J. Paediatr.

Child Health (1995) 31, 237-240

Clinical features of neonatal seizures

M. W. O’MEARA, A. M. E. BYE and D. FLANAGAN

Department of Neurology, Prince of Wales Children’s Hospital, Randwick, New South Wales, Australia

Objective: Identification of seizures in neonates is difficult. This study analyses the clinical features of seizures in a cohort of
neonates.
Methodology: The clinical events of 41 neonates referred for investigation of suspected seizures were studied with
prolonged video/electroencephalographic (EEG) telemetry.
Results: Sixteen neonates had no seizures recorded; 25 had confirmed seizures, 13 with clinical correlates. Each neonate
with electroclinical seizures had paroxysms of abnormal movements in stereotyped patterns. These patterns were consistently
found to have electrical correlates. Focal clonic movements were seen most frequently. Multiple clinical features characterized
the seizure repertoire in six neonates. In five neonates the clinical features became less evident during monitoring and these
seizures were difficult to recognize. This change was associated with anticonvulsant administration in three cases.
Conclusions: Electroclinical seizures are characterized by abnormal paroxysmal stereotyped behaviour, often with multiple
clinical features. Recommendations for the management of abnormal neonatal events are proposed.

Key words: electroclinical seizures; neonatal seizures; video/electroencephalographictelemetry.

The identification of seizures in neonates is a frequent concern
to both medical and nursing staff. The technique of video/electro-
encephalographic (EEG) telemetry has enabled the accurate
classification of abnormal events based on a detailed analysis
of clinical characteristics and their underlying electrographic
activity. The purpose of the present study was to determine the
clinical features of seizures in a cohort of neonates and use
these data to establish guidelines for clinicians to distinguish
electroclinical events from other normal or abnormal movements.
METHODS
Simultaneous video/EEG telemetry was used to study neonatal
seizures at the Prince of Wales Children’s Hospital. Forty-one
neonates were studied from 13 March 1992 to 13 March 1994.
They were referred to the neurology telemetry unit for inves-
tigation of abnormal movements described by the referring
doctor or because they were at high risk of having seizures.
Monitoring was carried out using a La Mont video patient
monitoring system (Medical Systems International, Sydney, NSW,
Australia) for a minimum of 3 h. Twelve scalp electrodes were
used and their positions were based on a modification of the
10-20 system. Monitoring was available 24 h a day and, where
possible, was commenced prior to the use of anticonvulsants.
The aetiologies of the seizures were defined with appropriate
investigations. Cerebral computerized tomography and ultra-
sound scans were carried out on all neonates.
Correspondence: Dr A. M. E. Bye, Prince of Wales Children’s Hospital,
Randwick, NSW 2031, Australia.
M. W. OMeara, MB, BS, Chief Resident. A. M. E. Bye. MB, BS, FRACP,
Staff Specialist, Paediatric Neurology. D.Flanagan, PhD, Research Officer,
Accepted for publication 23 January 1995.
Confirmed seizures were treated with a loading dose of
phenobarbital 20 mg/kg i.v. If seizures continued, increments
of 5-10 mg/kg were given until a cumulative dose of 40 mg/kg
or a plasma level of 170pmoVL was reached.’ Phenobarbital
was continued at a maintenance dose of 3-5mg/kg per day.
Other anticonvulsants, initially phenytoin 20 mg/kg i.v., were
added when phenobarbital alone was insufficient to control the
seizures.
The EEG background was classified according to Tharp et
for pre-term infants and Takeuchi and Watanabe3 for term
infants. Focal abnormalities, specifically abnormal sharp waves
as defined by Hrachovy ef a/.; were documented.
Electroclinical seizure identification was based upon the
identification of a consistent correlation between electrographic
seizures and a fixed repertoire of stereotyped, abnormal move-
ments. An electrographic seizure was defined as a paroxysmal
event with abnormal stereotyped waveforms that evolved tem-
porally and spatially and lasted a minimum of l O s 5 The entire
monitoring period was reviewed for each patient by one author
(D.F.) and the times of electrographic seizures were recorded.
After identifying the clinical features of interictal behaviour in
each neonate, clinical events corresponding to the times of
electrographic seizures were examined by another author
(M.O’M.) and classified according to the schemes of Kellaway et
abs and V ~ l p e For
. ~ those neonates with a high number of
seizures the first 15 were analysed.
The major clinical seizure types were characterized using this
c1assification6*~
(1) Focal clonic: rhythmical twitching of facial, limb or axial
muscle groups.
(2) Focal tonic: sustained asymmetrical posturing of limbs,
trunk or eyes.
(3) Generalized clonic: bilateral, rhythmical synchronous or
asynchronous jerking of limbs.
(4) Generalized tonic: bilateral extension or flexion of upper
and lower limbs.
 M.W. O’Meara el al.

(5) Myoclonic: random jerks of limbs or trunk.
(6) Motor automatisms: oral, buccal, lingual movements, ocular
signs, cycling movements of legs, swimming motions of arms,
complex purposeless movements.
One author (M.O’M.) reviewed the clinical descriptions pro-
vided by the referring doctors for the total cohort (41 patients)
and characterized those descriptions according to the preceding
classification. In order to estimate the accuracy of the clinical
evaluation of abnormal movements among neonates having
seizures, one author (A.B.) was shown a random selection of
video recorded events (without accompanying EEG) from the
five patients with (i) clear clinical manifestations, (ii) reduced
clinical manifestations and (iii)abnormal movements that were
not associated with electrographic seizures. The reviewer had
not previously studied in detail the events in these patients and
had to identify seizure from non-seizure.
RESULTS
The post-conceptional age of the 41 neonates studied ranged
from 30 to 44 weeks. Six neonates were less than 37 weeks and
five neonates were greater than 42 weeks post-conceptional
age. Thirty-five neonates were referred for investigation of
abnormal movements described by a referring doctor. A further
six patients were referred because their neurological problem
(cerebral malformation, asphyxia, meningitis) placed them at
high risk of seizures.
Clinical descriptions supplied by the referring doctor of focal
tonic or focal clonic movements were most consistently correl-
ated with seizures identified during the monitoring period. Only
two patients with those descriptions did not have seizures
confirmed during monitoring and one of those was diagnosed
as having benign sleep myoclonus. Clinical descriptions of
other types of abnormal movement, generalized tonic, motor
automatisms and myoclonic movements, were infrequently
correlated with electrographic events.
Twenty-five neonates had electrographic seizures during the
period of monitoring. Thirteen had clinical correlates recorded
with video/EEG monitoring and two had electroclinical seizures
confirmed by simultaneous clinical observations and short
duration EEG, (the data from those two patients were not
included in this study). Ten neonates had electrographic seizures
without clinical events; two of those had neuromuscular block-
ade and six had anticonvulsants prior to study. Sixteen neonates
had no electrographic seizures recorded during the period of
monitoring.
Electroclinicalseizures
Electroclinical seizures were analysed in 13 patients. Their age
ranged from 36 to 44 weeks post-conception. The EEG back-
grounds of three neonates were burst suppression. The EEG
backgrounds of the other neonates ranged from normal to
moderately depressed. Four had multifocal abnormalities. Nine
neonates had abnormal structural studies, four having multifocal
infarcts. The aetiologies were varied and hypoxic ischaemic
encephalopathy was the commonest diagnosis. The number of
seizures recorded per patient during their monitoring periods
ranged from one to 94 with a mean of 14. A total of 92 seizures
were analysed in this study. The clinical details of seizures in
these patients are recorded in Table 1.
For each neonate, seizures were characterized by stereotyped,
paroxysmal, abnormal movements. One neonate’s seizures, for
example, consisted of deviation of the head to one side, tonic
posturing of an arm and leg. conjugate lateral deviation of the
eyes and apnoea with desaturation. Another neonate’s repertoire
consisted of deviation of the head to one side, extension of the
left arm, eye-opening and cycling of the legs. These stereotyped
repertoires of features were consistently found to have electrical
correlates and never occurred without an electrographic seizure.
Focal clonic movements were noted in 10 of the 13 neonates,
with spread in five. Focal tonic movements occurred in four.

Table 1 Clinical features of neonates with electroclinical events

Patient no.
1 2 3 4 5 6 7 a 9 10 11 12 13

No. seizures reviewed 15 4 3 2 2 1 14 10 9 15 9 7 1

Focal clonic 15 4 2 2 1 9 1 9 7 1
Focal tonic 11 8 10 15
Generalized tonic 7
Generalized clonic 2
Motor automatism 3 8 7

Table 2 Accuracy of seizure identification

Electroclinicalseizures Reduced electroclinical seizures Non-ictal events

Patient no No. correctltotal no events No. correct/total no. events No. correctltotal no. events

1 12/13 114 13/13

7 10114 115 loll0
a 919 314 12/13
10 13/14 117 a/a
11 1 /4 011 loll0
Total no. correct (46) 45/54 (83%) 6/21 (29%) 53/54 (98%)
Neonatal seizures
Focal tonic events frequently seen were deviation of the head or
eyes to one side and flexion or extension of a limb. Motor
automatisms were evident in three neonates. These movements
were manifest by various combinations of eye-blinking, staring,
non-rhythmic mouthing and cycling movements of the legs.
Generalized tonic movements with extension of all four limbs
were noted in one child and generalized asynchronous clonic
movements were noted in another.
In five neonates focal tonic and focal clonic features were
less clinically evident during some seizures. In three cases this
occurred after the administration of anticonvulsants, but in two
others it occurred independent of anticonvulsant therapy.
Table 2 shows the accuracy of seizure identification when
one author (A.B.) reviewed a number of abnormal movements in
neonates with confirmed seizures. The reviewer had little diffi-
culty distinguishing seizures with a clear clinical component
from non-ictal movements. Discrimination of events with reduced
clinical manifestations proved more troublesome. In these events
the focal clonic features were of much reduced amplitude and
spread, and the focal tonic features briefer and less distinct.
DISCUSSION
As there is evidence that seizures during the newborn period
may directly damage immature brains8-12 and may lead to an
increased risk of subsequent ~ e i z u r e s , l ~ -it’ ~is important to
rapidly diagnose and treat seizures during this period. Most
neonatal nursery staff rely on clinical observation to alert them
to suspected seizures. To analyse the spectrum of abnormal
movements presenting to a tertiary referral unit we have reviewed
our experience obtained through intensive video/EEG moni-
toring of a cohort of neonates. We found that clinical seizure
manifestations in the neonates studied were characterized by
abnormal, paroxysmal, stereotyped behaviours and it was the
stereotyped nature of those behaviours that allowed clinicians
to distinguish seizures from other normal or abnormal neonatal
movements. The most common seizure manifestations identified
in our neonates were focal clonic movements and, less fre-
quently, focal tonic movements and these were generally
correctly identified by the referring doctor. A notable exception
was the patient with benign sleep myoclonus who was described
as having multifocal clonic movements despite displaying the
characteristic features of benign sleep myoclonus. This entity
has its onset in the neonatal period with myoclonic jerks
occurring only during sleep and abruptly ceasing with arousal.16
The myoclonic jerks are multifocal, continue for extended
periods of time and are not associated with an electrical correl-
ate. Anticonvulsants are not indicated.
Motor automatisms as clinical seizure manifestations were
found in only three patients in our study, and were the sole
seizure manifestation in one patient. Motor automatisms identi-
fied by the referring doctor as suspected seizures were not
reliably associated with electrographic seizures. In a study of a
neonatal cohort of similar age to the present investigation
Mizrahi and Kellaway also found a low incidence of motor
automatisms and a high incidence of focal clonic and focal
tonic events consistently associated with electrographic
seizures.17 Other studies of premature neonates have found a
higher incidence of motor automatisms consistently associated
with electrographic seizure^.^^^'^
239
Six neonates in our study had multiple clinical features charac-
terizing their electroclinical seizures. While other workers have
occasionally noted multiple clinical f e a t u r e ~ , l ~ - it~ ’was a
common finding in our investigation. This is probably due to our
being able to review video data rather than relying on clinical
observation at the time of the event. The identification of multiple
clinical events occurring in a stereotyped and paroxysmal pattern
enabled the reviewer (A.B.) to distinguish the vast majority of
electroclinical events from other non-ictal events (Table 2).
We noted that in five patients some clinical manifestations
were less evident in some seizures. This variation in clinical
intensity may represent an interim step towards complete electro-
clinical dissociation noted by 0 t h e r s 2 ~ When
* ~ ~ one author
(A.B.) reviewed a number of abnormal movements in patients
with confirmed seizures, problems were encountered in the
accurate identification of seizures with reduced clinical mani-
festations.
Ten neonates had purely electrographic seizures. Probable
reasons for this were alteration of clinical seizure characteristics
by anticonvulsants, the use of neuromuscular blockade and the
presence of severe diffuse cerebral injury6 In view of the
number of neonates without clinical correlates of electrographic
seizures and the difficulty associated with the clinical identific-
ation of some seizures and some seizure components, an EEG
is essential to diagnose electrographic seizures and to monitor
their treatment. In most units prolonged video/EEG monitoring
is impractical, time-consuming and expensive. We recently
analysed electrographic data from all the seizures recorded in
the population of the present report and found that, in general,
seizures were brief and frequent ranging from several per
minute to several per h0ur.2~A 60 min EEG, therefore, may not
identify electrographic seizures among all patients, but would
provide useful information for the majority of patients and
supplement data gained from clinical observation.
Integrating the results from our own and other studies6s7we
recommend the following to nursing and medical staff of neonatal
nurseries.
(1) Record a complete description of all the abnormal move-
ments of each discrete event, noting in addition autonomic
features, that is. desaturation, tachycardia, changes in blood
pressure and pupillary size. Determine if these events are stereo-
typed and whether the movements are tonic, clonic, or represent
motor automatisms.
(2) Determine response to tactile stimulation and whether this
response increases with increasing intensity of the stimulus.
(3) Determine if the movement can be altered by gentle
restraint and repositioning of the limb.
(4) An EEG is needed to diagnose electrographic seizures. A
short duration EEG will assist in the diagnosis of a significant
proportion.
An event that is stimulus-related and is altered by restraint is
unlikely to represent an electroclinical seizure6 Phenomena
that behave like a reflex action have been termed by Kellaway et
a/. as ‘brainstem release phenomenal6 and are more commonly
seen in neonates who have sustained severe and diffuse cortical
damage.
Clinical seizures in neonates are characterized by paroxysmal
stereotypic movements. Focal tonic and focal clonic events can
be clinically recognized and are reliably associated with electro-
graphic seizures. This study demonstrates that electroclinical
seizures are often characterized by multiple different clinical
features. Clinical events may change over time and with anti-
convulsant administration.
240
ACKNOWLEDGEMENTS
This work was supported by a N H & M R C grant 920228, the
Australian Brain Foundation and the Prince Henry Centenary
Foundation.
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