treatment on neonatal seizure

1. Neonatal seizures
Recent advance
Dr MANDAR HAVAL
DCH. DNB. Fellow In
Neonatology(NNF)

2. INTRODUCTION
• Seizures is defined clinically as a paroxysmal
alteration in clinical function
• i.e motor , behavior and autonomic function

3. Types
• Clonic movement (focal, multifocal,
genralised)
• Myoclonus (multifocal, genralised)
• Tonic movement (focal, genralised)
• Motor (automatism and subtle seizure)

4. Interesting Evidence
• Subtle and generalized seizure had a
significantly higher prevalance of epilepsy ,
mental retardation and cerebral palsy as
compare to other seizure type

5. • Neonatal seizures are not stimulus sensitive
not abolished by restraint or repositioning
and often associated with autonomic changes
and ocular phenomenon, are usually
stereotypic and repetitive , and the interictal
examination is often abnormal.

6. Common cause of neonatal seizure
• HIE
• Intracranial Infection
• Metabolic disorder (Hypoglycemia,
Hyponatrimia, Hypocaemia)
• Intracranial Hemorrhages (ICH)
• Inborn Error Of Metabolism
• Epileptic syndrome

7. Interesting evidence
• Study in PGI chandigarh found HIE is the
commonest cause of seizure followed by
meningitis

8. Investigation following seizure
• Cbc, Crp , Procalcitonin , Blood Culture, Csf
• Sr.Electrolyte (Na, iCa ) and BSL
• EEG
• Neuroimaging (MRI and cranial USG)
• Coagulation profile
• ABG with An ionic gap
• Lactate and Pyruate level
• TMS and HPLC

9. Recommendation for investigation
• 1st line ( BSL, iCa, Na, ABG)
• 2nd line - Add on Situational
A) Sick Neonate With Seizure
B) Intracranial Infection
C) Intracranial Hemorrhage
D) IEM workup

10. (EEG)
• Newborn frequently demonstrate
electrographic seizure without clinical
movement and vice versa

11. Interesting Evidance
• Focal clonic, some form of Myoclonic seizures,
focal tonic seizure where associated with EEG
changes
• Most Subtle seizure, all Generalized tonic seizures
and some form of Myoclonic seizure where
eighter not associated with EEG changes or had
inconsistent relationship.
• Only 21% of seizure are seen on EEG

12. TYPE OF EEG
• CONVENTIONAL EEG using international 10 -
20 system(channels) modified for neonate
with concurrent video is the gold standered
• aEEG compared with conventional eeg shows
76% sensitivity and 78% positive predictive
value for detection of neonatal seizure

13. EEG For Prognosis purpose
• Neurological sequelae are unusual when EEG
correlates occur on normal background
• In contrast sever background activity are
associated with neurological sequelae in 90%
of case

14. LUMBAR PUNTURE
• Lumbar puncture is done in neonatal seizures
to rule out bacterial and viral infection.
• Rare disease
Nonketotic hyperglycemia
GLUT1 deficiency deficiency
is like to get diagnosed

15. Neuroimaging (Recommendation)
• All sick looking neonate with seizure should
undergo bedside cranial USG ( rule out
intracranial hemorrhage, major malformation
and abscess )
• In term infant with seizures and encephalopathy ,
significant birth trauma, and evidence of low
hematocrit and /or coagulopathy, a non contrast
CT scan should be performed (Hemorrhage)

16. Treatment of neonatal seizure
• Followed in four step
1) Stabilization
2) Identification
3) Specific Treatment
4) Prevention of recurrence

17. Flow Chart
Neonate with seizure
Ensure TABC, IV access, check
dextrose
BSL<40
mg/dl
10 %
dextrose
2ml/kg bolus
Continuous
infusion at
6mg/kg/min

18. If Seizure Persist
Do ionized calcium
by ABG
Consider giving 10%
calcium gluconate
@ 2ml/kg IV over 5
to 10 min
If seizure persist
then repeat calcium
If no response then
consider 50%
MgSO4 @ 0.2ml/kg
IM
Calcium step is consider in case of IDM , IUGR , preterm and sick neonate

19. Seizure persist Dextrose and Ca normal
Inj. Phenobarbitone 20mg/kg IV over
15 min . If seizure persist consider 2nd
bolus of 10mg/kg (Total 30mg) assess
seizure control after 15min of bolus
Phenatoin or fosphenytoin
20mg/kg , infuse over 10 min .
Rate should be 1mg/kg/min.
assess seizure control after 30
min
In neonate with
hepatic dysfunction
the max dose should
be restricted to
20mg/kg

20. IF Seizure Persist *
Consider intubation ond mech. Ventilation
IV lidocacain loading dose 2mg/kg followed by
intravenous infusion of 6mg/kg/hour, then
4mg/kg/hr for 12 hr, followed by 2mg/kg/hr for 12
hr
Midazolam infusion 0.15mg/kg IV bolus , followed
by continuous infusion 1ug/kg/min increase by 0.5
to 1ug/kg/min every 2 min till response (max
18ug/kg/min
OR
* Consider using pyridoxine at these step

21. If Seizure persist
• Consider alternate drug
1) Levateracetam
2) Topiramate

22. Suggested guidelines for weaning AED
New born with seizure
Transient
metabolic problem
Difficult to control seizure
Treat the cause and stop
the AED immediately if
started initially
Stop AED observe for atleast
48 hr for seizure recurrence
Yes
No
No
Yes

23. Cont..
Continue phenobarbitone and stop other AED . Assess
neurological status after stoppage of AED and at discharge
Stop
phenobarbitone
immediately
Discharge on
phenobarbitone; repete
neurological exam at 1
month
NORMAL ABNORMAL

24. Normal
• Taper and stop
phenobarbitone
over 2 week
Abnormal • Do EEG
After 1
month of
repeat
neurologi
cal exam

25. Normal
• Taper and stop
phenobarbitone
over 2 week
Abnormal
• Reasses at 3
month
EEG

26. Follow up sequelae
• Early infancy (12 to 18 mt follow up recognise
most babies with major disability)
cerebral palsy, mental retardation or
hearing problem.
• School age and older age
learning and behavioral problem

27. Study of infant discharge wit neonatal
seizure over 12 yrs
• 24% had seizure recurrence and 16% had
multiple recurrence treated as epilepsy
• In other study 25% cerebral palsy, 20% mental
retardation, 27% learning disorder

28. Interesting Evidance
• A pure clonic seizure without facial
involvement in term infant suggestive of
favorable outcome
• Whereas generalized myoclonic seizure in
preterm infant where associated with increase
risk of mortality

29. Factor Associated With Poor Prognosis
• Severe HIE
• Cerebral dysgenesis
• IVH
• Seizure within 12hr of life
• Seizure lasting more than 30 min to one hour
• Recurrent seizure for more than 48 hr
• Generalized myoclonic , generalized tonic and
subtle seizure with severe background
abnormalities on EEG

30. ALL THE BEST