonatal seizures are limited in quality and
consist primarily of retrospective studies, with very few
prospective trials. These study designs are limited by ina-
bility to adequately control for confounding variables (e.g.,
disease severity, medication exposure, time to treatment).
This is, in part, due to variability in seizure identification—
some studies assess clinical seizures only and others
require amplitude-integrated EEG or conventional video-
EEG monitoring. Conventional video-EEG monitoring is
the gold standard for neonatal seizure identification [18] and
is essential for trials of treatment efficacy given high rates
of subclinical (electrographic only) seizures in neonates.
Assessment of medication response has also varied. Some
studies target complete seizure cessation, while others report
percent seizure reduction or response within 1 h, etc. This
variability reduces the opportunity to compare results across
studies. Lastly, long-term developmental outcome measures
are commonly not assessed, despite the critical importance
of this information to families and clinicians [19–21]. There
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J. M. Ziobro et al.
are a handful of randomized, controlled clinical trials in the
treatment of neonatal seizures, but some of these same chal-
lenges are still apparent. For example, in the landmark study
by Painter et al., comparing phenobarbital to phenytoin,
continuous video-EEG monitoring was not used through-
out the screening period [9]. Expert and key stakeholder
recommendations are available to assist in neonatal clinical
trial design and address the above limitations with specific
solutions for each clinical trial phase. These recommenda-
tions are an important contribution to improve the quality
of clinical trials in neonatal seizures[22]. A brief overview
of proposed solutions to the limitations of current neonatal
seizure treatment studies are shown in Table 1.
Treatment of Acute Symptomatic Seizures
Phenobarbital
Phenobarbital is strongly recommended by the World Health
Organization for the first-line treatment of neonatal seizures
and is the standard of care at most institutions, although
there are limited randomized controlled trials to support this
distinction [23]. Use of phenobarbital for neonatal seizures
has been very consistent for decades and across geographical
regions. Review of American hospital data from the Pediat-
ric Health Information System revealed that 97% of neonates
treated for seizures received phenobarbital and this practice
has been very consistent over time [24–27]. When antisei-
zure medications are prescribed to neonates at hospital dis-
charge, phenobarbital is also the most commonly prescribed
medication [27, 28]. These data highlight the importance of
phenobarbital in current treatment paradigms of neonatal
seizures.
Phenobarbital exerts its effect as an allosteric modula-
tor of the ­GABAA receptor. Yet, activation of the ­GABAA
receptor in neonatal neurons results in excitation, instead of
the typical inhibitory effect in adult models [29, 30]. These
maturational differences in the newborn are hypothesized to
underlie the reduced rates of response to phenobarbital as
compared to older children and adults with seizures.
The landmark study by Painter et al. was a randomized
controlled trial that directly compared phenobarbital to
phenytoin as first-line treatment for neonatal seizures [9].
Complete seizure resolution occurred in 43% of infants ran-
domized to receive phenobarbital, with an 80% reduction of
seizures in 80% of neonates. More recently, a randomized
controlled trial evaluated neonates treated with phenobar-
bital versus levetiracetam as first-line therapy after new-
onset conventional EEG-confirmed seizures (NEOLEV2;
NCT01720667) [31]. This study demonstrated seizure
freedom at 24 h in 70% of patients treated with a single
20 mg/kg dose of phenobarbital. Notably, this phenobarbital
Novel Therapeutics for Neonatal Seizures
Fig. 1  Graphic illustration of sites of action for the currently available
antiseizure medications used for neonatal seizures (black text, blue
boxes) and therapeutics in preclinical development (red italics text,
pink boxes). Note that in the neonatal brain, chloride efflux through
­GABAA receptors (black arrow) predominates due to the chloride
gradient created from relative greater expression of NKCC1 versus
KCC2. In the adult brain, this chloride gradient is reversed, allow-
ing for chloride influx (red arrow) through the ­GABAA receptor. The
response rate was higher than in the prior randomized con-
trolled trial by Painter et al. [9]. There are differences in
the study design between the two trials that could, in part,
explain the higher response rate in the NEOLEV2 study.
These include variability in EEG monitoring protocols and
use of therapeutic hypothermia for infants with hypoxic-
ischemic encephalopathy in NEOLEV2. Additionally, time
to treatment was not reported in either study. This variable
is important due to the natural temporal evolution of acute
TrkB pathway is activated following ischemia, leading to hypofunc-
tion of the KCC2 channel. Treatment with TrkB pathway modulators
have been shown to improve KCC2 function in preclinical models
of neonatal hypoxic–ischemic injury and reverse seizure refractori-
ness to phenobarbital, suggesting a future role as adjunctive therapy
for refractory acute symptomatic seizures in neonates. Figure created
with BioRender.com
symptomatic neonatal seizures [32]. Despite differences in
these two randomized controlled trials, the phenobarbital
response rate in the NEOLEV2 study is encouraging. There
remain concerns regarding the side effects of sedation, res-
piratory suppression, and hypotension [31]. Yet, these can
easily be managed in the intensive care unit environment.
The potential negative long-term effects of phenobarbital
on the developing brain continue to be a discussion point in
clinical practice and research. This concern is supported in
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 J. M. Ziobro et al.

Table 1  Study limitations and proposed trial design solutions

Current study limitations Proposed trial design solution

Parents and clinicians wish to determine the best initial treatment Use current common clinical practices (i.e., phenobarbital) as active
approach for neonatal seizures, rather than waiting for the seizures to control arms, and signal clinical equipoise, for future trials
be resistant to multiple medications
It is not ethical to prescribe a placebo to a neonate with active seizures Use active treatment controls based on current clinical practice and
prior randomized controlled trials
Neonates with seizures often have additional co-morbid health con- It is essential to include a control group in the design of future clinical
cerns and it is important to separate these from treatment-related trials
adverse events
Variability in EEG monitoring practices and high rates of electro- Continuous video-EEG monitoring is the gold standard for neonatal
graphic-only seizures in neonates, especially after treatment with seizure identification and needs to be included as part of screening,
antiseizure medication treatment, and follow-up periods for clinical trials of antiseizure
medication efficacy
Inter-reader variability in the identification of neonatal seizures Application of ACNS guidelines for identification of neonatal seizures
increases interrater reliability [176], consideration of central EEG reader
for interpretation or additional standardized site investigator training
Neonatal acute symptomatic seizures have a natural temporal evolution Time to treatment should ideally be standardized, e.g., within 1 h
with an increasing then gradual decreasing pattern [32] that influ- of seizure identification, controlled for in statistical analyses, and
ences evaluation of treatment effect reported in each study; control groups are also necessary
Lack of consistency regarding definition of seizure response and out- Seizure cessation within 1 h of study treatment and lasting for at least
come measures 24 h as standardized primary outcome measure
Small sample sizes limit ability to detect a difference in treatments Multicenter collaborations are essential; well-powered designs are key
Parents and clinicians are interested in improving long-term outcomes, Goal to monitor both treatment and control groups long-term as sec-
including developmental milestones and risk for future epilepsy ondary outcome measures. Consideration of sample size (to permit
relevant conclusions), logistical and financial implications of long-
term follow-up remain challenging
ACNS American Clinical Neurophysiology Society

non-injured animal models in which exposure to phenobar-
bital resulted in apoptosis of neurons in the cortex, white
matter, and limbic system, as well as disruption of inhibi-
tory synaptic development in hippocampal neurons [33–36].
These changes may explain the observed anxiety, behavio-
ral, and cognitive changes in rodent models after exposure
to phenobarbital [37, 38]. Additionally, it is proposed that
damage to ­GABAA receptor neurons results in an enhanced
excitatory network later in life [33].
However, there has also been suggestion of a neuroprotec-
tive effect of phenobarbital. In a mouse model of hypoxia
induced seizures, treatment with phenobarbital (compared
with saline placebo) resulted in less hippocampal neuronal
death after a second-hit and later life exposure to kainic acid
[37]. In this study, there were similar rates of neuronal cell
death between the control group of uninjured mice with-
out phenobarbital exposure and the phenobarbital exposed
groups (group 1—hypoxia-induced seizure model exposed
to phenobarbital and group 2—uninjured mice with pheno-
barbital exposure), although this was not controlled for the
initial response to phenobarbital or seizure burden [37]. Fur-
thermore, there was a clinical trial to evaluate for a potential
preventative neuroprotective effect of phenobarbital in new-
borns with hypoxic–ischemic encephalopathy [39]. It was
determined that early treatment with phenobarbital, prior
to seizure onset, did reduce incidence of seizures but was
not associated with a change in mortality or neurological
outcome at hospital discharge. Long-term outcome meas-
ures were not assessed. Overall, the data support concerns
for a negative effect of phenobarbital on the immature
brain and a Cochrane Review concluded that prophylactic
exposure in infants at risk for seizures is not recommended
[40]. Importantly, the negative effect of untreated neonatal
seizures is considered more clinically meaningful than the
potential adverse effects of phenobarbital. Thus, phenobar-
bital remains the first-line standard of care treatment option
for neonatal seizures. Yet, the above concerns highlight the
urgent need for novel therapeutic options.
Fosphenytoin and Phenytoin
Fosphenytoin is used in up to 15% of patients with neonatal
seizures [25, 26] but is typically prescribed when seizure
control is inadequate after initial treatment with phenobarbi-
tal. Fosphenytoin is a phosphorylated prodrug of phenytoin
and has the advantage of less cardiac toxicity and fewer local
extravasation effects as compared to phenytoin, although
both require careful consideration of drug interactions. The
reduced risk of local skin reactions with fosphenytoin is due
to the lower pH of 8.6 (compared to phenytoin pH of 11)

13
Novel Therapeutics for Neonatal Seizures
and absence of propylene glycol. Additionally, compared
to phenytoin, fosphenytoin is more likely to be compatible
with other co-administered medications or infusions in an
intravenous line.
Fosphenytoin is converted to phenytoin, the active
metabolite, and then acts to stabilize the neuronal mem-
brane by altering sodium currents. There was initial con-
cern that parenteral fosphenytoin administration may result
in reduced serum levels of free phenytoin, as early studies
of pharmacokinetics were in older children and adults. How-
ever, additional studies that included neonates demonstrated
adequate levels of free phenytoin serum concentration after
loading doses of fosphenytoin and similar times to conver-
sion to phenytoin as adult patients[41, 42]. Despite this, an
additional challenge remains with enteral administration of
phenytoin due to inconsistent (often limited) absorption and
variability in serum free phenytoin levels [43].
Studies comparing phenytoin or fosphenytoin to phe-
nobarbital in newborns demonstrate similar efficacy with
45–56% of patients becoming seizure free after initial treat-
ment with phenytoin/fosphenytoin [9, 44]. A single retro-
spective study reported a response rate of phenytoin for neo-
natal acute symptomatic seizures of 85.7% [45], although
the details about seizure burden, and timing of treatment
were not reported. There are a few case reports on the use
of fosphenytoin in preterm infants with no adverse effects
reported [46, 47].
There is also concern of a neuronal apoptotic effect with
phenytoin that is dose dependent but triggered at typical
loading doses [48]. However, a long-term follow-up study
demonstrated that newborns who received initial treatment
with fosphenytoin were more likely to have normal or only
mild developmental delay at 18–24 months, compared with
newborns treated with phenobarbital [44]. This study was
limited by the retrospective design and relatively small sam-
ples size in the fosphenytoin group (n = 23 in fosphenytoin
group; n = 80 in phenobarbital group) but may suggest an
alternative to the potential negative effects of phenobarbital
on the developing brain.
Levetiracetam
Levetiracetam acts through the synaptic vesicle glycopro-
tein 2A (SV2A), which is a protein involved in the release
of neurotransmitters, although the exact mechanism is not
known. Levetiracetam is used less commonly than pheno-
barbital for the initial treatment of neonatal seizures. Over
the past decade, use of levetiracetam increased from < 10%
of all neonates with seizures to nearly 40%, surpassing the
use of fosphenytoin/phenytoin [26, 28]. Recent interest in
levetiracetam is likely multifactorial and includes its avail-
ability for parenteral administration, relative safety profile,
minimal drug interactions, likelihood of less adverse effects
than phenobarbital on the newborn brain, and improved effi-
cacy compared to phenobarbital in infantile epilepsy [49].
Initial single-center, retrospective studies of levetiracetam
reported efficacy in both term and preterm infants with a
complete seizure cessation widely ranging between 26 and
86% of patients [50–54]. However, these studies were limited
by primarily retrospective study designs, lack of a control
group, and variable outcomes measures, as discussed pre-
viously. Yet, these numerous preliminary studies provided
encouraging initial data and rationale for the NEOLEV2
study, a randomized controlled phase IIb efficacy, dose-
escalation study of first-line treatment with levetiracetam
compared to treatment with phenobarbital. Seizure cessa-
tion for 24 h occurred in significantly more patients treated
with phenobarbital compared to levetiracetam (80% vs 28%,
p < 0.001) [31]. After dose escalation, with an additional
20 mg/kg of levetiracetam (total dose 60 mg/kg), the seizure
freedom rate at 24 h increased to 35%. Despite some efficacy
demonstrated by levetiracetam, this study provides strong
evidence of the superiority of phenobarbital as a first-line
antiseizure medication and lack of seizure control with up to
60 mg/kg in loading doses of levetiracetam as first-line treat-
ment for neonatal seizures. Although not powered to evalu-
ate levetiracetam as a second-line antiseizure medication for
neonatal seizures, it is notable that none of the neonates with
seizures refractory to two loading doses of phenobarbital
responded to levetiracetam. Thus, the NEOLEV2 study pro-
vides quite conclusive data that the secular trend of prescrib-
ing levetiracetam for neonatal seizures is not justified. As a
result, phenobarbital remains the first-line standard of care.
Animal studies have not clearly demonstrated neuronal
apoptosis with average doses of levetiracetam, although
there is a possible dose-dependent effect with neuronal
apoptosis after exposure to high doses (70 mg/kg) of leveti-
racetam as compared to low doses (7 mg/kg) in a neonatal
hypoxia mouse model [55]. However, long-term outcomes of
high-dose levetiracetam exposure were not evaluated. Short-
term follow-up studies have reported improved tone and pos-
ture among infants treated with levetiracetam compared with
neonates treated with phenobarbital [56], although prelimi-
nary data suggest long-term neurodevelopmental outcomes
appear similar [57].
Treatment of Status Epilepticus in Neonates
Guidelines from the American Clinical Neurophysiology
Society define neonatal status epilepticus as seizure duration
totaling > 50% of a 1-h epoch [58]. The causes of neonatal
status epilepticus are comparable to neonatal seizures in
general, with hypoxic–ischemic encephalopathy or intrac-
ranial hemorrhage most common. There are high rates of
13

morbidity and mortality associated with neonatal status
epilepticus, with death occurring in up to half of preterm
neonates [59].
Benzodiazepines
Benzodiazepines are first-line treatment for pediatric sta-
tus epilepticus, but there are limited data to guide their use
in neonatal status epilepticus. Benzodiazepines exert effect
through the G ­ ABAA receptors as allosteric agonists, with
the same challenges related to the maturational pattern in
the newborn brain as phenobarbital. Additionally, similar to
phenobarbital, animal models demonstrate that midazolam
may increase status epilepticus-associated neuronal injury
with no increase in animal survival [36, 60].
Available data regarding the use of benzodiazepines in
neonates for seizures are primarily limited to retrospective
studies. The response rate is varied with complete seizure
response occurring in < 20% of neonates treated with 0.1 mg/
kg midazolam as first-line treatment [61] and between 0 and
100% when midazolam or clonazepam are used as second-
line treatment for ongoing seizures [62–64]. Nearly half of
the neonates treated with midazolam as first-line treatment
had continued seizures [61]; given the limitations in study
design this number may, in fact, be higher.
In clinical studies, hypotension was the most frequently
reported adverse event, and occurred in nearly 10% of
infants, although transient hypoxia, apnea, decreased urinary
output, and tachycardia also can occur [61, 64]. Additionally,
in very preterm neonates (24–32 weeks gestation) exposure
to midazolam was found to be inversely associated with hip-
pocampal volume and cognitive outcomes [65]. The incon-
sistent response to benzodiazepines in neonates, as well as
the potential additive neurotoxic effect on the newborn brain,
highlights the need for alternative treatment options for neo-
natal status epilepticus.
Lidocaine
Lidocaine is commonly used as a local anesthetic but has
been employed for second and third-line treatment of neo-
natal seizures [26]. It is also an anti-arrhythmia drug and
has a narrow therapeutic window. Additionally, lidocaine
is metabolized in the liver by the cytochrome p450 system,
which can be influenced by gestational age and therapeu-
tic hypothermia; however, this can be mitigated with the
proposed dosing regimens available for preterm and term
neonates [66–68].
Retrospective and small clinical studies demonstrate effi-
cacy of lidocaine in neonates for whom phenobarbital failed
to control seizures. The response rate to lidocaine infusions
has been reported to be approximately 50–70% [63, 64, 69].
However, in the largest retrospective study (n = 413) only
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J. M. Ziobro et al.
approximately 20% of infants had a sustained response and
did not require additional antiseizure medications after sec-
ond line treatment with lidocaine infusion[69]. Additionally,
data suggest lidocaine may be more effective in term than
preterm infants [69].
Large retrospective studies have identified cardiac
arrhythmias in up to 4.8% of neonates during infusion with
lidocaine [70], although with a reduced dosing regimen
this number decreased to < 1% [71]. This highlights the
importance of continuous cardiac monitoring during treat-
ment with lidocaine. Future well-designed studies would be
beneficial to define the role of lidocaine in the treatment
of neonatal seizures. Until such data become available, we
suggest consideration of lidocaine for neonates with status
epilepticus despite loading doses of ≥ 40 mg/kg of pheno-
barbital. Note that exposure to fosphenytoin/phenytoin and
presence of congenital heart disease are contraindications
due to the risk of arrhythmia. Additionally, the clinical team
must have a plan for subsequent treatment after the 48 h of
lidocaine are completed.
Duration of Treatment with Antiseizure
Medication
It is important to also consider the duration of treatment
with either current or emerging therapeutics for neonatal
seizures in order to reduce any potential risk of treatment on
the immature neonatal brain. Neonatal seizures are predomi-
nantly acute symptomatic seizures and the highest seizure
burden is typically in the first 24 h after onset [32]. Seizures
usually resolve within several days, but up to 20% go on to
develop post-neonatal epilepsy [137, 138]. The incidence of
post-neonatal epilepsy and of abnormal neurodevelopmental
outcomes does not appear to be reduced by longer dura-
tion of treatment with antiseizure medications [137, 139].
A recent prospective, multicenter comparative effectiveness
study by the Neonatal Seizure Registry confirmed that dis-
continuation of antiseizure medication after resolution of
acute symptomatic seizures and prior to hospital discharge
does not alter future epilepsy risk, rates of cerebral palsy, or
2-year neurodevelopmental outcome [140].
The World Health Organization (WHO) recommends
discontinuation of antiseizure medication in neonates with
a normal neurological exam and/or normal EEG after at
least 72 h of seizure freedom [23]. This recommendation
is intended for neonates with acute symptomatic seizures,
and not for infants with neonatal-onset epilepsy. However,
in neonates with acute symptomatic seizures, there remains
significant variability in how long antiseizure medications
are continued, with medications often maintained after hos-
pital discharge at most centers [27]. A longer duration of
seizures in the neonatal period, abnormal MRI brain, and
Novel Therapeutics for Neonatal Seizures
some seizure etiologies are risk factors for longer duration
of treatment [27, 138, 141]. It is also known that the hospital
site influences duration of treatment, as well as availabil-
ity of a neonatal neurocritical care service [27, 142]. This
highlights the importance of institutional efforts to stand-
ardize the identification and treatment of neonatal seizures
and reduce unnecessarily prolonged exposure to antiseizure
medication. Most neonates with acute symptomatic neonatal
seizures do not require continued medication after hospital
discharge. Conversely, infants with neonatal-onset epilepsy
usually do require long-term treatment.
Emerging Treatment Options
Bumetanide
Bumetanide is a loop diuretic that blocks the Na–K-Cl
co-transporter. Early animal models suggested a potential
benefit when combined with phenobarbital for treatment of
neonatal seizures [72], although this was not a completely
consistent result and it has not been replicated in all rodent
models of birth asphyxia [73]. Additionally, there is concern
regarding the ability of bumetanide to cross the blood–brain
barrier and reach intended targets [74].
In an initial open-label, dose escalation, feasibility study
(NEMO trial; NCT01434225) of bumetanide administered
with a second dose of phenobarbital as second-line therapy
after phenobarbital failure (N = 14), the primary seizure
efficacy endpoint (80% seizure reduction) occurred in less
than half the cohort [75]. However, 5 of the neonates did
not have seizures in the baseline period. It has been argued
that if these neonates were excluded from efficacy analysis,
then 5/9 neonates demonstrated a > 80 seizure reduction and
reached the primary clinical efficacy endpoint of a > 50%
response rate [76]. Additionally, 3 of the 14 neonates dem-
onstrated hearing loss, although co-treatment with amino-
glycoside was common and there was no control group to
compare the rate of hearing loss in neonates who received
standard treatment without bumetanide. The study was
ended early due to insufficient efficacy and concern about
the potential increased prevalence of hearing loss. Subse-
quently, a randomized, double-blind, dose-escalation trial
(NCT00830531) designed to assess the safety and pharma-
cokinetics of bumetanide did not show a significant differ-
ence in hearing impairment between control (phenobarbital
alone) and bumetanide treated groups [77].
In the randomized control trial, neonates (postmenstrual
age 34–44 weeks) with persistent seizures despite initial
loading doses of 20–40 mg/kg phenobarbital were rand-
omized to subsequent treatment with either bumetanide plus
a 5–10 mg/kg phenobarbital dose or phenobarbital 5–10 mg/
kg alone (with saline as a control). There was a statistically
significant reduction in seizure burden with escalating doses
of bumetanide (0.1, 0.2, or 0.3 mg/kg) compared to the con-
trol group; however, the interpretation was complicated as
seizure severity was unexpectedly not randomly distributed
across groups. Yet, it appeared that infants with high sei-
zure burden had more than expected reduction in seizures
after bumetanide. Importantly, this was a pilot safety trial
not intended to assess primary efficacy outcomes. However,
this study revealed important initial data regarding tolerated
bumetanide doses and safety data for future trials design.
Topiramate
Topiramate has multiple mechanisms of action, including
glutamate-receptor inhibition and blockade of Na + chan-
nels, high-voltage Ca + currents, and carbonic anhydrase
isoenzymes. These characteristics have raised the potential
of a neuroprotective effect of topiramate through reduction
of excitatory pathways. This has been supported by both
in vitro and in vivo clinical studies, including models in the
newborn such as periventricular leukomalacia models [78].
There is also report of increased safety in animal models
as compared to phenobarbital or benzodiazepines, as well
neuronal apoptosis only with doses significantly higher than
currently used treatment doses [79, 80]. Two randomized
clinical trials of topiramate initiation at the start of therapeu-
tic hypothermia compared to hypothermia alone revealed a
decrease in seizure burden and need for less antiseizure med-
ications in the first 24 h, although the latter was not assessed
for significance [81]. There was no significant effect on mor-
tality or neurological disability [81, 82]. While the rate of
post-neonatal epilepsy was lower among neonates treated
with topiramate plus hypothermia compared to hypothermia
alone, this was not statistically significant (14.3% vs 30.4%,
P = 0.21) [82]. The first study by Filippi et al. included 21
neonates in the topiramate group, while the subsequent
study by Nunez-Ramiro et al. was slightly larger with 57
neonates in the topiramate group [81, 82]. These relatively
small sample sizes are a limiting factor and future studies
are warranted, especially as no adverse events were attrib-
uted to topiramate administration. There is an ongoing clini-
cal trial of topiramate in newborns with hypoxic–ischemic
encephalopathy treated with therapeutic hypothermia that
is currently recruiting participants (NCT01765218) with an
expected completion date of May 2022.
There are few data regarding topiramate for the acute
treatment of seizures in neonates. Its use is, in large part,
limited by absence of an intravenous formulation. In a recent
large multi-center review of practice variation in treatment
of neonatal seizures, topiramate was used < 1% of the time;
however, the paper did not specify whether topiramate was
prescribed for acute symptomatic seizures or neonatal epi-
lepsy [26]. A retrospective case series of neonates treated
13

with topiramate suggests tolerability and safety, as well as
efficacy in some patients [83], but larger prospective studies
are needed.
Brivaracetam
Brivaracetam is a n-propyl analogue of levetiracetam
designed with high affinity for the synaptic vesicle protein
2A (SV2A), a glycoprotein present in the membranes of syn-
aptic vesicles. Brivaracetam is well tolerated in the setting of
renal impairment, has minimal interactions with other medi-
cations, and is available in intravenous formulation. Like
levetiracetam, the precise mechanism of this medication is
not known, and these drugs may each act differently on the
SV2A protein. Animal studies suggest that there may be
developmental differences in SV2A with reduced expression
in newborn models, although antiseizure properties of bri-
varacetam are demonstrated in these models [84]. There are
limited clinical data regarding brivaracetam in the newborn
period, although this medication has been well-tolerated
in pediatric studies with side effects of mild somnolence,
psychosis/behavior changes, and stomach upset/decreased
appetite [85–87]. There is an active, open-label, single-arm
study to evaluate the pharmacokinetics, efficacy, and safety
of brivaracetam in neonates with repeated electroencepha-
lographic seizures despite initial antiseizure medication
(NCT03325439). The expected completion date is January
2022.
Lacosamide
Lacosamide is a sodium-channel blocking agent with a
novel mechanism through slow inactivation of voltage-gated
sodium channels. It was introduced for adult epilepsy treat-
ment in 2008 and studies report its use in pediatric epilepsy
management with limited side effects even with intravenous
administration [88]. Due to its action on the sodium channel,
there can be associated PR interval prolongation, although
this has rarely occurred with intravenous administration in
children.
There was a potential neuroprotective effect of lacosa-
mide demonstrated in animal models of traumatic brain
injury and status epilepticus [89, 90]. A model of neona-
tal arterial ischemic infarction revealed reduced areas of
ischemia after pretreatment with oral lacosamide, although
there was a dose-dependent response with higher rates of
toxicity and mortality seen with dose escalation [91]. It
remains unclear whether there is a neuroprotective effect
in the newborn brain, or any associated neuronal apoptosis
associated with exposure.
There are limited data available regarding the use of
lacosamide in the neonatal period. Studies aimed at charac-
terizing the pharmacokinetics in term and preterm neonates
13
J. M. Ziobro et al.
are important to help guide clinical use. Review of the lit-
erature demonstrates two patients who received lacosamide
at age 1 month with no adverse events reported [92, 93].
There is a planned, multi-center, open label randomized
active comparator study to evaluate the efficacy, safety, and
pharmacokinetics of lacosamide in neonates with repeated
electroencephalographic neonatal seizures (NCT04519645).
Ketamine
Ketamine is a non-competitive N-methyl-D-aspartate
(NMDA) receptor antagonist that crosses the blood–brain
barrier and is clinically used as a dissociative anesthetic.
During refractory status epilepticus there is loss of GABA
receptor inhibition as GABA receptors internalize and the
concentration of NMDA receptors increases [94, 95]. This
loss of GABA inhibition and activation of NMDA receptors
can further propagate seizure activity and contribute to self-
sustained status epilepticus [96]. In animal models, treat-
ment with ketamine can be used to halt this response and
resolve self-sustaining refractory status epilepticus [96, 97].
In a rat model of perinatal brain injury, exposure to ket-
amine resulted in a partial neuroprotective response with
reduced energy requirements and restored levels of ATP
compared to controls [98]. However, additional in vivo ani-
mal studies suggest neuronal apoptosis with ketamine expo-
sure and reduced cognitive testing outcomes in follow-up
studies, although the exact dose and vulnerable ages are not
known [99, 100].
Ketamine is also used as an analgesic. Data derived from
its use in the delivery room of preterm infants at the time of
intubation revealed no difference in neurological outcomes
at age 2 years compared with controls [101]. There may be a
ketamine dosing threshold and duration of treatment neces-
sary for negative effect and neuronal apoptosis.
The use of ketamine for treatment of neonatal seizures
is primarily based on case reports with little information
regarding dosing, safety, or efficacy [102, 103]. There are
more extensive data regarding the use of ketamine in chil-
dren and adults, although there are no randomized controlled
trials of this agent. A review of ketamine for the treatment of
status epilepticus in children suggested an overall response
rate of 73% in children and only rare adverse effects [104].
These encouraging data highlight the importance of future
studies to further evaluate ketamine for the treatment of
recurrent neonatal seizures and status epilepticus.
Preclinical Studies
Given the unique pathophysiology of neonatal seizures
[14], identification of potential treatments of neonatal sei-
zures cannot rely solely on extrapolation of antiseizure
Novel Therapeutics for Neonatal Seizures
medication data from older children and adults. Animal
models in various species have been developed to mimic the
consequences of neonatal hypoxic-ischemic injury (reviewed
in [105]). However, the majority of hypoxia-related seizure
models are performed with rodents. In rats, hypoxic seizures
are induced only during the critical developmental window
between post-natal day (P) 6–12, which roughly corresponds
to term brain development in humans [106–108]. Neonatal
mice have been used at the P7-9, during the maximal transi-
tion in synaptic receptor maturation, similar to term human
brain development [106].
In the hypoxia model, acute seizures are induced with
exposure to varying degrees of global hypoxia for varying
durations. Several models display spontaneous recurrent
seizures, without significant neuronal death, following the
acute insult [106]. In contrast, hypoxia–ischemia models
consist of unilateral ligation of the common carotid artery
in addition to a period of hypoxia exposure. This provides
a more severe insult and produces more substantial tissue
damage in addition to more severe recurrent seizures in the
long-term compared with the hypoxia model [106, 109].
This results in the recapitulation of many of the features seen
in human neonatal brain injury, including tissue pathology,
cognitive/behavioral deficits, and seizures during and after
the insult [106, 110]. In addition, chemoconvulsant seizures
have been induced with kainic acid or flurothyl to assess effi-
cacy of various antiseizure medications in neonatal rodents
[111, 112].
Chemoconvulsant modeling is technically easier to per-
form than current hypoxic-ischemic models, with consistent
elicitation of seizures by exposure to the chemoconvulsant
agent. This approach may allow for relatively high-throughput
screening of candidate anti-seizure compounds, while
providing insight into mechanisms required for appropri-
ate treatment of neonatal seizures. However, care should be
taken in interpretation of results derived from this appraoch,
as these models do not recapitulate the same complex cas-
cade of cellular and molecular mechanisms that lead to
hypoxic-ischemic seizures in neonates; candidate drug effi-
cacy should also be examined in more physiologically rel-
evant models of hypoxic–ischemic injury.
Potassium‑Channel Openers
Compared with the mature brain, GABAergic inhibition
is decreased in the neonatal brain. Given this, potassium
channels play a unique role in controlling excitability dur-
ing early development, as discussed above [11, 12] and
likely relate to the development and subsequent resolution
of KCNQ2/3 related self-limited familial neonatal epilepsies
[113]. This suggests that use of potassium channel openers
may be an effective approach to enhance inhibition and treat
neonatal seizures.
Flupiritine has been approved in Europe for decades as a
non-opioid analgesic. It has been shown to activate G-protein
regulated inward rectifying K + (GIRK) channels, which may
indirectly inhibit NMDA receptor activity. Activation of GIRK
channels leads to hyperpolarization of the neuronal membrane,
with resulting stabilization of the resting neuronal membrane
[114]. A series of eloquent experiments by Raol and colleagues
examined the effects of flupiritine in several models of neona-
tal seizures. They initially reported flupiritine to be more effi-
cacious in preventing and stopping chemoconvulsant induced
seizures than phenobarbital or diazepam in neonatal rats [115].
They later showed efficacy in treating seizures in a hypoxia
model [116] and hypoxia–ischemia model [117] of neonatal
seizures in rats. In follow-up studies, they also reported that
flupiritine treatment reduced injury induced volume loss and
partially reversed learning and memory impairments [118].
Unfortunately, the withdrawal of flupiritine from the Euro-
pean market was recommended in 2018 due to the risk of liver
injury with prolonged use [119].
Retigabine/ezogabine is chemically similar to flupiritine
and also showed antiseizure effects in limited preclinical
models of chemoconvulsant induced seizures in neonatal
rats [120]. Ezogabine was previously FDA approved as an
adjunctive treatment for focal seizures, though it was with-
drawn from clinical use in 2017 due to skin and eye abnor-
malities. Prior to withdrawal, ezogabine was explored as a
potential precision therapy for KCNQ2 developmental and
epileptic encephalopathy (KCNQ2-DEE), potentially show-
ing some benefit in patients treated prior to age 6 months
[121], though none of the patients received ezogabine treat-
ment in the neonatal period. Targeting potassium channels in
the acute neonatal period may be of future benefit in treating
acute symptomatic neonatal seizures in addition to target-
ing specific genetic etiologies. A phase 3 clinical trial of
a pediatric re-formulated ezogabine (XEN496) is expected
in 2021 as an orphan drug specifically for KCNQ2-DEE
(NCT04639310).
Tyrosine Receptor Kinase B Modulators
The age-dependent upregulation of the K + -Cl- co-transporter
(KCC2) plays a role in the shift of GABAergic signaling
from depolarizing to hyperpolarizing [11, 12] and thus
contributes to pharmacoresistant seizures. Excitotoxic injury
has been shown to phosphorylate tyrosine receptor kinase
B (TrkB) pathway signaling [122]. Recent preclinical stud-
ies have sought to modulate KCC2 to improve the efficacy
of ­GABAA agonists in neonatal seizures via antagonism of
TrkB signaling. In a mouse model of phenobarbital-refractory
postischemic seizures, the postischemic activation of
the TrkB pathway resulted in the hypofunction of KCC2
[123]. This study utilized a carotid-ligation ischemic sei-
zure model in which seizures were found to be refractory
13

to phenobarbital at P7, but responsive to phenobarbital at
P10, further under-scoring the age-dependent nature of neo-
natal seizure pathophysiology. Administration of a small-
molecule TrkB antagonist, ANA12, reversed phenobarbi-
tal resistant seizures at P7 by preventing activation of the
TrkB/phospholipase C, gamma 1 (PLCgamma1) pathway
in a dose-dependent manner, though it showed no change
in seizure rescue at P10 [123]. Significantly, treatment with
ANA12 also led to long-term benefits in improving sleep
dysfunction and activity-dependent markers of cognition
[124]. Similar results were reported from follow-up stud-
ies utilizing a brain-derived neurotrophic factor (BDNF)
memetic, LM22A-4, also prevented BDNF-mediated TrkB/
PLCgamma1 pathway activation and KCC2 hypofunction
[125]. Interestingly, the full TrkB agonists, HIOC, and
deoxygedunin also significantly rescued the phenobarbital
refractory phenotype and prevented postischemic degrada-
tion of KCC2 [125].
Taken together, these studies suggest that inhibition of
cascades associated with endogenous BDNF/TrkB pathway
activation may prevent the emergence of refractory neonatal
seizures. Indeed, the role of TrkB activation in epileptogene-
sis was shown in a study utilizing the TrkB inhibitor, lestaur-
tinib (CEP-701), to reverse TrkB phosphorylation following
hypoxia. This prevented seizure susceptibility to a “second
hit” with a chemoconvulsant [126]. These studies provide
promising evidence that targeting the TrkB pathway may be
a successful strategy for prevention of refractory seizures in
neonates and could lead to improved neurodevelopmental
outcomes following hypoxic–ischemic injury.
Cannabinoid‑Related Agents
Recent interest in cannabidiol as a novel antiseizure medica-
tion has led to further examination of the manipulation of the
endogenous cannabinoid (endocannabinoid) system in the
treatment of neonatal seizures. The endocannabinoid system
is thought to modulate neuronal hyperexcitability in adult
brains but targeting the cannabinoid system in developing
brains is still poorly understood.
A study designed to examine cannabinoid manipulation
in chemoconvulsant and hypoxia-induced seizure models in
P10 and P20 rats demonstrated that cannabinoid agonists
WIN 55,212–2 (WIN) and arachidonyl-2′-chloroethylamide
(ACEA) exerted anticonvulsant effects in a benzodiazepine
inverse agonist model of clonic seizures utilizing the chem-
oconvulsant methyl-6,7-dimethoxy-4-ethyl-beta-carboline-
3-carboxylate (DMCM). WIN also exhibited modest, but
significant, antiseizure effects in PTZ- and acute hypoxia-
induced seizures [127]. Conversely, CB1 receptor antago-
nism increased seizure severity.
13
J. M. Ziobro et al.
Later studies examined treatment with cannabidivarin
(CBDV), the propyl analog of cannabidiol (CBD). The
effects of CBDV were age- and model-dependent, with lit-
tle efficacy at P10, but significant antiseizure effects at P20
in the maximal electric shock model and DMCM-evoked
seizures [128]. These results suggest that targeting of the
endocannabinoid system for the treatment of neonatal sei-
zures deserves further attention in pre-clinical studies, with
additional focus on toxicity of manipulating the endocan-
nabinoid system in the developing brain, given the known
deleterious neurodevelopmental effects of in utero cannabis
exposure [129].
Other Agents
The unique physiology of the neonatal brain raises the pos-
sibility of targeting unique mechanisms to dampen hyperex-
citability. The mechanisms of pharmacoresistant status epi-
lepticus are poorly understood, but there is a need to explore
mechanisms beyond regulating GABA or sodium channels,
which are currently the first- and second-line approaches in
managing neonatal status epilepticus [26, 27, 130]. A recent
study in neonatal rats aimed to alter metabolism for seizure
control, arguing that neuronal activity is highly energy-
dependent and requires significant glucose metabolism
[131]. The investigators aimed to utilize a glycolysis inhibi-
tor, 2-deoxyglucose (2-DG) to compete with glucose for cell
entry and inhibit glycolysis and neuronal ATP production. In
the rat model of pilocarpine-induced neonatal status epilep-
ticus, 2-DG was as effective at aborting status epilepticus as
phenobarbital or levetiracetam [131]. Though this appears
to be an intriguing target in the treatment of refractory sta-
tus epilepticus, significant work needs to be done to ensure
that these results translate to more physiologic models of
hypoxic-ischemic induced refractory seizures and to exam-
ine adverse effects of systemic inhibition of glycolysis, even
if administered only for a short time.
An additional recent study has implicated chloride chan-
nels, specifically the voltage-dependent CLC-3 Cl- channels
as playing a significant role in neonatal seizures [132]. The
investigators reported that CLC-3 Cl- channels mediated
a large voltage-dependent outward rectifying Cl- current
in neonatal, but not adult, mouse brains, and this current
was blocked with the administration of sodium-gluconate
in vitro. Intriguingly, this in vitro finding was translated to
several in vivo models. Administration of sodium gluconate
blocked kainic acid induced status epilepticus in neonatal,
but not adult rats. Additionally, in the hypoxia–ischemia
model of neonatal seizures, administration suppressed epi-
leptiform bursts as well as phenobarbital and their effects
were synergistic when co-administered [132]. These results
are impressive and deserve further attention in the human
condition, as gluconate is already FDA approved as a food
Novel Therapeutics for Neonatal Seizures

additive. The authors noted that the gluconate concentrations
needed to treat seizures were rather high and that brain pen-
etration and side effects would need to be evaluated further.
Kainate and AMPA receptors may be additional targets
for neonatal seizures, as they show peak brain expression
during late embryonic and early postnatal periods [14].
Indeed, knocking out the GluK2 kainic acid receptor subunit
or blocking kainic acid receptors by a novel drug, UBP310,
blocked excitatory neurotransmission in vitro [133]. In vivo,
GluK2 knockout mice and those treated with UBP310 were
less susceptible to seizures during reoxygenation follow-
ing hypoxia [133]. Given the importance of kainate recep-
tor signaling on brain development, blocking kainic acid
receptors may result in significant toxicity, which has not
been fully assessed. The noncompetitive AMPA antagonist,
talampanel, suppressed hypoxia-induced neonatal seizures
and also prevented enhanced seizure susceptibility later in
life [134]. Notably, treatment with talampanel did not result
in any increase in cell death, suggesting that AMPA receptor
antagonism may be a safe and effective target for hypoxia-
induced neonatal seizures.
Lastly, bumepamine, a lipophilic benzylamine derivative
of bumetanide has been considered for use in neonatal sei-
zures in preclinical models. Bumepamine was first devel-
oped in 1978 by Nielsen and Feit [135]. It demonstrates 80%
lower diuretic activity and lower ionization rate at physiolog-
ical pH compared to bumetanide. Additionally, bumepamine
has shown a more potent dose dependent effect as compared
to bumetanide in potentiating the effect of phenobarbital in
animal models of chronic epilepsy, although the mechanism
of this effect is not fully understood [136]. These factors
have prompted interest in this compound as a treatment for
neonatal seizures. However, data at this time are limited to
animal models.
Neonatal‑Onset Epilepsy
Though neonatal-onset epilepsies make up only 13% of
patients with neonatal seizures in the neonatal intensive care
unit [6], the early identification of epilepsy rather than acute
symptomatic seizures can have significant consequences for
guidance of management and informing prognosis in these
cases. As rapid genetic testing becomes more widely avail-
able, our future ability to deliver precision medicine will
provide opportunities to improving outcomes for children
with neonatal-onset epilepsies. However, until such time that
rapid genetic testing is standard of care, clinicians must be
aware of clinical features that may indicate a genetic etiol-
ogy that may be responsive to targeted treatment. Neonatal-
onset epilepsies with a genetic etiology may be related to
structural brain abnormalities, metabolic diseases, or other
genetic syndromes [143]. Targeted therapies are available
for some genetic etiologies of neonatal-onset epilepsy, with
others in preclinical development (Table 2).
Structural Brain Abnormalities
Structural brain anomalies may be identified by in utero
imaging or with early magnetic resonance imaging (MRI)
during initial seizure work-up. A recent report of neona-
tal epilepsy found that ~ 29% of neonatal-onset epilepsies
were related to congenital brain malformations [6]. Con-
genital malformations of brain development may be mul-
tifactorial, though multiple pathogenic genes and chromo-
somal anomalies have been implicated. Early imaging is
essential to narrowing the differential diagnosis, as many
of these malformations are due to genetic syndromes that
may be associated with extracerebral congenital anoma-
lies. Early consultation with a geneticist is recommended

Table 2  Select genetic neonatal epilepsies with targeted treatments

Genetic disorder Current targeted treatments Emerging treatments

Tuberous sclerosis complex (TSC1/TSC2) Vigabatrin Everolimus

mTOR-related structural epilepsies (DEPDC5,
TSC1, TSC2, AKT3, MTOR)
Pyridoxine-dependent epilepsy (ALDH7A1)
Cerebral folate transport deficiency (FOLR1)
Molybdenum cofactor deficiency (MOCS1)
KCNQ2-DEE
SCN1A-DEE (with Thr226Met pathogenic variant)
SCN2A
KCNT1
Everolimus, consider early surgery
for infants with structural seizure
etiology
Pyridoxine, lysine restriction, arginine
Folinic acid
Phenytoin, carbamazepine
Phenytoin, carbamazepine, lacosamide
Quinidine Bepridil
Rapamycin
ALDH7A1 directed antisense oligonucleotide
(ASO); upstream reduction therapy
Cyclic pyranopterin monophosphate (cPNP), viral
vectors to increase hepatic expression of molyb-
dopterin synthase
Ezogabine
Phenytoin, carbamazepine

DEE developmental and epileptic encephalopathy

13

to ensure that the appropriate diagnostic tests are pur-
sued [129]. Isolated structural malformations can lead to
neonatal seizures due to focal or diffuse abnormalities in
brain structure or neuronal migration, including agenesis
of the corpus callosum (L1CAM, ZEB2, TUBA1, TUBB2A,
etc.), polymicrogyria (ADGRG1, AKT2, MTOR, PTEN,
etc.), lissencephaly (PAFAH1B1, TUBA1A, DCX, ARX,
FKTN), schizencephaly (EMX2, SIX3, SHH, COL4A1),
megalencephaly (MTOR, SHH, PIK3CA, LYK5/STRADA),
holoprosencephaly (SHH, ZIC2, SIX3, TGIF1), and het-
erotopias (RELN, DCX, TUBBA1A, etc.) [144]. Though
age of seizure onset can vary in patients with structural
abnormalities, most with an early presentation of seizures
have a disorder of neuronal migration [6]. Neonates with
epilepsy due to brain malformations are more likely to die
or to be discharged to hospice care than those with other
genetic epileptic encephalopathies [6], underscoring the
severity of their epilepsy and need for additional thera-
peutic interventions.
Targeted therapeutics in structurally related neonatal-
onset epilepsies are limited. Though people with tuberous
sclerosis complex rarely have seizures starting in the neo-
natal period, the ability to identify these infants as high-risk
patients may allow for early intervention to prevent epilep-
togenesis. A recent study of infants with tuberous sclero-
sis complex (TSC1, TSC2) aimed to improve outcomes at
24 months by treating with vigabatrin prior to seizure onset,
but after the first interictal discharges were detected, versus
conventional treatment once seizures had developed [145].
Children in the early treatment group, compared with con-
trols, had a later onset of epilepsy and a decreased incidence
of infantile spasms and refractory epilepsy. Interestingly,
there was no significant difference in developmental out-
comes at 24 months of age, suggesting that developmental
delays related to tuberous sclerosis complex may be some-
what independent from seizure severity [145]. However, this
is contradictory to larger long-term studies that suggest that
early onset and severe epilepsy in the first 2 years of life is
associated with long-term intellectual disabilities in indi-
viduals with tuberous sclerosis complex [146]. Given this
disconnect, longer-term evaluation of children who received
early treatment with vigabatrin deserves evaluation, as the
suppression of epileptogenesis with early treatment remains
intriguing.
The mammalian target of rapamycin (mTOR) pathway
includes several genes that may be related to early-onset
structural epilepsies including DEPDC5, TSC1, TSC2,
AKT3, and MTOR. The use of mTor inhibitors, such as
everolimus and rapamycin, have shown limited success in
the treatment of epilepsy in these disorders, though they
have not been fully explored in the neonatal period or prior
to seizure onset [147, 148]. Additionally, early evaluation
for epilepsy surgery may be considered in patients with
13
J. M. Ziobro et al.
treatment-resistant focal seizures due to a structural etiol-
ogy, even those with a genetic basis [149].
Metabolic Disorders
Though rare, it is important to recognize treatable metabolic
neonatal epileptic encephalopathies (reviewed in [150]).
Clinical features that may raise suspicion for an underly-
ing metabolic disorder include an initial symptom-free
period followed by feeding difficulty and lethargy, hypoto-
nia, respiratory distress and abnormal laboratory test result
including hypoglycemia, non-anion gap metabolic acidosis,
ketosis, hyperammonemia, elevated lactate, and transamini-
tis [136, 137, 145]. Seizures in metabolic disorders may be
either a primary manifestation or secondary to metabolic
abnormalities and EEG may show a burst-suppression or
hypsarrhythmia pattern [145]. Imaging may show evidence
of severe injury without a clinical history to suggest an
obvious hypoxic injury at birth [145]. Magnetic resonance
spectrography (MRS) may be an essential tool in identifying
suspected metabolic disorders [137].
Potentially treatable causes of metabolic neonatal-onset
seizures include pyridoxine-dependent epilepsy, PNPO defi-
ciency, nonketotic hyperglycinemia, organic acidurias, urea
cycle disorders, peroxisomal disorders, folinic acid-responsive
seizures, biotinidase deficiency, molybdenum cofactor
deficiency, sulphite oxidase deficiency, and congenital
disorders of glycosylation (reviewed in [144]). Even with
appropriate treatments, responses are often varied; metabolic
epileptic encephalopathies are frequently associated with
poor outcomes. This underscores the need for early identi-
fication and the development of more precise and effective
targeted therapies.
Preclinical and clinical studies of therapeutics for meta-
bolic epileptic encephalopathies are limited. There are cur-
rent clinical trials of cyclic pyranopterin monophosphate
(cPNP) for the treatment of Molybdenum cofactor deficiency
(NCT02629393) after treatment in an initial compassionate-
use cohort showed safety and efficacy, most notably in the
patients who were treated before the onset of recurrent sei-
zures [151]. Preclinical studies are also examining the use of
viral vectors to increase hepatic expression of molybdopterin
synthase [152].
Current treatments of pyridoxine-dependent epilepsy
have focused on pyridoxine supplementation, with some
evidence supporting additional lysine restriction and argi-
nine supplementation [153]. Emerging therapeutic strate-
gies for pyridoxine-dependent epilepsy include ALDHA7A1
directed antisense therapy [154] and targeting of upstream
lysine degradation pathways to prevent the build-up of toxic
metabolites [153, 155]. Gene therapies for inherited neuro-
metabolic diseases continue to be investigated as a means
of precision therapy for these rare diseases. Importantly,
Novel Therapeutics for Neonatal Seizures
immune tolerance to foreign proteins in the neonate may be
an important factor in successful gene or protein replace-
ment therapies, making early diagnosis essential for success-
ful treatment [156, 157].
Genetic Neonatal Epilepsy Syndromes
Neonatal epilepsy syndromes often present in the first days
to weeks of life. Clinical identification of a genetic neona-
tal epilepsy syndrome is useful to establish a diagnosis and
etiology, understand the pathophysiology, guide treatment,
estimate prognosis, and identify expected comorbidities
[158]. Interestingly, neonatal-onset epilepsies have a broad
range of phenotypic severity, with some self-limited and
others severe and progressive, even though they may have
common genetic loci. Monogenetic causes of neonatal-onset
epilepsies have been reviewed extensively as our diagnos-
tic testing and understanding of specific genetic disorders
continue to expand [130, 144]. Yet, targeted therapeutic
options remain inadequate and only clinically relevant to a
few known disorders.
In a recent study of neonatal-onset epilepsies, autoso-
mal dominant pathogenic variants in KCNQ2 were the most
common finding on genetic testing [6]. KCNQ2 encodes a
voltage-gated potassium channel (Kv7.2) responsible for
dichotomous epilepsy syndromes. Self-limited familial
neonatal epilepsy due to (often familial) pathogenic vari-
ants in KCNQ2 often presents in the first few days of life
with focal tonic seizures, often with apnea, vocalizations,
or autonomic changes [154]. Seizures are typically brief,
but cluster and require treatment. Interictal EEG is normal.
Seizures abate within the first year of life, though up to 15%
of individuals may develop epilepsy later in life [159]. Con-
versely, KCNQ2 related neonatal encephalopathy presents
with a much more severe phenotype. Patients present with
early onset, often tonic seizures that are difficult to control,
and have a severely abnormal interictal EEG that may dis-
play a burst suppression pattern or multifocal discharges.
Seizure frequency tends to decrease over time, but chil-
dren have poor developmental outcomes. Targeted therapy
with the potassium channel opener, ezogabine, was poten-
tially beneficial in treating refractory seizures in patients
with KCNQ2 encephalopathy, especially in patients treated
before 6 months of age, whereas patients treated at older
ages showed a less robust response [121]. Unfortunately,
ezogabine was discontinued by the manufacturer in 2017
due to skin discoloration and potential vision loss due to
retinal pigmentation [160]. Interestingly, treatment with
sodium channel blockers, such as carbamazepine or phe-
nytoin, has been reported to be relatively effective in treat-
ing seizures in KCNQ2-DEE. In a recent study of children
with KCNQ2-DEE, 53% were seizure free on carbamazepine
and 33% responded the phenytoin [161]. It is unclear how
sodium-channel blockers act in a potassium channel muta-
tion, though the authors suggested that voltage-gated sodium
channels co-localize with KCNQ potassium channels and
that modulation of one channel may significantly affect the
function of the channel complex [161].
Pathogenic variants in voltage-gated sodium channel
subunits, including SCN1A and SCN2A, are associated with
several neonatal-onset epilepsy syndromes. Loss-of-function
mutations in SCN1A are most commonly implicated in Dravet
syndrome with seizure onset in the first year of life. How-
ever, SCN1A is rarely implicated in epilepsy of infancy with
migrating focal seizures (EIMFS) and early onset SCN1A-
DEE with seizure onset in the neonatal period [162]. It is
notable that in SCN1A-DEE, most patients have a recurrent
de novo missense mutation, Thr226Met variant, which is
proposed to create a dual-action, gain-of-function and loss-
of-function phenotype, contrary to the loss-of-function phe-
notype most commonly seen in Dravet syndrome [163, 164].
This would suggest that children with SCN1A-DEE may have
seizures responsive to sodium-channel blockers, even though
these medications are contraindicated in SCN1A-associated
Dravet syndrome. However, this has not been adequately sup-
ported in the limited published literature [163].
Pathogenic variants in SCN2A have been associated with
self-limited familial or nonfamilial neonatal epilepsies as
well as more severe developmental and epileptic encepha-
lopathies with neonatal-onset, in addition to other neurologic
disorders with onset beyond the neonatal period [165]. There
is wide phenotypic variation associated with SCN2A patho-
genic variants, though missense variants in epileptic enceph-
alopathies are often activating, suggesting gain of function
physiology [166]. As such, these children’s seizures often
respond to sodium-channel blockers (e.g., phenytoin and
carbamazepine [166]). Another recent case series showed
response to lacosamide in two children with SCN2A associ-
ated infantile onset epilepsy after they had both shown an
incomplete response to phenytoin [93].
The syndrome of epilepsy of infancy with migrating focal
seizures (EIMFS) is most commonly associated with patho-
genic variants in the KCNT1 gene, which encodes a subunit
of a sodium-dependent potassium channel [167]. Seizures
in EIMFS often begin in the neonatal period and are char-
acterized by focal seizures that appear to migrate from one
region to another on EEG. Seizures are often refractory to
antiseizure medications and there is associated arrest of
psychomotor development. Pathogenic variants in KCNT1
typically have a gain-of-function effect. Precision treatment
with the potassium-channel blocker quinidine has been
reported to be effective in controlling seizures in a small
subset of patients with KCNT1 [168–170] although more
recent, larger case series have reported mixed effects [171,
172]. Additional in vitro studies have been conducted with
the KCNT1 current blocker, bepridil, showing more potent
13

KCNT1 blockade than quinidine for two patient-associated
KCNT1 variants, though it was not trialed in patients [173].
The authors suggested that bepridil may provide another
agent for precision medicine in KCNT1 associated EIMFS,
though it must be noted that functional evaluation of spe-
cific mutations should be considered prior to treatment with
KCNT1-blocking agents [169, 173].
Conclusions
The treatment of neonatal seizures presents a unique chal-
lenge in pediatric neurology and neonatology due to the
unique pathophysiologic features of the immature brain.
Despite significant advances in preclinical research, cur-
rent available therapeutics for acute symptomatic neonatal
seizures have not changed substantially in decades. By con-
trast, the Food and Drug Administration (FDA) and Euro-
pean Medicines Agency (EMA) have approved greater than
20 new antiseizure medications for adults, none of which
are approved for newborn infants [174]. The challenges in
bringing new drug treatments to clinical trials for neonatal
seizures are great. There are ethical considerations in balanc-
ing the risks and benefits in administering a new drug when
safety and efficacy data from adults cannot be adequately
extrapolated to neonates. Logistic considerations are even
greater, as participants are recruited within hours to days
following birth, with consent provided by parents who have
likely also gone through a series of parallel medically and
emotionally traumatic events. In addition, adequate EEG
monitoring—with real-time interpretation—and ability
to perform frequent blood monitoring is necessary to per-
form high quality trials. It is also recommended to include
a control arm; either with current first-line therapy (i.e.,
phenobarbital) or to design trials that directly compare sec-
ond-line treatment options for seizures that persist despite
phenobarbital. These steps require close multidisciplinary
collaboration.
Given these challenges, collaboration across multi-
ple centers is essential for future trials. Rapid distinction
between acute symptomatic seizures versus neonatal-onset
epilepsy with early appropriate imaging, laboratory and
genetic testing is crucial as we move toward precision medi-
cine. Use of electronic health records and learning health-
care systems [175]—particularly for identification of chil-
dren with rare neonatal-onset epilepsies or for long-term
follow-up data—could allow study sites to maintain consist-
ent data collection and lead to more robust interpretation of
the gathered data. The learning healthcare system construct
could also be applied for assessment of implementation of
new trial results in real-world clinical practice.
13
J. M. Ziobro et al.
The need for new treatments for neonatal seizures is evi-
dent. However, despite limited new antiseizure medications
for neonatal seizures in the past, there is hope for the future.
Emerging clinical trials and preclinical data are encouraging,
as is the expanding genetic landscape and potential for pre-
cision therapy. Long-term developmental outcomes remain
of paramount importance and our hope is that in the next
decade we will have antiseizure medications that are not only
more effective than our current treatment options for neona-
tal seizures, but also decrease the risk of neuronal injury in
the developing brain. The combination of these features will
provide the best hope for the future of neonates with seizures.
Supplementary Information  The online version contains supplemen-
tary material available at https://​doi.​org/​10.​1007/​s13311-​021-​01085-8
Required Author Forms  Disclosure forms provided by the authors are
available with the online version of this article.
References
1. Lanska MJ, Lanska DJ. Neonatal Seizures in the United States:
Results of the National Hospital Discharge Survey, 1980-1991.
Neuroepidemiology. 1996;15:117–125.
2. Saliba RM, Annegers JF, Waller DK, et al. Incidence of neonatal
seizures in Harris County, Texas, 1992-1994. Am J Epidemiol.
1999;150:763–769.
3. Glass HC, Pham TN, Danielsen B, et al. Antenatal and Intrapar-
tum Risk Factors for Seizures in Term Newborns: A Population-
Based Study, California 1998-2002. J Pediatr. 2009;154:24-28.
e1.
4. Lloyd RO, O’Toole JM, Pavlidis E, et al. Electrographic Seizures
during the Early Postnatal Period in Preterm Infants. J Pediatr.
2017;187:18–25.e2.
5. Glass HC, Shellhaas RA, Wusthoff CJ, et al. Contemporary
Profile of Seizures in Neonates: A Prospective Cohort Study. J
Pediatr. 2016;174:98-103.e1.
6. Shellhaas RA, Wusthoff CJ, Tsuchida TN, et al. Profile of neo-
natal epilepsies. Neurology. 2017;89:893–899.
7. Uria-Avellanal C, Marlow N, Rennie JM. Outcome following
neonatal seizures. Semin Fetal Neonatal Med. 2013;18:224–232.
8. Glass HC, Soul JS, Chu CJ, et al. Response to antiseizure medi-
cations in neonates with acute symptomatic seizures. Epilepsia.
2019;60:e20–e24.
9. Painter MJ, Scher MS, Stein AD, et al. Phenobarbital Compared
with Phenytoin for the Treatment of Neonatal Seizures. N Engl
J Med. 1999;341:485–489.
10. Yamada J, Okabe A, Toyoda H, et al. Cl- uptake promoting depo-
larizing GABA actions in immature rat neocortical neurones is
mediated by NKCC1. J Physiol. 2004;557:829–841.
11. Dzhala VI, Talos DM, Sdrulla DA, et  al. NKCC1 trans-
porter facilitates seizures in the developing brain. Nat Med.
2005;11:1205–1213.
12. Rivera C, Voipio J, Payne JA, et al. The K+/Cl− co-transporter
KCC2 renders GABA hyperpolarizing during neuronal maturation.
Nature. 1999;397:251–255.
Novel Therapeutics for Neonatal Seizures
13. Carrasco M, Stafstrom CE. How Early Can a Seizure Happen?
Pathophysiological Considerations of Extremely Premature
Infant Brain Development. Dev Neurosci. 2018;40:417–436.
14. Nardou R, Ferrari DC, Ben-Ari Y. Mechanisms and effects of
seizures in the immature brain. Semin Fetal Neonatal Med.
2013;18:175–184.
15. Dzhala VI, Kuchibhotla KV., Glykys JC, et  al. Progressive
NKCC1-Dependent Neuronal Chloride Accumulation during
Neonatal Seizures. J Neurosci. 2010;30:11745–11761.
16. Stafstrom CE, Thompson JL, Holmes GL. Kainic acid seizures in
the developing brain: status epilepticus and spontaneous recur-
rent seizures. Dev Brain Res. 1992;65:227–236.
17. Miller S, Goasdoue K, Björkman St. Neonatal seizures and
disruption to neurotransmitter systems. Neural Regen Res.
2017;12:216-217.
18. Shellhaas RA, Chang T, Tsuchida T, et al. The American Clinical Neuro-
physiology Societyʼs Guideline on Continuous Electroencephalogra-
phy Monitoring in Neonates. J Clin Neurophysiol. 2011;28:611–617.
19. Lemmon ME, Donohue PK, Parkinson C, et al. Communication
Challenges in Neonatal Encephalopathy. Pediatrics [Internet].
2016;138:e20161234. Available from: www.​aappu​blica​tions.​org/​
news. Accessed January 1, 2021  and Motor Function in Adult Rats. J Pharmacol Exp Ther
20. Lemmon ME, Donohue PK, Parkinson C, et  al. Parent
Experience of Neonatal Encephalopathy. J Child Neurol.
2017;32(3):286–292.
21. Hill E, Glass HC, Kelley K, et al. Seizures and Antiseizure Medi-
cations are Important to Parents of Newborns With Seizures.
Pediatr Neurol. 2017;67:40–44.
22. Soul JS, Pressler R, Allen M, et al. Recommendations for the
design of therapeutic trials for neonatal seizures. Pediatr Res.
2019;85:943–954.
23. WHO Department of Mental Health and Substance Abuse, WHO
Department of Maternal Newborn Child and Adolescent Health,
OASI Department of Mental Retardation Unit of Neurology and
Clinical Neurophysiopathology. Guidelines on neonatal seizures.
[Internet]. World Health Organ. 2011. Available from: https://​apps.​
who.​int/​iris/​handle/​10665/​77756. Accessed November 30, 2020.
24. Blume HK, Garrison MM, Christakis DA. Neonatal seizures:
Treatment and treatment variability in 31 United States pediatric
hospitals. J Child Neurol. 2009;24:148–154.
25. Dizon MLV, Rao R, Hamrick SE, et al. Practice variation in anti-
epileptic drug use for neonatal hypoxic-ischemic encephalopa-
thy among regional NICUs. BMC Pediatr. 2019;19:67. Accessed
November 30, 2021.
26. Ahmad KA, Desai SJ, Bennett MM, et al. Changing antiepileptic
drug use for seizures in US neonatal intensive care units from
2005 to 2014. J Perinatol. 2017;37:296–300.
27. Shellhaas RA, Chang T, Wusthoff CJ, et al. Treatment Duration
After Acute Symptomatic Seizures in Neonates: A Multicenter
Cohort Study. J Pediatr. 2017;181:298-301.e1.
28. Le VT, Abdi HH, Sánchez PJ, et al. Neonatal Antiepileptic Medi-
cation Treatment Patterns: A Decade of Change. Am J Perinatol.
2021;38:469-476.
29. Ben-Ari Y, Cherubini E, Corradetti R, et  al. Giant synaptic
potentials in immature rat CA3 hippocampal neurones. J Physiol.
1989;416:303–325.
30. Cherubini E, Rovira C, Gaiarsa JL, et al. GABA mediated excita-
tion in immature rat CA3 hippocampal neurons. Int J Dev Neu-
rosci. 1990;8:481–490.
31. Sharpe C, Reiner GE, Davis SL, et al. Levetiracetam Versus
Phenobarbital for Neonatal Seizures: A Randomized Controlled
Trial. Pediatrics [Internet]. 2020;145:e20193182. Available at:
https://p​ ediat​ rics.a​ appub​ licat​ ions.o​ rg. Accessed January 1, 2021.
32. Lynch NE, Stevenson NJ, Livingstone V, et al. The temporal
evolution of electrographic seizure burden in neonatal hypoxic
ischemic encephalopathy. Epilepsia. 2012;53:549–557.
33. Al-Muhtasib N, Sepulveda-Rodriguez A, Vicini S, et al. Neonatal
phenobarbital exposure disrupts GABAergic synaptic maturation
in rat CA1 neurons. Epilepsia. 2018;59:333–344.
34. Kaushal S, Tamer Z, Opoku F, et al. Anticonvulsant drug-
induced cell death in the developing white matter of the rodent
brain. Epilepsia. 2016;57:727–734.
35. Forcelli PA, Kim J, Kondratyev A, et al. Pattern of antiepileptic
drug-induced cell death in limbic regions of the neonatal rat
brain. Epilepsia. 2011;52:e207–e211.
36. Noguchi KK, Fuhler NA, Wang SH, et al. Brain pathology
caused in the neonatal macaque by short and prolonged
exposures to anticonvulsant drugs. Neurobiol Dis [Internet].
2021;149:105245. Available from: https://​doi.​org/​10.​1016/j.​
nbd.​2020.​105245. Accessed February 20, 2021. 
37. Quinlan SMM, Rodriguez-Alvarez N, Molloy EJ, et al. Com-
plex spectrum of phenobarbital effects in a mouse model
of neonatal hypoxia-induced seizures. Sci Rep [Internet].
2018;8:9986. Available from: https:// ​ w ww. ​ n ature. ​ c om/
​artic​les/​s41598-​018-​28044-2. Accessed January 1, 2021. 
38. Forcelli PA, Kozlowski R, Synder C, et al. Effects of Neo-
natal Antiepileptic Drug Exposure on Cognitive, Emotional,
[Internet]. 2012 [cited 2020 Dec 30];340:558–566. Available
from: https://​doi.​org/​10.​1124/​jpet.​111.​188862.
39. Singh D, Kumar P, Narang A. A randomized controlled trial of
phenobarbital in neonates with hypoxic ischemic encephalopa-
thy. J Matern Neonatal Med. 2005;18:391–395.
40. Young L, Berg M, Soll R. Prophylactic barbiturate use for the pre-
vention of morbidity and mortality following perinatal asphyxia.
Cochrane Database Syst. Rev.[Internet]; 2016:5(5):CD001240.
Available from: https://​doi.​org/​10.​1002/​14651​858.​CD001​240.​
pub3/​full. Accessed December 30, 2020. 
41. Bohannon KK, Leung N, Cook AM, et al. Evaluation of two
fosphenytoin loading dose regimens and monitoring in infants
and neonates less than six months of age. J Pediatr Pharmacol
Ther. 2020;25:617–622.
42. Morton LD. Clinical experience with fosphenytoin in children.
J Child Neurol. 1998;13:19–22.
43. Al Za’abi M, Lanner A, Xiaonian X, et al. Application of routine
monitoring data for determination of the population pharmacoki-
netics and enteral bioavailability of phenytoin in neonates and
infants with seizures. Ther Drug Monit. 2006;28:793-799.
44. Alix V, James M, Jackson AH, et al. Efficacy of Fosphenytoin as
First-Line Antiseizure Medication for Neonatal Seizures Com-
pared to Phenobarbital. J Child Neurol. 2021;36:30-37.
45. Sicca F, Contaldo A, Rey E, et al. Phenytoin administration in
the newborn and infant. Brain Dev. 2000;22:35–40.
46. Kriel RL, Cifuentes RF. Fosphenytoin in infants of extremely low
birth weight. Pediatr Neurol. 2001;24:219–221.
47. Takeoka M, Kishnamoorthy K, Soman TB, et al. Fosphenytoin
in Infants. J Child Neurol. 1997;13:537–540.
48. Bittigau P, Sifringer M, Ikonomidou C. Antiepileptic drugs
and apoptosis in the developing brain. Ann N Y Acad Sci.
2003;993:103-114.
49. Grinspan ZM, Shellhaas RA, Coryell J, et al. Comparative effec-
tiveness of levetiracetam vs phenobarbital for infantile epilepsy.
JAMA Pediatr. 2018;172:352-360.
50. Abend NS, Gutierrez-Colina AM, Monk HM, et  al. Lev-
etiracetam for treatment of neonatal seizures. J Child Neurol.
2011;26:465–470.
51. Ramantani G, Ikonomidou C, Walter B, et al. Levetiracetam:
Safety and efficacy in neonatal seizures. Eur J Paediatr Neurol.
2011;15:1–7. 
52. Khan O, Cipriani C, Wright C, et al. Role of intravenous lev-
etiracetam for acute seizure management in preterm neonates.
Pediatr Neurol. 2013;49:340–343.
13

53. Kurtom W, Courchia B, Pensirikul A, et al. Lack of response
to treatment with levetiracetam in extreme preterm infants with
seizures. J Perinatol. 2019;39:1480–1484.
54. Han JY, Moon CJ, Youn YA, et al. Efficacy of levetiracetam for
neonatal seizures in preterm infants. BMC Pediatr. 2018;18:1–6.
55. Strasser K, Lueckemann L, Kluever V, et al. Dose-dependent
effects of levetiracetam after hypoxia and hypothermia in the
neonatal mouse brain. 2016 [cited 2020 Dec 30]; Available from:
https://​doi.​org/​10.​1016/j.​brain​res.​2016.​05.​040.
56. Falsaperla R, Mauceri L, Pavone P, et al. Short-term neurodevel-
opmental outcome in term neonates treated with phenobarbital
versus levetiracetam: A single-center experience. Behav Neu-
rol [Internet]. 2019;2019:3683548. Available at: https://​www.
​hinda​wi.​com. Accessed January 1, 2021.  peutic targeting of cation-chloride cotransporters in neonatal
57. Arican P, Olgac Dundar N, Mete Atasever N, et al. Comparison
of the neurocognitive outcomes in term infants treated with lev-
etiracetam and phenobarbital monotherapy for neonatal clinical
seizures. Seizure [Internet]. 2020;80:71–74. Available at: https://​
www.​seizu​re-​journ​al.​com. Accessed November 30, 2020.
58. Tsuchida TN, Wusthoff CJ, Shellhaas RA, et al. American clini-
cal neurophysiology society standardized EEG terminology and
categorization for the description of continuous eeg monitoring
in neonates: Report of the american clinical neurophysiology
society critical care monitoring committee. J Clin Neurophysiol.
2013;30:161–173.
59. Pavlidis E, Spagnoli C, Pelosi A, et al. Neonatal status epi-
lepticus: Differences between preterm and term newborns.
Eur J Paediatr Neurol [Internet]. 2015;19:314–319. Available
from:  https://​doi.​org/​10.​1016/j.​ejpn.​2015.​01.​002. Accessed
November 30, 2020.
60. Torolira D, Suchomelova L, Wasterlain CG, et al. Phenobarbital
and midazolam increase neonatal seizure-associated neuronal
injury. Ann Neurol. 2017;82:115–120.
61. Dao K, Giannoni E, Diezi M, et al. Midazolam as a first-line
treatment for neonatal seizures: Retrospective study. Pediatr Int.
2018;60:498–500.
62. Castro Conde JR, Hernández Borges AA, Doménech Martínez
E, et al. Midazolam in neonatal seizures with no response to
phenobarbital. Neurology. 2005;64:876-879.
63. Boylan GB, Rennie JM, Chorley G, et al. Second-line anticon-
vulsant treatment of neonatal seizures: A video-EEG monitoring
study. Neurology. 2004;62:486-488.
64. Shany E, Benzaqen O, Watemberg N. Comparison of continuous
drip of midazolam or lidocaine in the treatment of intractable
neonatal seizures. J Child Neurol. 2007;22:255–259.
65. Duerden EG, Guo T, Dodbiba L, et  al. Midazolam Dose
Correlates with Abnormal Hippocampal Growth and Neu-
rodevelopmental Outcome in Preterm Infants. Ann Neurol.
2016;79:548-559.
66. Favié LMA, Huitema ADR, van den Broek MPH, et al. Lido-
caine as treatment for neonatal seizures: Evaluation of previously
developed population pharmacokinetic models and dosing regi-
men. Br J Clin Pharmacol. 2020;86:75–84.
67. Malingré MM, Van Rooij LGM, Rademaker CMA, et al. Devel-
opment of an optimal lidocaine infusion strategy for neonatal
seizures. Eur J Pediatr. 2006;165:598–604.
68. Van Den Broek MPH, Huitema ADR, Van Hasselt JGC, et al.
Lidocaine (lignocaine) dosing regimen based upon a population
pharmacokinetic model for preterm and term neonates with sei-
zures. Clin Pharmacokinet. 2011;50:461–469.
69. Weeke LC, Toet MC, Van Rooij LGM, et al. Lidocaine response
rate in aEEG-confirmed neonatal seizures: Retrospective study of
413 full-term and preterm infants. Epilepsia. 2016;57:233–242.
70. Van Rooij LGM, Toet MC, Rademaker KMA, et al. Cardiac
arrhythmias in neonates receiving lidocaine as anticonvulsive
treatment. Eur. J. Pediatr. 2004;163:637–641.
13
J. M. Ziobro et al.
71. Weeke LC, Schalkwijk S, Toet MC, et  al. Lidocaine-Asso-
ciated Cardiac Events in Newborns with Seizures: Incidence,
Symptoms and Contributing Factors. Neonatology [Internet].
2015;108:130–136. Available from: www.​k arger.​c om/​n eo.
Accessed January 1, 2021.
72. Dzhala VI, Brumback AC, Staley KJ. Bumetanide enhances
phenobarbital efficacy in a neonatal seizure model. Ann Neurol.
2008;63:222–235.
73. Johne M, Römermann K, Hampel P, et al. Phenobarbital and
midazolam suppress neonatal seizures in a noninvasive rat model
of birth asphyxia, whereas bumetanide is ineffective. Epilepsia.
2021;62:920–934.
74. Puskarjov M, Kahle KT, Ruusuvuori E, et al. Pharmacothera-
seizures. Epilepsia. 2014;55:806–818.
75. Pressler RM, Boylan GB, Marlow N, et al. Bumetanide for the
treatment of seizures in newborn babies with hypoxic ischaemic
encephalopathy (NEMO): An open-label, dose finding, and fea-
sibility phase 1/2 trial. Lancet Neurol. 2015;14:469–477.
76. Thoresen M, Sabir H. Epilepsy: Neonatal seizure still lack safe
and effective treatment. Nat Rev - Neurol. 2015;11:311–312.
77. Soul JS, Bergin AM, Stopp C, et al. A Pilot Randomized, Con-
trolled, Double‐Blind Trial of Bumetanide to Treat Neonatal
Seizures. Ann Neurol. 2021;89:327-340.
78. Follett PL, Deng W, Dai W, et al. Glutamate Receptor-Mediated
Oligodendrocyte Toxicity in Periventricular Leukomalacia: A
Protective Role for Topiramate. J Neurosci. 2004;24:4412–4420.
79. Glier C, Dzietko M, Bittigau P, et  al. Therapeutic doses of
topiramate are not toxic to the developing rat brain. Exp Neurol.
2004;187:403–409.
80. Silverstein FS, Ferriero DM. Off-Label Use of Antiepileptic
Drugs for the Treatment of Neonatal Seizures. Pediatr Neurol.
2008;39:77–79.
81. Nuñez-Ramiro A, Benavente-Fernández I, Valverde E, et al.
Topiramate plus cooling for hypoxic-ischemic encephalopathy:
A randomized, controlled, multicenter, double-blinded trial. Neo-
natology. 2019;116:76–84.
82. Filippi L, Fiorini P, Catarzi S, et al. Safety and efficacy of topira-
mate in neonates with hypoxic ischemic encephalopathy treated
with hypothermia (NeoNATI): a feasibility study. J Matern Neo-
natal Med. 2018;31:973–980.
83. Glass HC, Poulin C, Shevell MI. Topiramate for the treatment of
neonatal seizures. Pediatr Neurol. 2011;44:439–442.
84. Dupuis N, Matagne A, Staelens L, et al. Anti-ictogenic and antie-
pileptogenic properties of brivaracetam in mature and immature
rats. Epilepsia. 2015;56:800–805.
85. Nissenkorn A, Tzadok M, Bar-Yosef O, et al. Treatment with
brivaracetam in children – The experience of a pediatric epilepsy
center. Epilepsy Behav. 2019;101(PtA):106541.
86. Liu E, Dilley D, McDonough B, et  al. Safety and Toler-
ability of Adjunctive Brivaracetam in Pediatric Patients < 16
Years with Epilepsy: An Open-Label Trial. Pediatr Drugs.
2019;21:291–301.
87. McGuire S, Silva G, Lal D, et al. Safety and Efficacy of Brivar-
acetam in Pediatric Refractory Epilepsy: A Single-Center Clini-
cal Experience. J Child Neurol. 2020;35:102–105.
88. Welsh SS, Lin N, Topjian AA, et  al. Safety of intravenous
lacosamide in critically ill children. Seizure. 2017;52:76–80.
89. Licko T, Seeger N, Zellinger C, et al. Lacosamide treatment
following status epilepticus attenuates neuronal cell loss and
alterations in hippocampal neurogenesis in a rat electrical sta-
tus epilepticus model. Epilepsia. 2013;54:1176–1185.
90. Wang B, Dawson H, Wang H, et al. Lacosamide improves out-
come in a murine model of traumatic brain injury. Neurocrit
Care. 2013;19:125–134.
Novel Therapeutics for Neonatal Seizures
91. Kim GH, Byeon JH, Eun BL. Neuroprotective effect of lacosa-
mide on hypoxic-ischemic brain injury in neonatal rats. J Clin
Neurol. 2017;13:138–143.
92. Arkilo D, Gustafson M, Ritter FJ. Clinical experience of intra-
venous lacosamide in infants and young children. Eur J Paedi-
atr Neurol. 2016;20:212–217.
93. Hadar F-H, Eli H, Ayelet L, et al. Lacosamide for SCN2A-
related intractable neonatal and infantile seizures. Epileptic
Disord. 2018;20:440–446.
94. Naylor DE, Liu H, Wasterlain CG. Trafficking of GABAA
receptors, loss of inhibition, and a mechanism for pharmacore-
sistance in status epilepticus. J Neurosci. 2005;25:7724–7733.  model of global hypoxia. Neurosci Lett. 2015;607:46–51.
95. Chen J, Naylor DE, Wasterlain CG. Advances in the patho-
physiology of status epilepticus. Acta Neurol Scand.
2007;186:7–15.
96. Mazarati AM, Wasterlain CG. N-Methyl-D-asparate receptor
antagonists abolish the maintenance phase of self-sustaining
status epilepticus in rat. Neurosci Lett. 1999;265:187–190.
97. Wasterlain CG, Chen JWY. Mechanistic and pharmacologic
aspects of status epilepticus and its treatment with new antiepi-
leptic drugs. Epilepsia. 2008;49:63-73.
98. Spandou E, Karkavelas G, Soubasi V, et al. Effect of ketamine
on hypoxic–ischemic brain damage in newborn rats. Brain Res.
1999;819:1–7.
99. Brambrink AM, Evers AS, Avidan MS, et al. Ketamine-induced
Neuroapoptosis in the Fetal and Neonatal Rhesus Macaque
Brain. Anesthesiology. 2012;116:372–384.  2012;101:135–140.
100. Paule MG, Li M, Allen RR, et al. Ketamine anesthesia during
the first week of life can cause long-lasting cognitive deficits in
rhesus monkeys. Neurotoxicol Teratol. 2011;33:220–230.
101. Elalouf C, Le Moing AG Le, Fontaine C, et al. Prospective follow-
up of a cohort of preterm infants < 33 WG receiving ketamine for
tracheal intubation in the delivery room: Neurological outcome
at 1 and 2 years. Arch Pediatr. 2018;25:295–300.
102. Tarocco A, Ballardini E, Garani G. Use of ketamine in a newborn
with refractory status epilepticus: A case report. Pediatr Neurol.
2014;51:154–156.
103. Freibauer A, Jones K. KCNQ2 mutation in an infant with enceph-
alopathy of infancy with migrating focal seizures. Epileptic Dis-
ord. 2018;20:541–544.
104. Höfler J, Trinka E. Intravenous ketamine in status epilepticus.
Epilepsia. 2018;59:198-206.
105. Yager JY, Ashwal S. Animal Models of Perinatal Hypoxic-
Ischemic Brain Damage. Pediatr Neurol. 2009;40:156–167.
106. Sun H, Juul HM, Jensen FE. Models of hypoxia and ischemia-
induced seizures. J Neurosci Methods. 2016;260:252–260.
107. Chiba S. Long-term effect of postnatal hypoxia on the seizure
susceptibility in rats. Life Sci. 1985;37:1597–1604.
108. Jensen FE, Applegate CD, Holtzman D, et al. Epileptogenic
effect of hypoxia in the immature rodent brain. Ann Neurol.
1991;29:629–637.
109. Levine S. Anoxic-Ischemic Encephalopathy in Rats. Am J Pathol.
1960;36:1–17.
110. Rice JE, Vannucci RC, Brierley JB. The influence of immatu-
rity on hypoxic-ischemic brain damage in the rat. Ann Neurol.
1981;9:131–141.
111. Zhang Y, Zhang M, Liu S, et  al. Xenon exerts anti-seizure
and neuroprotective effects in kainic acid-induced status epi-
lepticus and neonatal hypoxia-induced seizure. Exp Neurol.
2019;322:113054.
112. Nolan SO, Hodges SL, Condon SM, et al. High seizure load
during sensitive periods of development leads to broad shifts
in ultrasonic vocalization behavior in neonatal male and female
C57BL/6J mice. Epilepsy Behav. 2019;95:26–33.
113. Chapman KE, Raol YH, Brooks-Kayal A. Neonatal seizures:
Controversies and challenges in translating new therapies from
the lab to the isolette. Eur J Neurosci. 2012;35:1857–1865.
114. Harish S, Bhuvana K, Bengalorkar GM, et  al. Flupirtine:
Clinical pharmacology. J Anaesthesiol Clin Pharmacol.
2012;28:172–177.
115. Raol YSH, Lapides DA, Keating JG, et al. A KCNQ channel
opener for experimental neonatal seizures and status epilepticus.
Ann Neurol. 2009;65:326–336.
116. Sampath D, Shmueli D, White AM, et al. Flupirtine effectively
prevents development of acute neonatal seizures in an animal
117. Sampath D, Valdez R, White AM, et al. Anticonvulsant effect
of flupirtine in an animal model of neonatal hypoxic-ischemic
encephalopathy. Neuropharmacology. 2017;123:126–135.
118. Sampath D, Lam PM, Laoprasert M, et al. Effects of a potassium
channel opener on brain injury and neurologic outcomes in an
animal model of neonatal hypoxic–ischemic injury. Pediatr Res.
2020;88:202–208.
119. European Medicines Agency. Withdrawal of pain medicine flu-
pirtine endorsed [Internet]. 2018. Available from: https://​www.​
ema.​e uropa.​e u/​e n/​d ocum​e nts/​r efer ​r al/​f lupi​r tine-​a rtic​l e-​3 1-​
refer ​ral-​withd​rawal-​pain-​medic​ine-​flupi​r tine-​endor​sed_​en.​pdf.
Accessed January 2, 2021.
120. Forcelli PA, Soper C, Lakhkar A, et al. Anticonvulsant effect of
retigabine during postnatal development in rats. Epilepsy Res.
121. Millichap JJ, Park KL, Tsuchida T, et al. KCNQ2 encephalopa-
thy: Features, mutational hot spots, and ezogabine treatment of
11 patients. Neurol Genet. 2016;2;e96.
122. Kang SK, Johnston M V., Kadam SD. Acute TrkB inhibition
rescues phenobarbital-resistant seizures in a mouse model of
neonatal ischemia. Eur J Neurosci. 2015;42:2792–2804.
123. Carter BM, Sullivan BJ, Landers JR, et al. Dose-dependent rever-
sal of KCC2 hypofunction and phenobarbital-resistant neonatal
seizures by ANA12. Sci Rep. 2018;8:11987.
124. Kang SK, Ammanuel S, Adler DA, et al. Rescue of PB-resistant
neonatal seizures with single-dose of small-molecule TrkB antag-
onist show long-term benefits. Epilepsy Res. 2020;159:106249.
125. Kipnis PA, Sullivan BJ, Carter BM, et al. TrkB agonists prevent
postischemic emergence of refractory neonatal seizures in mice.
JCI Insight. 2020;5:e136007.
126. Obeid M, Rosenberg EC, Klein PM, et al. Lestaurtinib (CEP-701)
attenuates “second hit” kainic acid-induced seizures following
early life hypoxic seizures. Epilepsy Res. 2014;108:806–810.
127. Huizenga MN, Wicker E, Beck VC, et al. Anticonvulsant effect of
cannabinoid receptor agonists in models of seizures in develop-
ing rats. Epilepsia. 2017;58:1593–1602.
128. Huizenga MN, Sepulveda-Rodriguez A, Forcelli PA. Preclini-
cal safety and efficacy of cannabidivarin for early life seizures.
Neuropharmacology. 2019;148:189–198.
129. Badowski S, Smith G. Cannabis use during pregnancy and post-
partum. Can Fam Physician. 2020;66:98–103.
130. Ziobro J, Shellhaas RA. Neonatal Seizures: Diagnosis, Etiolo-
gies, and Management. Semin Neurol. 2020;40:246–256.
131. Janicot R, Stafstrom CE, Shao LR. 2-Deoxyglucose terminates
pilocarpine-induced status epilepticus in neonatal rats. Epilepsia.
2020;61:1528–1537.
132. Wu Z, Huo Q, Ren L, et al. Gluconate suppresses seizure activity
in developing brains by inhibiting CLC-3 chloride channels. Mol
Brain. 2019;12:50.
133. Grosenbaugh DK, Ross BM, Wagley P, et al. The Role of Kainate
Receptors in the Pathophysiology of Hypoxia-Induced Seizures
in the Neonatal Mouse. Sci Rep. 2018;8:7035.
13

134. Aujla PK, Fetell MR, Jensen FE. Talampanel suppresses the
acute and chronic effects of seizures in a rodent neonatal seizure
model. Epilepsia. 2009;50:694–701.
135. Nielsen O., Feit PW. Structure-activity relationships of amin-
obenzoic acid diuretics and related compounds (1). Diuret Agens.
1978;83:12–23.
136. Brandt C, Seja P, Töllner K, et al. Bumepamine, a brain-permeant
benzylamine derivative of bumetanide, does not inhibit NKCC1
but is more potent to enhance phenobarbital’s anti-seizure efficacy.
Neuropharmacology. 2018;143:186–204.
137. Guillet R, Kwon J. Seizure recurrence and developmental dis-
abilities after neonatal seizures: Outcomes are unrelated to use
of phenobarbital prophylaxis. J Child Neurol. 2007;22:389–395.
138. Natarajan N, Beatty CW, Gust J, et al. Provider Practices of Phe-
nobarbital Discontinuation in Neonatal Seizures. J Child Neurol.
2018;33:153–157.
139. Fitzgerald MP, Kessler SK, Abend NS. Early discontinuation
of antiseizure medications in neonates with hypoxic–ischemic
encephalopathy. Epilepsia. 2017;58:1047–1053.
140. Glass HC, Soul JS, Chan T, et al. Duration of antiseizure medi-
cation treatment and 2-year outcome after acute symptomatic
neonatal seizures - a Neonatal Seizure Registry study. 16th Int
Child Neurol Virtual Congr. 2020.
141. Bartha AI, Shen J, Katz KH, et al. Neonatal Seizures: Multi-
center Variability in Current Treatment Practices. Pediatr Neurol.
2007;37:85–90.
142. Wietstock SO, Bonifacio SL, McCulloch CE, et al. Neonatal neu-
rocritical care service is associated with decreased administration
of seizure medication. J Child Neurol. 2015;30:1135–1141.
143. Cornet MC, Sands TT, Cilio MR. Neonatal epilepsies: Clinical
management. Semin Fetal Neonatal Med. 2018;23:204–212.
144. Kaur S, Pappas K. Genetic Etiologies of Neonatal Seizures. Neo-
reviews. 2020;21:e663-e672.
145. Moavero R, Kotulska K, Lagae L, et al. Is autism driven by epi-
lepsy in infants with Tuberous Sclerosis Complex? Ann Clin
Transl Neurol. 2020;7:1371–1381.
146. Tye C, Mcewen FS, Liang H, et al. Long-term cognitive out-
comes in tuberous sclerosis complex. Dev Med Child Neurol.
2020;62:322–329.
147. Parrini E, Conti V, Dobyns WB, et al. Genetic basis of brain
malformations. Mol Syndromol. 2016;7:220–233.
148. Saffari A, Brösse I, Wiemer-Kruel A, et al. Safety and efficacy
of mTOR inhibitor treatment in patients with tuberous sclerosis
complex under 2 years of age - A multicenter retrospective study.
Orphanet J Rare Dis. 2019;14:1–13.
149. Wilmshurst JM, Gaillard WD, Vinayan KP, et al. Summary of
recommendations for the management of infantile seizures: Task
Force Report for the ILAE Commission of Pediatrics. Epilepsia.
2015;56:1185–1197.
150. Pearl PL. Amenable Treatable Severe Pediatric Epilepsies. Semin
Pediatr Neurol. 2016;23:158–166.
151. Schwahn BC, Van Spronsen FJ, Belaidi AA, et al. Efficacy and
safety of cyclic pyranopterin monophosphate substitution in
severe molybdenum cofactor deficiency type A: A prospective
cohort study. Lancet. 2015;386:1955–1963.
152. Reiss J. Molybdenum cofactor deficiency type B knock-in mouse
models carrying patient-identical mutations and their rescue by
singular AAV injections. Hum Genet. 2019;138:355–361.
153. Pena IA, MacKenzie A, Van Karnebeek CDM. Current knowl-
edge for pyridoxine-dependent epilepsy: a 2016 update. Expert
Rev Endocrinol Metab. 2017;12:5–20.
154. Pérez B, Gutiérrez-Solana LG, Verdú A, et al. Clinical, biochem-
ical, and molecular studies in pyridoxine-dependent epilepsy.
Antisense therapy as possible new therapeutic option. Epilepsia.
2013;54:239–248.
13
J. M. Ziobro et al.
155. Al Teneiji A, Bruun TUJ, Cordeiro D, et al. Phenotype, biochem-
ical features, genotype and treatment outcome of pyridoxine-
dependent epilepsy. Metab Brain Dis. 2017;32:443–451.
156. Poletti V, Biffi A. Gene-Based Approaches to Inherited Neuro-
metabolic Diseases. Hum Gene Ther. 2019;30:1222–1235.
157. Hinderer C, Bell P, Louboutin J-P, et al. Neonatal tolerance
induction enables accurate evaluation of gene therapy for MPS I
in a canine model. Mol Genet Metab. 2016;119:124–130.
158. Pearl PL. Epilepsy Syndromes in Childhood. Continuum.
2018;24:186–209.
159. Maljevic S, Lerche H. Potassium channel genes and benign famil-
ial neonatal epilepsy. Prog Brain Res. 2014;213:17-53.
160. Reif PS, Tsai MH, Helbig I, et  al. Precision medicine in
genetic epilepsies: break of dawn? Expert Rev Neurother.
2017;17:381–392.
161. Pisano T, Numis AL, Heavin SB, et al. Early and effective treat-
ment of KCNQ2 encephalopathy. Epilepsia. 2015;56:685–691.
162. Scheffer IE, Nabbout R. SCN1A-related phenotypes: Epilepsy
and beyond. Epilepsia. 2019;60:S17–S24.
163. Sadleir LG, Mountier EI, Gill D, et al. Not all SCN1A epi-
leptic encephalopathies are Dravet syndrome. Neurology.
2017;89:1035–1042.
164. Berecki G, Bryson A, Terhag J, et al. SCN1A gain of function in
early infantile encephalopathy. Ann Neurol. 2019;85:514–525.
165. Reynolds C, King MD, Gorman KM. The phenotypic spec-
trum of SCN2A-related epilepsy. Eur J Paediatr Neurol.
2020;24:117–122.
166. Wolff M, Johannesen KM, Hedrich UBS, et al. Genetic and
phenotypic heterogeneity suggest therapeutic implications in
SCN2A-related disorders. Brain. 2017;140:1316–1336.
167. McTague A, Appleton R, Avula S, et al. Migrating partial sei-
zures of infancy: Expansion of the electroclinical, radiological
and pathological disease spectrum. Brain. 2013;136:1578–1591.
168. Milligan CJ, Li M, Gazina EV, et al. KCNT1 gain of function
in 2 epilepsy phenotypes is reversed by quinidine. Ann Neurol.
2014;75:581-590.
169. Mikati MA, Jiang YH, Carboni M, et al. Quinidine in the treatment
of KCNT1-positive epilepsies. Ann Neurol. 2015;78:995–999.
170. Bearden D, Strong A, Ehnot J, et al. Targeted treatment of migrat-
ing partial seizures of infancy with quinidine. Ann Neurol.
2014;76:457–461.
171. Borlot F, Abushama A, Morrison‐Levy N, et al. KCNT1‐related
epilepsy: An international multicenter cohort of 27 pediatric
cases. Epilepsia. 2020;61:679–692.
172. Fitzgerald MP, Fiannacca M, Smith DM, et  al. Treatment
Responsiveness in KCNT1-Related Epilepsy. Neurotherapeutics.
2019;16:848–857.
173. Rizzo F, Ambrosino P, Guacci A, et al. Characterization of two
de novo KCNT1 mutations in children with malignant migrating
partial seizures in infancy. Mol Cell Neurosci. 2016;72:54–63.
174. Pressler RM, Lagae L. Why we urgently need improved seizure
and epilepsy therapies for children and neonates. Neuropharma-
cology. 2020;170:107854.
175. Grinspan ZM, Patel AD, Shellhaas RA, et al. Design and imple-
mentation of electronic health record common data elements for
pediatric epilepsy: Foundations for a learning health care system.
Epilepsia. 2021;62:198-216.
176. Wusthoff CJ, Sullivan J, Glass HC, et al. Interrater agreement in
the interpretation of neonatal electroencephalography in hypoxic-
ischemic encephalopathy. Epilepsia. 2017;58:429–435.
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