Neonatal seizures
Dr Naeeme Taslimi Taleghani
Assistant Professor of Pediatrics
(Neonatologist)
Shahid Beheshti University of Medical Sciences
3/15/2016
• “Neonatal seizures continue to pose a
challenge for clinicians worldwide because
they are difficult to diagnose and treat and are
associated with poor outcomes.”
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The immature brain is prone to seizures
• The sensitivity to seizures is higher in the developing
brain than during the rest of life:
1. External factors increase the susceptibility of the
immature brain to seizures: birth trauma, hypoxicischemic insults, perinatal acquired infections,
intracranial hemorrhage, fever and metabolic
disturbances
2. In addition to insults, several neonatal disorders such
as congenital brain anomalies, inborn errors of
metabolism, and genetic factors can be initially
present with seizures or can lead to recurrent seizures
during the neonatal period.
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The immature brain is prone to seizures
• Developmental factors predispose the
immature brain to seizures
• Besides external factors, various intrinsic
factors make the immature brain more
susceptible to seizures than the adult brain:
1. early development of excitatory neurotransmitter
systems
2. delayed development of inhibition
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Effects of seizures in the immature brain
• Whether or not the effects of seizures add to
the long-term effects of their underlying cause
is still not clear.
• seizures may also produce indirect harmful
effects on brain function.
• The presence of seizures can alter these
developmental sequences and lead to
persistent deleterious effects.
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Epidemiology and etiology of
neonatal seizures
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Epidemiology and etiology of neonatal seizures
• Seizures constitute the most frequent and distinctive
manifestation of neurological disturbance in the
neonatal period .
• The exact incidence of neonatal seizures in the
general newborn population is difficult to estimate
for a number of reasons:
1) clinical presentation of seizures in the neonatal period is
subjective
2) In preterm infants, presentation is often subtle
3) The phenomenon of electro clinical dissociation or the
‘uncoupling’ of neonatal seizures is now well recognized.
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Epidemiology and etiology of neonatal seizures
Timing of seizures:
• Most neonatal seizures occur very early in life
with nearly a third occurring within the first
day, and another third occurring within the
first week.
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Epidemiology and etiology of neonatal seizures
Risk factors for neonatal seizures:
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Etiology of neonatal seizures
Etiology of neonatal seizures
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Clinical types of seizures in infants
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Clinical types of seizures in infants
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Selected Major Manifestations of Subtle Seizure
Subtle Seizure Activity :
a)
b)
c)
d)
e)
orbital-ocular movements
bucco-lingual movements
unusual bicycling or pedaling
autonomic findings :changes in heart rate, blood pressure, oxygenation
Others: penile erections, skin changes, salivation, and
tearing,…
Autonomic expressions may be intermixed with motor findings.
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Differential diagnosis of epileptic seizures in infancy
including the neonatal period
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Jitteriness ( recurrent tremors)
Jitters are the most frequently occurring in the neonatal period
1.
2.
3.
4.
5.
6.
It occurring in up to two-thirds of newborn babies in the first three days
of life.
It is seen most frequently in sleepy or active infants, and least frequently
in quietly wakeful infants.
They are most pronounced during vigorous crying, and diminish during
the course of the first weeks.
Tremors are stimulus sensitive, diminish with passive flexion of the
extremity.
Tremors are not associated with abnormality of gaze or eye movements.
Tremors associated with metabolic conditions are usually of high
frequency and low amplitude, whereas the tremors associated with CNS
disorders are low frequency, high amplitude movements.
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cause of Jitteriness ( recurrent tremors)
• The exact cause of jitteriness is not
established.
 one theory is that neonatal tremor is due to immaturity of spinal
inhibitory interneuron's causing an excessive muscle stretch reflex.
 Another theory is that elevated levels of circulating catecholamines
account for the tremor.
 Jitteriness in its pronounced form maybe symptomatic of various
conditions requiring specific attention: hypoglycemia, hypocalcaemia,
sepsis, hypoxiceischaemic encephalopathy, intracranial hemorrhage and
drug withdrawal.
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Benign neonatal sleep myoclonus (BNSM)
• Myoclonus is a brief limb movement, a jerk, caused by a muscle
contraction.
• BNSM is a condition where such jerks occur only in sleep.
• It is the most common condition misdiagnosed for epilepsy in the term
neonate, and consequently over treated.
1) BNSM can be distinguished from epileptic myoclonus by the fact the
jerks occur only during sleep, and settle on arousal.
2) It tends to occur in term healthy neonates
3) It is bilateral and repetitive, and may involve all limbs but not the face.
4) Onset is usually in the first few days of life, but it resolves by four months
of age.
5) jerks resolve on arousal and are not associated with EEG change should
this be performed during episodes.
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Apnea
• Apnea spells in the neonate, defined as cessation of respirations for at
least 20 s
• This may or may not be associated with a transient bradycardia.
• In preterm babies, the most common cause is immaturity, ‘apnea of
prematurity’, where the normal stimulation of respiratory drive by arterial
hypoxia and hypercapnia is delayed.
• apnea beyond this period is more likely to be associated with other
pathology, such as: sepsis, metabolic disorders, GER, poor pharyngeal
coordination and, rarely, seizures.
• With seizures as a cause in a term infant the only manifestation may be
apnea, particularly with temporal lobe onset, and motor manifestations
may not be demonstrated.
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Investigations for neonatal
seizures
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Investigations for neonatal seizures
• Seizures during the neonatal period are always medical
emergencies.
• Apart from the need for rapid anticonvulsive treatment, the
underlying condition is often not immediately obvious.
• In the search for the correct diagnosis:
1) A thorough history
2) Clinical examination
3) Laboratory work-up
4) Neurophysiologic and neuroradiological investigations
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Clinical history
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Clinical examination
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The level of consciousness
Tone
Gaze
body-posture
Tendon reflex
Cranial nerve and newborn reflexes
The general body examination focuses on finding indications for an
underlying disease condition
• The skin is inspected for bleeding and bruising,eruptions,birth-marks (for
example in the face, indicating phacomatosis)
• Cardiac examination includes checking for murmurs, including
auscultation over the fontanels as AVmalformations
• Abdominal examination focuses on intraabdominal masses (liver, spleen,
kidneys).
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Initial laboratory work-up
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Neuroimaging
A. A cranial ultrasound is routine management in the
investigation of neonatal seizures.
• It should be carried out as soon as possible after the first
occurrence of seizures .
• It will help in early diagnosis of many underlying causes
including :
 intraventricular hemorrhage
 arterial stroke
 malformation
 infections
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Neuroimaging
• Magnetic resonance imaging (MRI) is the ‘gold
standard’ in the examination of the newborn
brain .
• We suggest that computed tomography (CT) is
reserved for emergency situations where MRI
is not available and intracranial hemorrhage
(particularly in the posterior fossa) is a real
possibility.
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Monitoring neonatal seizures
• All suspected neonatal seizures need EEG
confirmation.
• At-risk neonates should be continuously
monitored using multiple EEG electrodes for a
minimum of 72 h after birth.
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Treatment of neonatal seizures
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The most important questions that still need to be answered
• Which drugs should we use ?
• How aggressively should we treat neonatal
seizures?
• How long should we treat neonatal seizures?
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Acute Management of Neonatal Seizures
• After each step, evaluate the infant for ongoing seizures. If seizures
persist, advance to next step.
• Step 1. Stabilize vital functions
• Step 2.Correct transient metabolic
disturbances
• a. Hypoglycemia (target blood sugar 70-120 mg/dL)
10% dextrose water IV bolus dose 2 mL/kg followed by a continuous
infusion at 8 mg/kg/min
• B.Hypocalcemia :5% calcium gluconate IV at 4 mL/kg (need cardiac
monitoring)
• c. Hypomagnesemia :50% magnesium sulfate IM at 0.2 mL/kg
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Acute Management of Neonatal Seizures
• Step 3. Phenobarbital 20 mg/kg IV load
Cardiorespiratory monitoring
5 mg/kg IV (may repeat to total dose of 40
mg/kg)
Consider continuous EEG monitoring
Consider intubation/ventilation
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Acute Management of Neonatal Seizures
• Step 4.Lorazepam
0.05 mg/kg IV (may repeat to total dose of 0.1
mg/kg)
• Step 5.Phenytoin (fosphenytoin)
20 mg/kg slow IV load
5 mg/kg slow IV (may repeat to total dose of 30
mg/kg)
• Step 6.Pyridoxine 50-100 mg/kg IV (with EEG
monitoring)
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Outcome following neonatal
seizures
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Factors determining high risk of poor outcome in
neonatal seizures:
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Associated with favorable outcome:
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Sugar & Safe Care
Temperature
Airway
Blood Pressure
Lab Work
Emotional Support
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THANKS FOR YOUR ATTENTION
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