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Iowa Neonatology Handbook
https /uichildrens org/health library/iowa neonatology
handbook

Neonatal
seizures
Michael J Acarregui MD
Peer Review Status Internally Peer
Reviewed

Background
It is important to recognize the
presence of seizures in the neonatal
period since they are often related to
a significant underlying illness In
addition seizures may be sustained
for considerable periods of time
interfering with essential supportive
care There are major types of
seizures in neonates

Subtle seizures are relatively

common in the neonatal period
and are more often encountered
in the preterm than full term
infant Such seizures include
oral buccal lingual movements
certain ocular phenomena
peculiar limb movements
autonomic alterations and
apnea
Clonic seizures include focal and
multifocal varieties which may
migrate to another part of the
body in a non ordered fashion
Tonic seizures include focal
episodes less common and
generalized episodes more
common Generalized tonic
seizures may mimic decerebrate
and decorticate posturing
Myclonic seizures may be focal
multifocal or generalized and are
the least common of the four
varieties during the neonatal
period
Seizure like phenomena may not be
accompanied by seizure activity on
EEG and possibly represent
movements or posturing generated
by diencephalon brainstem activity
when released from the inhibitory
effects of the cerebral cortex Careful
clinical assessment is often necessary
to distinguish seizure from
nonseizure activity Non seizure
activity is usually provoked by sensory
stimulation suppressed by passive
restraint associated with normal eye
movements and not accompanied by
autonomic phenomena

Pathophysiology
A number of etiologies should be
considered for neonatal seizure
These include
Asphyxia/hypoxia ischemia
There is usually an interval of
time between the event and the
onset of seizures but this
interval is quite variable
hr
Intracranial hemorrhage
Seizures may be a manifestation
of any form of intracranial
hemorrhage including
subarachnoid intraventricular
or intraparenchymal
hemorrhage
Metabolic disturbances
Seizures may accompany
alterations of glucose calcium
or sodium homeostasis as well
as inborn errors of metabolism
e g hyperammonenia
Intracranial infection
Meningitis encephalitis
 Drug withdrawal Heroin
methadone
Structural defects of the central
nervous system

Diagnosis
A detailed history of prenatal and
postnatal events is paramount in
diagnosing neonatal seizures At the
time of the seizure attention should
be directed to identifying treatable
causes as outlined in the previous
section A short term screening EEG
may be helpful in establishing
diagnosis and prognosis Other
studies including head ultrasound
CT or MRI and skull X rays should be
considered depending upon the
history obtained
Treatment
Once a seizure has been diagnosed
treatment directed at the underlying
disease needs to be initiated
Anticonvulsant therapy includes the
following

Phenobarbital is the drug of

first choice to treat neonatal
seizures It is relatively effective
the side effects are well
appreciated and the
pharmacokinetics are reasonably
well understood for term and
preterm infants A loading dose
of phenobarbital mg/kg will
achieve a therapeutic level of
approximately µg/ml which is
not affected by birth weight or
gestational age The intravenous
route is preferred because of
the more rapid onset of action
and more reproducible effects
on blood levels The
maintenance dose of
phenobarbital is lower in the
first week of life
mg/kg/day and increases to
mg/kg/day with increasing
postnatal age
Dilantin is often the second
drug of choice to be added
when seizures are not controlled
by phenobarbital alone A
loading dose of mg/kg
intravenously will achieve
therapeutic blood levels
approximately µg/ml and a
maintenance dose is
mg/kg/day
Lorazepam is useful for infants
with uncontrolled seizures in
 spite of therapy with
phenobarbital and dilantin The
usual dose is mg/kg
per dose Due to the possibility
of respiratory depression
especially with phenobarbital
on board the safest use of
these drugs is when ventilatory
support has been initiated

Intracranial up Neurological
hemorrhage /health disorders
/health library/neurology
Asphyxia
library/intracranial
nicu /health
hemorrhage handbook
library/neurological
disorders
asphyxia

iowa neonatology handbook

/health library/iowa
neonatology handbook
Abbreviations commonly used in th
nursery /health library/abbreviation
commonly used nursery
Cardiology NICU Handbook /healt
library/cardiology nicu handbook
Feeding NICU Handbook /health
library/feeding nicu handbook
Fluid management NICU Handbook
/health library/fluid management n
handbook
Gastrointestinal NICU Handbook
/health library/gastrointestinal nicu
handbook
General NICU Handbook /health
library/general nicu handbook
Hematology NICU Handbook /hea
library/hematology nicu handbook
Infection NICU Handbook /health
library/infection nicu handbook
Jaundice NICU Handbook /health
library/jaundice nicu handbook
Metabolic NICU Handbook /health
library/metabolic nicu handbook
Neurology NICU Handbook /healt
library/neurology nicu handbook
Criteria for cooling for hypoxic
ischemic encephalopathy /he
library/criteria cooling hypoxic
ischemic encephalopathy
Intracranial hemorrhage /hea
library/intracranial hemorrhage
Neonatal seizures /health
library/neonatal seizures
Neurological disorders Asphyx
/health library/neurological
disorders asphyxia
Whole body hypothermia for
hypoxic ischemic encephalopa
HIE /health library/whole b
 hypothermia hypoxic ischemic
encephalopathy hie
Pharmacology NICU Handbook /h
library/pharmacology nicu handboo
Procedures NICU Handbook /heal
library/procedures nicu handbook
Pulmonary NICU Handbook /healt
library/pulmonary nicu handbook
Temperature NICU Handbook /he
library/temperature nicu handbook
Iowa Neonatology Handbook Prefa
/health library/iowa neonatology
handbook preface
Iowa Neonatology Handbook Autho
and contributing authors /health
library/iowa neonatology handbook
authors and contributing authors
Translations of the Iowa Neonatolog
Handbook /health library/translatio
iowa neonatology handbook
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