Neonatal Seizures

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Purpose

The purpose of this session is to introduce the knowledge, skills, and competencies required to correctly identify, diagnose, classify, and treat neonatal seizures.

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Learning Objectives
1. Define seizures and differentiate between epileptic and non-epileptic seizures. 2. Know the incidence of neonatal seizures. 3. Describe the four types of seizures and their clinical pictures. 4. Identify benign movements that are not seizures.

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7. 6.Learning Objectives (cont) 5. Diagnose neonatal seizures. 4 . Treat neonatal seizures. both common and less common etiologies. 8. List the causes of neonatal seizures. Inform parents of the neonate¶s prognosis.

5 .Definition of Seizure Seizures are transient disturbances in brain function manifesting as episodic impairments in consciousness in association with abnormal motor or automatic activity.

Epileptic and Non-Epileptic Seizures Epileptic seizures originate from the cortical neurons and are associated with EEG changes. Non-epileptic seizures are initiated in the subcortical area and are not usually associated with any EEG changes.provoked by stimuli and ameliorated by restraint and body repositioning. . 6 .

5% of all term and preterm neonates.Incidence of Neonatal Seizures The overall incidence is 0.9% if gestational age < 30 weeks). The incidence is higher in preterm neonates (3. 7 .

Types and Clinical Presentations of Neonatal Seizures Four types of seizures are frequently encountered in neonates: Tonic Seizures Clonic Seizures Myoclonic Seizures Subtle (Fragmentary) Seizures 8 .

 Generalized tonic seizures: .Tonic flexion or extension of the upper extremities. 9 . neck.Mainly manifest in preterm neonates (< 2500 grams). . or skin flushing. or trunk and are associated with tonic extension of the lower extremities. .In 85% of cases are not associated with any autonomic changes such as increases in heart rate or blood pressure.Tonic Seizures  Tonic seizures can be either generalized or focal.

10 .  Mostly occur with diffuse central nervous system disease and intraventricular hemorrhage.Focal Tonic Seizures Present with asymmetrical posturing of one of the limbs or trunk or with tonic head or eye deviation.

They are commonly seen in full-term neonates >2500 grams 11 . Each movement is composed of a rapid phase followed by a slow one.Clonic Seizures  Consist of slow (1-3 /minute) rhythmic jerking movements of the extremities. They may be focal or multi-focal.  Changing the position or holding the moving limb does not suppress the movements.

Clonic Seizures (cont) There is no loss of consciousness and they are associated with focal trauma. 12 . infarction or metabolic disturbances.

Myoclonic Seizures Myoclonic seizures can be focal. multi focal or generalized. Focal myoclonic seizures typically involve the flexor muscles of the extremities. 13 . Multi-focal myoclonic seizures present as asynchronous twitching of several parts of the body.

They are associated with diffuse CNS pathology.Myoclonic Seizures (cont) Generalized myoclonic seizures present as massive flexion of the head and trunk with extension or flexion of the extremities. 14 .

 Deviation or jerking of the eyes with repetitive blinking. 15 .Subtle (Fragmentary) Seizures Usually occurs in association with other types of seizures and may manifest with:  Stereotypic movements of the extremities such as bicycling or swimming movements.

16 .Subtle (Fragmentary) Seizures (cont) Drooling. Apnea or sudden changes in respiratory patterns. sucking or chewing movements. Rhythmic fluctuations in vital signs.

Benign Movements that are Not Seizures     Jitteriness Sleep apnea Isolated sucking movements Benign neonatal sleep myoclonus 17 .

Clinically they differ from clonic seizures in the following aspects: 18 .Jitteriness Jitteriness is often misdiagnosed as clonic seizures.

 Neonates are generally alert.  Passive flexion or repositioning of the limb diminishes the tremors.Jitteriness (cont)  The flexion and extension phases are equal in amplitude. 19 . with no abnormal gaze or eye movements.  No EEG abnormalities. though they may be spontaneous. Tremors are provoked by tactile stimulation.

hypocalcemia. 20 .Jitteriness (cont) often seen in neonates with hypoglycemia. hypothermia and in (SGA) neonates. drug withdrawal. spontaneously resolve within few weeks.

21 . When seizures are present with apnea abnormal movements. tachycardia and increased blood pressure are present as well.Sleep Apnea Not associated with abnormal movements and is usually associated with bradycardia.

22 .Isolated Sucking Movements Random. infrequent and not well sustained sucking movements are not seizures.

Benign Neonatal Sleep Movements  Predominantly seen in preterm neonates during sleep. 23 . They do not stop with restraint. multi-focal. or generalized. They can be focal.  resolve spontaneously within a few minutes and require no medication.

24 .  suppressed by the waking state.Benign Neonatal Sleep Movements (cont) They differ from myoclonic seizures in the following: can be triggered by noise or motion. not associated with any autonomic changes.

hypocalcemia.Most Common Causes of Seizures HIE Infections (TORCH. hypomagnesemia CNS bleed (intraventricular. trauma. meningitis. subdural.) 25 . septicemia) Hypoglycemia. etc.

cocaine. methadone.Less Common Causes of Seizures  Congenital brain anomalies  Inborn errors of metabolism  Maternal drug withdrawal (heroin. and hyponatremia more than one underlying cause 26 .)  Kernicterus  Pyridoxine (B6) dependency. barbiturates. etc.

Diagnosis of Seizures Obtain a good maternal and obstetric history 27 .

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 28 .

Laboratory Investigations (cont)  TORCH titers. 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 29 . ammonia level.

 Correct the underlying cause if possible. breathing and circulation). 30 .Management of Seizures  Management goals  Achieve systemic homeostasis (airway.

Seizures will stop within minutes . if hypocalcemia is suspected .  Magnesuim sulfate 50%.  Calcium gluconate (200mg/kg IV).Medical Management of Seizures  10% dextrose solution (2cc/kg IV) empirically to any seizing neonate.2ml/kg or 2ml Eq/kg.  In pyridoxine dependency give pyridoxine 50mg IV as a therapeutic trial.  Antibiotics in suspected sepsis. 0. 31 .

loading dose. y Apnea Add 5 mg/kg to y Administer IV a maximum of over 5 minutes. . and assess IV 12 hours after 32 site.Stopping Seizures with Anticonvulsants Drug Dose Comments Side Effects Phenobarbital y Loading dose: y It is the drug of y Hypotension 10-20 mg/kg. doses every 12 y Begin therapy administration hours. y Monitor 3-5 mg/kg/day respiratory IV. 40 mg/kg y Therapeutic level: 20-40 Qg/ml. or PO every in divided status during 12 hours. y Maintenance: y Administer IM. choice.

5 mg/kg/min y Maintenance: 48 mg/kg/day by y IV push or PO. y Divide total dose and administer IV every 12 hours. y Toxicity is a problem with this drug. y Cardiac arrhythmias y Cerebellar damage 33 . y Do not give IM.Stopping Seizures with Anticonvulsants (cont) Drug Dose Comments Side Effects Phenytoin y Loading dose: y Administer IV at 15-20 mg/kg IV a maximum rate over 30 min. of 0.

34 .05 ± 0. bilirubin binding to doses if needed.3 mg/kg/dose. y It can be given once as a PO dose of 0.1 ± y Interferes with minutes for 2-3 0.1-0.3 mg/kg.1 mg/kg y Repeat every 15 depression. albumin y Maximum dose is 2-5 mg.Stopping Seizures with Anticonvulsants (cont) Drug Dose Comments Side Effects Benzodiazepines y Lorazepam: y Administer IV. y Diazepam: 0. y Respiratory 0.

Prognosis  Best prognosis with:  Hypocalcemia  Pyridoxine dependency  Subarachnoid hemorrhage  Hypoglycemia  Anoxia  Brain malformation  Chronic seizures 1520%  Mental retardation  Cerebral palsy  Worse prognosis with:  Sequelae: 35 .

TERIMAKASIH 36 .

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