Neonatal Seizures

Lamiaa Mohsen, M.D

Cairo University
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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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Learning Objectives (cont)

5. List the causes of neonatal seizures,

both common and less common
etiologies.
6. Diagnose neonatal seizures.
7. Treat neonatal seizures.
8. Inform parents of the neonate’s
prognosis.
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Definition of Seizure

Seizures are transient disturbances in

brain function manifesting as episodic
impairments in consciousness in
association with abnormal motor or
automatic activity.

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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.
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Incidence of Neonatal Seizures

 The overall incidence is 0.5% of all term

and preterm neonates.

 The incidence is higher in preterm

neonates (3.9% if gestational age < 30
weeks).

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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

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Tonic Seizures
 Tonic seizures can be either generalized or focal.

 Generalized tonic seizures:

- Mainly manifest in preterm neonates (< 2500
grams).
- Tonic flexion or extension of the upper
extremities, neck, 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, or skin flushing.

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Focal Tonic Seizures
Present with asymmetrical posturing of
one of the limbs or trunk or with tonic
head or eye deviation.

 Mostly occur with diffuse central

nervous system disease and
intraventricular hemorrhage.

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Clonic Seizures
 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. They are commonly seen
in full-term neonates >2500 grams
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Clonic Seizures (cont)

 There is no loss of consciousness and

they are associated with focal trauma,
infarction or metabolic disturbances.

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Myoclonic Seizures
Myoclonic seizures can be focal, multi
focal 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.

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Myoclonic Seizures (cont)

 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.

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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.
 Deviation or jerking of the eyes with
repetitive blinking.
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Subtle (Fragmentary) Seizures
(cont)

 Drooling, sucking or chewing

movements.
 Apnea or sudden changes in respiratory
patterns.
 Rhythmic fluctuations in vital signs.

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Benign Movements that are
Not Seizures

Jitteriness
Sleep apnea
Isolated sucking movements
Benign neonatal sleep
myoclonus

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Jitteriness

Jitteriness is often misdiagnosed as

clonic seizures. Clinically they differ
from clonic seizures in the following
aspects:

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Jitteriness (cont)

 The flexion and extension phases are equal

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

 often seen in neonates with

hypoglycemia, drug withdrawal,
hypocalcemia, hypothermia and in
(SGA) neonates.
 spontaneously resolve within few weeks.

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Sleep Apnea
Not associated with abnormal
movements and is usually associated
with bradycardia.

When seizures are present with apnea

abnormal movements, tachycardia and
increased blood pressure are present as
well.
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Isolated Sucking
Movements

Random, infrequent and not well

sustained sucking movements are not
seizures.

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

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Benign Neonatal Sleep
Movements (cont)
They differ from myoclonic seizures in
the following:

can be triggered by noise or motion.

 suppressed by the waking state.
not associated with any autonomic
changes.
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Most Common Causes of
Seizures
 HIE
 Infections (TORCH, meningitis,
septicemia)
 Hypoglycemia, hypocalcemia,
hypomagnesemia
 CNS bleed (intraventricular, subdural,
trauma, etc.)
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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

more than one underlying cause 26

Diagnosis of Seizures

Obtain a good maternal and obstetric

history

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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
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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
 Achieve systemic homeostasis
(airway, breathing and circulation).
 Correct the underlying cause if
possible.

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Medical Management of
Seizures
 10% dextrose solution (2cc/kg IV) empirically to
any seizing neonate.
 Calcium gluconate (200mg/kg IV), if
hypocalcemia is suspected .
 Magnesuim sulfate 50%, 0.2ml/kg or 2ml Eq/kg.
 Antibiotics in suspected sepsis.
 In pyridoxine dependency give pyridoxine 50mg
IV as a therapeutic trial. Seizures will stop within
minutes .

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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
32 site.
loading dose.
 Stopping Seizures with
Anticonvulsants (cont)
Drug Dose Comments Side Effects

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.
 8 mg/kg/day by  Cardiac
IV push or PO. arrhythmias
 Divide total dose  Cerebellar
and administer damage
IV every 12
hours.

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 Stopping Seizures with
Anticonvulsants (cont)
Drug Dose Comments Side Effects

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.

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Prognosis
 Best prognosis with:  Hypocalcemia
 Pyridoxine dependency
 Subarachnoid
hemorrhage

 Worse prognosis
with:  Hypoglycemia
 Anoxia
 Brain malformation
 Sequelae:
 Chronic seizures 15-20%
 Mental retardation
 Cerebral palsy
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TERIMAKASIH

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