Queensland Health

Queensland Health

Queensland Clinical Guidelines

Translating evidence into best clinical practice

Neonatal seizures
Clinical Guideline Presentation v2.0

45 minutes
Towards CPD Hours
 References:
The Queensland Clinical Guideline Neonatal seizures is the primary reference for this package.

Recommended citation:
Queensland Clinical Guidelines. Neonatal seizures clinical guideline education presentation E17.23-1-V1-R22 Queensland Health. 2017.

Disclaimer:
This presentation is an implementation tool and should be used in conjunction with the published guideline. This information does not supersede
or replace the guideline. Consult the guideline for further information and references.

Feedback and contact details:

M: GPO Box 48 Brisbane QLD 4001 | E: guidelines@health.qld.gov.au | URL: www.health.qld.gov.au/qcg
Funding:
Queensland Clinical Guidelines is supported by the Queensland Health, Healthcare Improvement Unit.

Copyright:

State of Queensland (Queensland Health) 2017

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 Learning outcomes
In relation to neonatal seizures:
Understand causes
Understand and describe the classification
Identify assessments and investigations
Understand treatment and management
Identify important factors regarding ongoing care

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 Abbreviations
AED Antiepileptic drugs
CNS Central nervous system
CSF Cerebrospinal fluid
EEG Electro-encephalogram
HIE Hypoxic ischaemic encephalopathy
MRI Magnetic resonance imaging
USS Ultrasound scan

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 Definitions
Apoptosis
Cell death
Automatisms
Non-purposeful, stereotyped, and repetitive behaviours
Most common are oral lip smacking, chewing, swallowing and cycling; performed
without conscious control
Hyperekplexia
Neurologic disorder where there is a pronounced startle response to
tactile or acoustic stimuli, and hypertonia

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 Definitions
Hypsarrhythmia
Abnormal inter-ictal pattern with electroencephalogram (EEG) high
amplitude and irregular waves and spikes with background of
chaotic and disorganised activity
Ictal
Relating to seizures
Opisthotonos
Abnormal extensor posture where the head and lower limbs are bent
backwards and the body is arched forward

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 Introduction

Neonates are at high risk for Associated with greater risk

seizures for long term
Neurological emergency neurodevelopmental
difficulties
Difficult to diagnose and treat
Occurs when excessive and
Clinical signs variable and synchronised depolarisation
may be absent occurs in large group of
neurons

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 Causes of seizures
What are the CNS causes? What are other causes?
Hypoxic-ischemic Biochemical e.g.
encephalopathy hypoglycaemia

Intracranial haemorrhage Inborn errors of metabolism

Infection of CNS e.g. pyridoxine deficiency

Other cerebrovascular (e.g. Developmental/congenital

stroke) Other e.g. drug withdrawal

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 Presentation
When do neonatal seizures Day 1
typically occur? Traumatic brain injury
Evolve over time dependent HIE
Stroke
on aetiology
Hypoglycaemia
Typical day of onset may Neurometabolic disorders
be variable Drug withdrawal
Peak incidence between 12 Pyridoxine dependent
and 24 hours of age Day 2
Stroke
Often cease by 72 hours of Glucose transporter
age deficiency
Infection may be a cause at Electrolyte disturbance
any time Day 3
Neurometabolic disorders
Cerebral malformations
Other genetic malformations

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 Seizure classification
How are neonatal seizures
classified?
Clonicrecurrent muscle
contraction Seizures may be:
Tonicsustained muscle Generalised-involving
contraction bilateral brain structures
Myoclonicbrief active muscle Focal-involving one part of
contraction the brain

Subtleautomatisms, autonomic
phenomena, ocular phenomena
and include seizures with apnoea

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 Jittery versus seizure
Clinical feature Jitteriness Seizure
Abnormal gaze or No Yes
eye movement
Predominant Tremor, rapid, Clonic, jerking,
movement oscillatory tonic
Movements cease Yes No
with passive
flexion
Stimulus provoked Yes No
movements
Conscious state/ Awake or asleep Altered
Autonomic change

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 Assessment
History: Investigations
Ask about maternal, family and Pathology
birth history Blood, urine, CSF
Examination: Neurophysiology
Physicalcongenital EEG
anomalies, head Neuroimaging
circumference, birth marks,
somatic abnormalities, facial MRI (to identify brain
dysmorphology malformations, intracranial
haemorrhage, ischaemic
Neurological damage)
Sepsis USS (to detect
haemorrhage)

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 Principles for acute management
Rapid, accurate diagnosis by EEG
Rapid titration of medication to stop
seizures
Early discontinuation of medications once
seizures ceased
Prevention of secondary problems by
maintaining physiological vital signs, blood
glucose and ventilation

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 Management
What is the initial What other care?
management?
Documentation of seizure
Resuscitation activity
Ongoing assessment and EEGcorrelate with
examination videorecording of babys
activity (if available)
Treat underlying causes
Family centred care and
Medicationsantibiotics,
ongoing parental support
antivirals, antiepileptic
drugs (AEDs), others as Referral for ongoing care
indicated and management

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 Drug therapy
Principles: Administer anti-
Treat underlying cause convulsants:
Commence AEDs treatment IV to achieve rapid onset
when: of action and predictable
blood levels (at high
Seizures clinically
therapeutic range)
apparent lasting more
than 3 minutes Give maximum dosage
before introducing second
More than two briefer
line medication
seizures
Electroencephalographic
seizures present

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 Duration of treatment
What is the optimal duration Consider risks and benefits:
of AEDs? Potential efficacy
Unknown Potential toxicity
Usually ceased after 72 Side effects
hours of no seizures and Anticipated rapidity of
normal neurological response
examination Assess:
Babys neurological status
EEG
Underlying aetiology

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 Antiepileptic drugs
First line Second line
Phenobarbital No general agreement on
First line treatment preferred second line drug(s)
Controls seizures in
43%85% babies
Administer loading dose Practice tip:
o Commence daily Always refer to Australian
maintenance doses if pharmacopoeia for
seizures continue complete drug information
Side effects include
respiratory depression,
hypotonia, hypotension,
reduced level of
consciousnessmonitor
baby
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 Discharge planning
Provide parents with:
Seizure emergency management
plan
Copy of discharge summary
including type of seizures and
medications
Copies of referrals
Follow up appointments/plan
Contact details of support services
Queensland Clinical Guidelines
information sheet about neonatal
seizures

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