Neonatal Seizures

Dr Gopal Agrawal, Dr R Kishore Kumar
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Treatment
No evidence-based guidelines exist currently for the management of neonatal seizures7. Management of seizures includes stabilization, identification of underlying cause and specific treatment.
• Neonates with brief seizures due to transient, reversible electrolyte or glucose abnormalities do not require immediate treatment with anti-seizure drugs.
• All clinical seizures with EEG correlates and all EEG seizures should be aggressively treated with AED
• Clinical seizures that are prolonged (greater than 2 minutes) or that are frequent (greater than 3 episodes in 2 minutes) warrant treatment.
In practice phenobarbital remains the drug of first choice for confirmed or suspected seizures8. The dose is 20 mg/kg/IV slowly over 20 minutes, with maximum cumulative dose of 40 mg/kg (See Figure 1). If seizure persists despite maximal dose of phenobarbitone, fosphenytoin (preferably) or phenytoin is indicated. The dose is 20 mg/kg IV under cardiac monitoring. Either midazolam or lidocaine may be used as third line agents for seizures refractory to phenobarbital and/or phenytoin.

Figure 1: Immediate management of seizures including use if anti-seizure medications
Immediate management of seizures including use if anti-seizure medications



Neonatal seizures are associated with high mortality and morbidity rates, with preterm babies even at higher risk of poor outcome. Neonates with seizures have a risk for epilepsy (20-25%) during childhood(9).
Indicators of poor outcomes in neonatal seizures:
• Refractory seizures
• Subtle or myoclonic form of seizures
• Abnormal neurological status before onset of seizures and after the seizures are controlled
• Cerebral dysgenesis, HIE III, meningitis, hypoglycemia
• EEG: low background activity or a burst suppression pattern
• Neuro imaging: deep grey matter / multifocal or diffuse cortical involvement

Neonatal seizures rarely reoccur during the first 2 years of life, and prophylactic antiepileptic drug administration need not be maintained past 3 months of age, even in the child at risk(10). Definite guidelines do not exist regarding the duration of anticonvulsant treatment for neonatal seizures. The protocol recommended by Volpe(11) is usually followed at most places (See Figure 2).

Figure 2: Strategy to wean off AED in neonates
Figure 2: Strategy to wean off AED in neonates


References
Neonatal Seizures Neonatal Seizures 09/05/2018
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