Neonatal Seizures                                   Dr. Kalpana Malla                                       MD Pediatrics ...
INTRODUCTION• Not uncommon•Always due to some underlying cause•25% cases cause – unknown•Often first sign of neurological ...
Pathophysiology1.Large group of neurons undergo    excessive, synchronized depolarization which    results from –a) Increa...
PROBABLE MECHANISMSc. Disruption of ATP – dependent resting  membrane potentials - Failure of Na - K  pump – flow of sodiu...
Incidence• 1 in 200 healthy newborns• 0.5 -0.8% Term babies• 6-12% <1.5 kg (1 in 4 premature and  LBW• Many seizures are v...
SEIZURE PATTERN1. Subtle seizure: 50%of seizures- Tonic horizontal deviation of eyes,    staring look,Repetitive blinking ...
SEIZURE PATTERN2.Clonic - Focal / Multifocal – twitching migrate haphazardly from one limb to another, occur due to HIE & ...
SEIZURE PATTERN4. Focal clonic –   Localized & often assoc with loss of  consciousness  They are signs of bilateral c’bral...
SEIZURE PATTERN5. Tonic seizure –  - Stiffening similar to decerebrate    posture but with eye signs and    heavy breathin...
SEIZURE PATTERN6.Myoclonic seizures• Rare in newborns• Single/multiple flexion  movements, slow and jerky• Seen in develop...
Features      Jitteriness       SeizureStimulus          ++                 _ sensitiveCessation     Passive flexion      ...
Features              Jitterine Seizure                      ssFrequency of jerks    5-6 / sec 2-3 / secAbnormal gaze-Eye ...
ETIOLOGYA. Perinatal causes 1. Neonatal encephalopathy - 20-     40% of seizures2. Intracranial hemorrhages- CNS          ...
B. METABOLIC CAUSES• Hypoglycemia• Hypocalcemia – most common metabolic  cause for NNS• Hypomagnesemia• Hypo / Hypernatrem...
C. Infections• Intracranial  - Meningitis  - encephalitis – herpes, coxachie, echo, CMV,   - ToxoplasmosisExtracranial    ...
D. Developmental defects– Cerebral Dysgenesis– Hydrocephalus– Microcephaly– Neuronal migration defects-  Lissencephaly,pac...
OthersE. Drugs- prolonged maternal  administration     - Vit B6-pyridoxin dependancy     - Narcotic withdrawal     - Theop...
OthersH .Hypertensive encephalopathyI . Benign familial epilepsy – does not  continue after neonatal periodJ .Unknown(Idio...
Diagnosis – time of onset• 1st day – birth asphyxia (HIE)         - C’bral trauma        - Pyridoxin dependancy        - N...
Diagnosis – time of onset• 1-3 days –      - ICH      - Hhypocalcemia      - Hypoglycemia      - Hypo & hypernatremia     ...
Diagnosis – time of onset• 4-7 days –      - Meningitis      - Encephalitis      - Hypomagnesemia      - TORCH infection  ...
Refractory seizures•   IEM –•   Developmental defects of CNS•   Narcotic withdrawal•   Pyridoxin dependancy•   Kernicterus...
Investigations• CBC• Blood – glucose, calcium, electrolytes, Mg,  bilirubin, ABG• CSF analysis• Blood C/S , urine C/S• Cra...
Second line investigations• TORCH screening• IEM screening – urine organic acids•              - S. amino acid assay• Imag...
Management• Collect all samples• IV line• Thermoneutral environment• Glucose 10% - 2-4ml/kg as bolus followed by  10% gluc...
ANTICONVULSANTSPhenobarbitone      15 - 20mg / kg IV loading dose      3.5 - 5mg / kg / day maintenance dosePhenytoin     ...
ANTICONVULSANTS• Phenobarbitone       ↓↓• Phenytoin       ↓↓• Lorazepam, midazolam drip – 48 hrs        ↓↓
ANTICONVULSANTS            ↓↓• Barbiturate coma – pentobarbital& thiopental  on ventilator – try to wean every 24 hrs     ...
TREATMENT1. Optimise ventilation   Maintain CO, BP, Serum electrolytes & pH2. Treat underlying diseases- Metabolic abnorma...
Benign familial neonatal seizure•   Typically occur in first 48- 72 hrs of life•   Disappear by age 2-6 months•   A family...
Benign idiopathic NNS•   Typically Presents at day 5 of life•   Also called 5th day fits•   Multifocal in type•   No cause...
FOLLOW UP -            ANTICONVULSANTS1. Stop all others except maintenance PB2. Maintenance PB : 2wks - 2months3. Risk of...
PROGNOSISNormal Outcome: 56%Neurological sequelae: 30 - 40%Death : 15-25%Chronic seizure disorder: 15-20%Outcome depends o...
GOOD PROGNOSIS• Uncomplicated hypoglycemia• Narcotic withdrawal• SAH
POOR PROGNOSIS•   Low APGAR score ≤ 6 at 5min•   Onset o seizures within 24 hrs of life•   Presence of myoclonic attacks• ...
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Neonatal seizures

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Neonatal seizures

  1. 1. Neonatal Seizures Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  2. 2. INTRODUCTION• Not uncommon•Always due to some underlying cause•25% cases cause – unknown•Often first sign of neurological disorders•Powerful predictors of long termcognitive and developmental impairement
  3. 3. Pathophysiology1.Large group of neurons undergo excessive, synchronized depolarization which results from –a) Increase in excitatory neurotransmitters (glutamate)b) Decrease in inhibitory neurotransmitters (gamma amino butyric acid- GABA
  4. 4. PROBABLE MECHANISMSc. Disruption of ATP – dependent resting membrane potentials - Failure of Na - K pump – flow of sodium into the neuron & potassium out of neurond. Membrane alteration - Increased Na permeability
  5. 5. Incidence• 1 in 200 healthy newborns• 0.5 -0.8% Term babies• 6-12% <1.5 kg (1 in 4 premature and LBW• Many seizures are very subtle – go undetected
  6. 6. SEIZURE PATTERN1. Subtle seizure: 50%of seizures- Tonic horizontal deviation of eyes, staring look,Repetitive blinking / fluttering of eyelids - Oro- buccal movements-chewing, lip smacking, sucking, yawning - Tonic posturing of a limb - Apnea- Swimming/ bycycling movements
  7. 7. SEIZURE PATTERN2.Clonic - Focal / Multifocal – twitching migrate haphazardly from one limb to another, occur due to HIE & birth trauma3.Generalised seizure - rare
  8. 8. SEIZURE PATTERN4. Focal clonic – Localized & often assoc with loss of consciousness They are signs of bilateral c’bral disorder Common in metabolic disorder, birth trauma and c’bral infarction
  9. 9. SEIZURE PATTERN5. Tonic seizure – - Stiffening similar to decerebrate posture but with eye signs and heavy breathing - Often associated with apnea - Seen in IVH, preterm and Kernicterus
  10. 10. SEIZURE PATTERN6.Myoclonic seizures• Rare in newborns• Single/multiple flexion movements, slow and jerky• Seen in developmental defects and anencephaly
  11. 11. Features Jitteriness SeizureStimulus ++ _ sensitiveCessation Passive flexion - Gentle graspRhythmicity Rhythmic Fast & slow oscillation components
  12. 12. Features Jitterine Seizure ssFrequency of jerks 5-6 / sec 2-3 / secAbnormal gaze-Eye Nil PresentmovementAutonomic disturbance Nil Increase HR, BP)EEG Normal Abnormal
  13. 13. ETIOLOGYA. Perinatal causes 1. Neonatal encephalopathy - 20- 40% of seizures2. Intracranial hemorrhages- CNS trauma, SAH, PVH,
  14. 14. B. METABOLIC CAUSES• Hypoglycemia• Hypocalcemia – most common metabolic cause for NNS• Hypomagnesemia• Hypo / Hypernatremia• Pyridoxine dependency• IEM - Disorders of amino acid metabolism
  15. 15. C. Infections• Intracranial - Meningitis - encephalitis – herpes, coxachie, echo, CMV, - ToxoplasmosisExtracranial – septicemia - Tetanus - Severe rep distress
  16. 16. D. Developmental defects– Cerebral Dysgenesis– Hydrocephalus– Microcephaly– Neuronal migration defects- Lissencephaly,pachygyria,schizenceph aly
  17. 17. OthersE. Drugs- prolonged maternal administration - Vit B6-pyridoxin dependancy - Narcotic withdrawal - TheophyllineF. PolycythemiaG. Focal infarcts
  18. 18. OthersH .Hypertensive encephalopathyI . Benign familial epilepsy – does not continue after neonatal periodJ .Unknown(Idiopathic : 3-25%
  19. 19. Diagnosis – time of onset• 1st day – birth asphyxia (HIE) - C’bral trauma - Pyridoxin dependancy - Narcotic withdrawal - IEM
  20. 20. Diagnosis – time of onset• 1-3 days – - ICH - Hhypocalcemia - Hypoglycemia - Hypo & hypernatremia - Pyridoxin deficiency - Cong C’bral malformations - Narcotic withdrawal
  21. 21. Diagnosis – time of onset• 4-7 days – - Meningitis - Encephalitis - Hypomagnesemia - TORCH infection - Developmental malformations - Kernicterus - IEM - Pyridoxin dependancy - Tetanus
  22. 22. Refractory seizures• IEM –• Developmental defects of CNS• Narcotic withdrawal• Pyridoxin dependancy• Kernicterus• Benign familial seizures
  23. 23. Investigations• CBC• Blood – glucose, calcium, electrolytes, Mg, bilirubin, ABG• CSF analysis• Blood C/S , urine C/S• Cranial USG
  24. 24. Second line investigations• TORCH screening• IEM screening – urine organic acids• - S. amino acid assay• Imaging – CT scan - MRI - EEG brain
  25. 25. Management• Collect all samples• IV line• Thermoneutral environment• Glucose 10% - 2-4ml/kg as bolus followed by 10% glucose as drip @ 8mg/kg/min• IV calcium – gluconate 2ml/kg
  26. 26. ANTICONVULSANTSPhenobarbitone 15 - 20mg / kg IV loading dose 3.5 - 5mg / kg / day maintenance dosePhenytoin 15 - 20 mg / kg IV at 1mg / kg / min 4 - 8 mg / kg day maintenance doseMidazolam 0.02 - 0.4 mg/kg IM 0.02 - 0.1mg/kg IV 0.06 - 0.4mg/kg/hrOthers Lorazepam, diazepam, Paraldehyde
  27. 27. ANTICONVULSANTS• Phenobarbitone ↓↓• Phenytoin ↓↓• Lorazepam, midazolam drip – 48 hrs ↓↓
  28. 28. ANTICONVULSANTS ↓↓• Barbiturate coma – pentobarbital& thiopental on ventilator – try to wean every 24 hrs ↓↓• GA with isoflurane or halothane + neuromuscular blockade (muscle paralysis)
  29. 29. TREATMENT1. Optimise ventilation Maintain CO, BP, Serum electrolytes & pH2. Treat underlying diseases- Metabolic abnormalities,meningitis,Narcotic withdrawal3. Pyridoxine dependency- 50mg IV, repeatevery 10 min till control- maintenance dose –5mg/kg PO daily6. Hyperbilirubinemia –phototherapy, exchange transfusion
  30. 30. Benign familial neonatal seizure• Typically occur in first 48- 72 hrs of life• Disappear by age 2-6 months• A family history seizures is usual• Development - normal
  31. 31. Benign idiopathic NNS• Typically Presents at day 5 of life• Also called 5th day fits• Multifocal in type• No cause detected
  32. 32. FOLLOW UP - ANTICONVULSANTS1. Stop all others except maintenance PB2. Maintenance PB : 2wks - 2months3. Risk of recurrence Little: transient metabolic abnormalities 30-50% : HIE High : Cortex malformations
  33. 33. PROGNOSISNormal Outcome: 56%Neurological sequelae: 30 - 40%Death : 15-25%Chronic seizure disorder: 15-20%Outcome depends on 1. Level of maturity 2. Etiology 3. Neurological examination 4. EEG / Imaging studies
  34. 34. GOOD PROGNOSIS• Uncomplicated hypoglycemia• Narcotic withdrawal• SAH
  35. 35. POOR PROGNOSIS• Low APGAR score ≤ 6 at 5min• Onset o seizures within 24 hrs of life• Presence of myoclonic attacks• Abnormal EEG• 3 or more days of uncontrolled seizures
  36. 36. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
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