Recognasmg seizures
1.Abnormal
mOIIements
2.Jitteriness
3.Seizure types
4.Causes and
approach
5. Case(s)
Teesside
Universit
y
Examination of the Newborn
Thursday 18th September
9th National Conference
Seizures in the term infant
how do I recognize
them?
Dr. Andrew Villis Paediatric/Neonatal
Registrar andrew.villis@nhs.net
Contents
Recognising seizures
1.Abnormal movements
2. Jitteriness
3. Seizure types
4. Causes and approach
5. Case(s)
Recognising seizures
1.Abnormal movements
2.Jitteriness
3.Seizure types
4.Causes and approach
s. Case(s)
The baby with abnormal movements
Recognition of abnormal movements depends on previous
experience (of parents, and healthcare professionals)
The most important things ... recognition of abnormality
recognition of the sick child early and appropriate response
Not all abnormal movements are seizures, but all should be
reviewed/assessed by the appropriate person at the
appropriate time.
Assessment of abnormal movements should include a full
history and systemic examination, followed by appropriate
investigations.
Abnormal movements
Generally one of the most important considerations
deciding between jitteriness vs. seizures.
Stimulus provoked
Yes
No
Predominant movement
Rapid, oscillatory
Clonic, tonic
Cease when limb held
Yes
No
Conscious state
Awake or asleep
Altered
Eye deviation
No
Yes
is
Table reproduced from Essential Neonatal Medicine, Sinha.
Jitteriness
An involuntary, tremulous type of movement.
Often stimulus provoked.
Can be overcome by holding the Limbs
concerned.
No altered state of consciousness.
Can co-exist with seizures.
Most commonly in our practice:
• Neonatal abstinence syndrome
• Neonatal hypoglycaemia
http://newborns.stanford.edu/PhotoGallery/J itteryl.html
http://newborns.stanford.edu/PhotoGallery/J ittery3.html
In NAS, may be accompanied by other signs of
withdrawal such as inconsolability, hyperactivity,
sneezing, Loose stools, sweating, vomiting, poor
feeding.
History gives important clues.
r
Seizures
Incidence:
120per 100,000 term babies (Sheth, 1999) Up to 0.5% of live
term births (multiple sources)
Seizure I convulsion I fit I? epilepsy Seizure
a transient occurrence of signs or symptoms due to
abnormal excessive or synchronous neuronal activity in the
brain.
Classification
•
•
•
•
•
Tonic
Clonic
Myoclonic
Subtle
Also classified by Location eg. generalised or focal
Tonic
More common in preterm infants.
Stiffening/spasms Flexion or
extension
Whole body or specific Limb
Cannot be interrupted with
repositioning, nor overcome
May stop with arousal or
stimulation
Generalised tonic seizures often
occur with background of
significant brain injury
Clonic Seizures
•Slow rhythmic jerking of
a Limb, or rhythmic
twitching of the face.
•More common in term
babies.
•If appear generalised this is often multiple focal
seizures happening at
once.
•Jitteriness, Limb clonus
and benign sleep
myoclonus can be
mistaken for this.
-
Tonic/Clonic
Generalised tonic clonic seizures do
not usually occur around the time of
birth -the brain at this stage does not
have the capacity to manifest this
type of seizure.
Relative brain immaturity (compared
to older infants) and Less capacity
for seizures to generalise from a
single focus or for seizures from
multiple foci to coalesce into a
generalised
0
se1zure.
r
Myoclonic
Quick single jerks of a Limb, or Limbs
and trunk
Typically occur when awake
Occasionally can be normal.
May be first sign of an underlying
metabolic or genetic condition
Benign sleep myoclonus- only in
sleep, stops when aroused, other
causes excluded.
Subtle
Hardest seizures to identify.
May be motor or autonomic Motor:
•Eye deviation
•Eye nystagmus
•Mouthing
•Lip smacking
•Cycling/Swimming type movements
Autonomic:
•
•
•
•
Apnoea
Desaturation
Tachycardia
Blood pressure disturbance
http://newborns.stanford.edu/PhotoGallervJSz3.htmL
http://newborns.stanford.edu/PhotoGallervJSz2.htmL
Recognising seizures
1. Abnormal movements
2. Jitteriness
3. Seizure types
4. Causes and approach
5. Case(s)
NAS
Inborn error
of metabolism
Birth asphyxia
Intracranial event
Infection- Sepsis
Meningitis, Encephalitis
Low blood sugar
Stroke I Haemorrhage
Significant
jaundice
Congenital brain
malformations
Benign familial
Low sodium
Low calcium
Low magnesium
High blood
pressure
Global Assessment
History
Maternal past medical history - diabetes, thyroid, hypertension, seizures
Pregnancy history - scans, infections (?treated), medications, substances
Risk factors for neonatal infection
•Known infections eg. GBS
•Prolonged rupture of membranes
•Maternal pyrexia in Labour
•Maternal antibiotics in Labour
•Prematurity
Delivery - method, traum1a, suggestion of asphyxia
Post-natal - feeding, activity, concerns
Call for
help early
Examination
Routine newborn examination? Observations
Full ABCDE/systemic assessment
Assess responsiveness, temperature, blood sugar
Accurate description of abnormal movements noted
Investigations/Management
Bloods: glucose, FBC, U/E, LFT, Bone profile (caLcium), Magnesium, CRP
Infection: Blood culture, Lumbar puncture, urine, chest x-ray, congenital infection
(TORCH) screen
Imaging: cranial ultrasound scan, CT/MRI Electroencephalograph (EEG)
I
Cerebral function monitoring (CFM)
Genetics? Metabolic screen?
Management directed towards Likely/possible causes:
•persisting seizures: phenobarbitone, phenytoin, clonazepam, Lignocaine
•dextrose, calcium, magnesium, sodium replacement
•antibiotic cover
•cooling
•? omit feeds
•? further investigation/observation
•Longer term neurodevelopmental follow-up
Table 22..8 The chance of normal outcome
depending on the cause of the neonatal
seizure
Cause of seizures
Chance of normal
development(%)
Hypoxic-ischaemic
encephalopathy
50
Subarachnoid
haemorrhage
90
Other intracranial
haemorrhage
50
Hypoglycaemia
50
Hypocalcaemia
90
Bacterial meningitis
2050
Developmental
, structural
CNS
abnormality
0
75
Idiopathic
Table reproduced from Essential Neonatal Medicine, Sinha.
Case 1
Term baby
Normal vaginal delivery No risk factors for sepsis
Problems between 24-40 hours of age with maintaining temperature
Seen by midwife, SHO, registrar
Registrar commenced IV antibiotics - persistent hypothermia
Midwives had noticed ?abnormal movements on a couple of occasions Whenever reviewed, no
abnormal movements seen
Seen by consultant as well as the above
At 60 hours of age, poor feeding, temperature improving Reviewed again ?abnormal movements
Left sided focal clonic seizure noted
Blood sugar normal
IV antibiotics continued
MRI scan showed Large right sided infarct
= Neonatal Stroke
If people have noticed abnormal movements, but they aren't persistent- this warrants at Least c
observation.
Case 2
Term baby, birthweight 3.5kg Primigravida
No risk factors for infection
Moaning at 4 hours of age -antibiotics commenced
Asked to urgently review at 6 hours of age A - moaning, grunting
B - clear chest, increased work of breathing, saturations 96-98% C - no
murmur, femoral pulses normal, pale
D - Lethargic, Looks sick, not crying on handling, fontanelle normal E abdomen normal, no rashes
Generally floppy- went quieter, stopped moaning/grunting, arms
stiffened, extended briefly
Case 2 Continued
Then informed that 1hour ago - BG 0.8 mmol/L Attempted
breast feed with top up - unsuccessful
BG rechecked - <0.6 mmol/L
Dextrose bolus given - moaning and grunting resumed. No
further abnormal movements.
Moved to NNU
Confirmed Group B Streptococcus Sepsis (result within
ten hours of sample being sent) No meningitis
Don't Ever Forget Glucose!
Sepsis can still occur in absence of risk factors
It is essential to call for
help early if you suspect a
child is having seizures
No matter what the cause is, the sooner you
can get the appropriate help and treatment,
the better the chances of Limiting any ongoing
brain injury that may be occurring.
Low blood sugar Infection
?asphyxia - cooling
Essential Neonatal Medicine 5th Edition. Sinha et al. Wiley-Blackwell
2012
Neonatal Seizures. Olson. NeoReviews 2012;13;e213
Sheth RD, Hobbs GR, Mullett M. Neonatal seizures: incidence, onset,
and etiology by gestational age. J Perinatal. Jan 1999;19(1):40- 3
http://newborns.stanford.edu
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Recognising seizures
1.Abnormal movements
2.Jitteriness
3.Seizure types
4.Causes and approach
s. Case(s)