NEONATAL SEIZURES

Trauma & Emergency System

Neonatologi Division.Department of Child Health
Medical Faculty of Hasanuddin University
 Definition

Seizures are transient disturbances in brain

function manifesting as episodic
impairments in consciousness in association
with abnormal motor or automatic activity.
 Probable Mechanisms of Some Neonatal
Seizures

PROBABLE MECHANISM DISORDER

Failure of Na + -K + pump secondary to Hypoxemia, ischemia,

 adenosine triphosphate and hypoglycemia
Excess of excitatory neurotransmitter
(eg.glutamic acid—excessive excitation) Hypoxemia, ischemia
and hypoglycemia
Deficit of inhibitory neurotransmitter Pyridoxine dependency
(i.e., relative excess of excitatory
neurotransmitter)
Membrane alteration—  Na + Hypocalcemia and
Permeability hypomagnesemia
_________________________________________________________________
Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4th ed.
 Classification of Neonatal
Seizures

 Clinical

 Electroencephalographic
Classification
I. Clinical Seizure
 Subtle
 Tonic
 Clonic
 Myoclonic

II. Electroencephalographic seizure

 Epileptic
 Non-epileptic
 …..Clinical Classification
1. Subttle
Usually occurs in association with other types of seizures
and may manifest with:
 Stereotypic movements of the extremities such as
bicycling or swimming movements.
 Deviation or jerking of the eyes with repetitive
blinking
 Drooling, sucking or chewing movements.
 Apnea or sudden changes in respiratory patterns.
 Rhythmic fluctuations in vital signs
 More in preterm than in term
 …..Clinical Classification
2. Tonic
 Primarily in Preterm
 May be focal or generalized
 Sustained extension of the upper and lower limbs
(mimics decerebrate posturing)
 Sustained flexion of upper with extension of lower
limbs (mimics decorticate posturing)
 Signals severe ICH in preterm infants
 In 85% of cases are not associated with any autonomic
changes such as increases in heart rate or blood
pressure, or skin flushing.
 …..Clinical Classification
3. Clonic

 Consist of slow (1-3 /minute) rhythmic jerking movements of

the extremities. They may be focal or multi-focal. Each
movement is composed of a rapid phase followed by a slow one.
 Changing the position or holding the moving limb does not
suppress the movements.
 Commonly seen in full-term neonates >2500 grams
 Consciousness may be preserved
 Signals focal cerebral injury, infarction or metabolic
disturbances.
 …..Clinical Classification
4. Myoclonic

Focal, multifocal, or generalized

 Focal myoclonic seizures typically involve the flexor
muscles of the extremities.
 Multi-focal myoclonic seizures present as
asynchronous twitching of several parts of the body.
 Generalized myoclonic seizures present as massive
flexion of the head and trunk with extension or flexion
of the extremities. They are associated with diffuse
CNS pathology
Electroencephalographic seizure
I. Epileptic
 Consistently associated with electro-cortical
seizure activity on the EEG
 Cannot be provoked by tactile stimulation
 Cannot be suppressed by restraint of involved
limb or repositioning of the infant
 Related to hyper synchronous discharges of a
critical mass of neuron
 Electroencephalographic
seizures
II. Non-epileptic
 No electro-cortical signature: seizures are initiated
in the subcortical area and are not usually
associated with any EEG changes.
 Provoked by stimulation
 Suppressed by restraint or repositioning
 Brainstem release phenomena (reflex)
Relation between Clinical seizure and EEG seizure

ELECTROENCEPHALOGRAPHIC SEIZURE

CLINICAL SEIZURE COMMON UNCOMMON

Subtle +*
Clonic
Focal +
Multifocal +
Tonic
Focal +
Generalized +
Myoclonic
Focal, multifocal +
Generalized +
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*Only specific varieties of subtle seizures are commonly associate with simultaneous
Electroencephalographic seizure activity.

Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4 th ed.

 Jitteriness Versus Seizure
CLINICAL FEATURE JITTERINESS SEIZURE

Abnormality of gaze or eye - +

movement
Movements exquisitely stimulus + -
sensitive
Predominant movement Tremor Clonic jerking

Movements cease with passive + -

flexion
Autonomic changes - +
The flexion and extension phases + -
are equal in amplitude
EEG abnormalities - +/-
------------------------------------------------------------------------------------------------------------------
 ......Jitteriness (cont)

 often seen in neonates with hypoglycemia, drug

withdrawal, hypocalcemia, hypothermia and in
(SGA) neonates.
 spontaneously resolve within few weeks.
Most Common Causes of Seizures
 Perinatal asphyxia Hypoxic Ischemic Enchephalopathy
 Intracranial hemorrhage : subarachnoid,
perivntricular/intraventricular, subdural
 Metabolic disturbances (Hypoglycemia, hypocalcemia,
hypomagnesemia)
 Infections (TORCH, meningitis, septicemia)
Less Common Causes of Seizures
 Congenital brain anomalies
 Inborn errors of metabolism
 Maternal drug withdrawal (heroin, barbiturates,
methadone, cocaine, etc.)
 Kernicterus
 Pyridoxine (B6) dependency, and hyponatremia
 Diagnosis of Seizures
A. History
Obtain a good maternal and obstetric history;
Pregnancy history is important
 Search for history that supports TORCH infections
 History of fetal distress, preeclampsia or maternal infections
 Maternal drug history
Delivery history:
 type of delivery and antecedent events
 Apgar scores offer some guidance : Low Apgar score without
the need for resuscitation and subsequent neonatal intensive
care is unlikely to be associated with neonatal seizures
 …..Diagnosis of Seizures

Postnatal history
Neonatal seizures in infants without uneventful antenatal
history and delivery may result from postnatal cause
Tremulousness may be secondary to drug withdrawal or
hypocalcemia
Temperature and blood pressure instability may suggest
infection.
 Diagnosis of Seizures
A. Physical examination
Determine :
Gestational age
Blood pressure
Presence of skin lesion
Precense of hepatosplenomegaly

B. Neurologic evaluation
C. Notation of the seizure pattern ( onset, spread, nature,
duration, and level of conciousness)
 Laboratory Investigations

Primary tests
 Blood glucose
 Blood calcium and magnesium
 Complete blood count, differential leukocytic
count and platelet count
 Electrolytes
 Arterial blood gas
 Cerebral spinal fluid analysis and cultures
 Blood cultures

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….Laboratory Investigations, cont

 TORCH titers, ammonia level, head sonogram

and amino acids in urine.
 EEG
Normal in about 1/3 of cases
 Cranial ultrasound
For hemorrhage and scarring
 CT
To diagnose cerebral malformations and
hemorrhage
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 Management of Seizures

Management goals
 To minimize brain damage
 Achieve systemic homeostasis (airway,
breathing and circulation).
 Correct the underlying cause if possible.

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 Stopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects

Phenobarbital  Loading dose:  It is the drug of  Hypotension

10-20 mg/kg. choice.  Apnea
Add 5 mg/kg to  Administer IV
a maximum of over 5 minutes.
40 mg/kg  Therapeutic
level: 20-40
g/ml.
 Maintenance:  Administer IM,  Monitor
3-5 mg/kg/day IV, or PO every respiratory
in divided 12 hours. status during
doses every 12  Begin therapy administration
hours. 12 hours after and assess IV
loading dose. site.
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Stopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects

When seizures are not controlled with phenobarbital alone.

Phenytoin  Loading dose:  Administer IV at  Do not give IM.

15-20 mg/kg IV a maximum rate  Toxicity is a
over 30 min. of 0.5 mg/kg/min problem with this
 Maintenance: 4- drug.
 Maintenance: 8 mg/kg/day by  Cardiac
3-5 mg/kg/day. IV push or PO. arrhythmias
 Divide total dose  Cerebellar
and administer damage
IV every 12
hours.

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Stopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects

For treatment of status epilepticus.

Benzodiazepines  Lorazepam:  Administer IV.  Respiratory

0.05 – 0.1 mg/kg  Repeat every 15 depression,
 Diazepam: 0.1 – minutes for 2-3  Interferes with
0.3 mg/kg/dose. doses if needed. bilirubin binding to
 Maximum dose is albumin
2-5 mg.
 It can be given
once as a PO
dose of 0.1-0.3
mg/kg. 24
Medical Management :
 10% dextrose solution (2cc/kg IV) empirically to any
seizing neonate.
 Anticonvulsant drugs
 Calcium gluconate (200mg/kg IV), if hypocalcemia is
suspected .
 Magnesium sulfate 50%, 0.2ml/kg or 2 mEq/kg.
 In pyridoxine dependency give pyridoxine 50mg IV as a
therapeutic trial. Seizures will stop within minutes.
 Antibiotics in suspected sepsis.
 Be prepared to manage any complication
When to Stop Anticonvulsant Drugs /
AEDS

 No specific practice guidelines for the timing for

stopping these medications, however:

 Stopping AEDs two weeks after last seizure

episode is acceptable as prolonged medication can
adversely affect the developing brain.

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When to Stop Anticonvulsant Drugs /
AEDS (cont)

 Discontinuation before discharging from the

neonatal unit is generally recommended unless the
neonate demonstrates a significant brain lesion on
head sonogram or CT, or abnormal neurological
signs at the time of discharge.

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 Determinants of Duration of
anticonvulsant therapy for neonatal
seizures

 Neonatal neurological examination

 Cause of neonatal seizure

 Electroencephalogram
 Prognosis
Two most useful approaches in utilizing outcome

 EEG

 Recognition of the underlying neurological

disease
 Complications
 Cerebral palsy
 Hydrocephalus
 Epilepsy
 Spasticity
 Feeding difficulties
 Further Outpatient Care
 Neurology outpatient evaluation
 Developmental evaluation for early
identification of physical or cognitive deficits
 Orthopedic evaluations if with joint deformities
 Consider physical medicine/physical therapy
referral if indicated
 References
1.Volpe JJ.Neonatal seizures. In:Neurology of the newborn.4th
ed.Philadelphia,Pa:WB Saunders's Co;2001:178-214
2.Hahn J,Olson D.Etiology of neonatal
seizures.NeoReviews.2004;5:327-335
3.Riviello,J.Drug therapy for neonatal seizures:Part
I.NeoReviews.2004;5:215-220
4.Riviello,J.Drug therapy for neonatal seizures:Part
II.NeoReviews.2004;5:262-268
5.Fanaroff A,Martin R,Neonatal seizures.In:Neonatal-Perinatal
Medicine-Diseases of the fetus and infant.6th
ed.St.Louis,MO:Mosby-Yearbook Inc.1997:899-911
6.Sheth R, Neonatal seizures;Emedicine.com
Thank You