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 acidexcessive 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.4
th
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

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
..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)




ELECTROENCEPHALOGRAPHIC SEIZURE

CLINICAL SEIZURE COMMON UNCOMMON

Subtle +*
Clonic
Focal +
Multifocal +
Tonic
Focal +
Generalized +
Myoclonic
Focal, multifocal +
Generalized +
---------------------------------------------------------------------------------------------------------------
*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.
Relation between Clinical seizure and EEG seizure


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 - +/-
------------------------------------------------------------------------------------------------------------------
often seen in neonates with hypoglycemia, drug
withdrawal, hypocalcemia, hypothermia and in
(SGA) neonates.
spontaneously resolve within few weeks.


......Jitteriness (cont)
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 oh skin lesion
Precense of hepatosplenomegaly

B. Neurologic evaluation
C. Notation of the seizure pattern ( onset, spread, nature,
duration, and level of conciousness)
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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
20
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

.Laboratory Investigations, cont
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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.
22
Stopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects

Phenobarbital
Loading dose:
10-20 mg/kg.
Add 5 mg/kg to
a maximum of
40 mg/kg


Maintenance:
3-5 mg/kg/day
in divided
doses every 12
hours.
It is the drug of
choice.
Administer IV
over 5 minutes.
Therapeutic
level: 20-40
g/ml.
Administer IM,
IV, or PO every
12 hours.
Begin therapy
12 hours after
loading dose.
Hypotension
Apnea





Monitor
respiratory
status during
administration
and assess IV
site.


23
Drug Dose Comments Side Effects

When seizures are not controlled with phenobarbital alone.


Phenytoin

Loading dose:
15-20 mg/kg IV
over 30 min.

Maintenance:
3-5 mg/kg/day.
Administer IV at
a maximum rate
of 0.5 mg/kg/min
Maintenance: 4-
8 mg/kg/day by
IV push or PO.
Divide total dose
and administer
IV every 12
hours.
Do not give IM.
Toxicity is a
problem with this
drug.
Cardiac
arrhythmias
Cerebellar
damage


Stopping Seizures with Anticonvulsants
24
Drug Dose Comments Side Effects

For treatment of status epilepticus.
Benzodiazepines
Lorazepam:
0.05 0.1 mg/kg
Diazepam: 0.1
0.3 mg/kg/dose.
Administer IV.
Repeat every 15
minutes for 2-3
doses if needed.
Maximum dose is
2-5 mg.
It can be given
once as a PO
dose of 0.1-0.3
mg/kg.
Respiratory
depression,
Interferes with
bilirubin binding to
albumin


Stopping Seizures with Anticonvulsants
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



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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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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.
When to Stop Anticonvulsant Drugs /
AEDS (cont)
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.4
th

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.6
th

ed.St.Louis,MO:Mosby-Yearbook Inc.1997:899-911
6.Sheth R, Neonatal seizures;Emedicine.com