Neonatal seizures: Definition, classification, Etiology and management

1. SEIZURES IN PEDIATRIC
ICU
PROF. Nahed Salah
Prof. of neurology Ain Shams University

2. Seizures are the most common medical problem for emergency medical
services transport in children, accounting for approximately 15% of all
pediatric calls in the USA

3. Status epilepticus (SE) and seizures are the most common neurologic
conditions managed in pediatric intensive care units. However, while often
encountered, management is highly variable and treatment delays have
been reported. Further, there is increasing evidence that many seizures in
critically ill children are electrographic-only, so identification requires
continuous electroencephalographic (EEG) monitoring.

4. Seizures in PICU have different clinical characteristics from those in adults.
Recognizing the common seizure etiologies in PICU is likely to lead to a
more prompt and effective treatment.

5. Their detection and management is important for two major reasons:
a) seizures in this age group are symptoms of an underlying neurologic
disease that may require specific treatment; and
b) both animal and human studies suggest that, at least in certain
circumstances, seizures in the newborn may cause or worsen brain injury.

6. The clinical manifestations of neonatal seizures are more subtle and less well
organized than in the infant or older child.
These differences relate to the relative immaturity of the brain at birth.

7. Electroclinical seizures
• Clinical seizures plus EEG seizure pattern
Electrographic seizures
• EEG seizure pattern without clinical symptoms
Clinical-seizures-without electroencephalographic-seizure activity
NEONATAL SEIZURES
Definition
(Volpe J.J. 2001)

8.  Subtle
 Multifocal clonic
 Focal clonic
 Tonic
 Myoclonic
 Tonic-clonic seizures uncommon
Neonatal seizures
classification

9. Classification (Volpe)
■ Subtle seizures (50%)
■ Clonic seizures (25%)
■ Myoclonic seizures (20%)
■ Tonic seizures (5%)
Generalized tonic–clonic seizures are rare in neonates due to incomplete
myelination.

14. Apnea with tonic stiffening of body
Focal clonic movements
• One limb, both limbs on one side
Multifocal clonic limb movements
Myoclonic jerking
Tonic deviation of the eye
• Upward / to one side
Tonic stiffening of the body
NEONATAL SEIZURE
clinical patterns
(Fenichel ,Clinical Pediatric Neurology,2005)

15. Subtle seizures
withouth tonic or clonic movements
Apnea
Ocular symptoms
Oral automatism
Movement automatisms
Autonomic symptoms

16. Apnea
•plus tonic deviation of the eyes
Ocular symptoms only
• tonic deviation of the eyes (term > preterm staring (preterm >
term )
• repetitive eye opening, fluttering of eyelids
• nystagmus
SUBTLE SEIZURES
preterm > term newborns

17. SUBTLE SEIZURES
 Oral autmatisms
• chewing, sucking, drooling
• repetitive tongue movements

18. SUBTLE SEIZURES
 Movement automatisms
• complex unintended movements
- pedaling
- swimming
- boxing
- head movements

19. MULTIFOCAL CLONIC SEIZURES
Migratory
Shift from one limb to another
Usual cause: whole enceph. involvem.(H.I.E.)

20. FOCAL CLONIC SEIZURES
Localized to one limb / one side
• slow: 1 to 3 jerks/sec
• faster: 3 to 4 jerks/sec
Spread to other body parts
Usual cause:intracerebral hemorrhage infarction

21. TONIC SEIZURES
Generalized tonic stiffening of the body plus
Tonic deviation of the eyes and/or
Asymmetrical posturing of the limbs on one side

22. MYOCLONIC SEIZURES
Synchronized jerking movements of arms or legs (or both) –
uncommon
Multifocal myoclonic jerks and
decreased states of consciousness
(Usual related to: Inborn error of metabolism)

23. Precise frequency difficult to delineate for wide spectrum of clinical manifestations
• 6.9 (term) /1000 life births
 61.4 (preterm) / 1000 life births
( Kumar A et al., Indian J Pediatr 2007)
• 57.5 / 1000 with birth weight < 1500g
• 2.8 / 1000 with birth weight 2500 – 3990 g
( Volpe JJ, Neurology of the newborn, Fourth Ed. 2001)
NEONATAL SEIZURES
Incidence

24. NEONATOL SEIZURES ETIOLOGY
Hypoxic-ischemic encephalopathy
Infection
Vascular disease
Stroke, venous thrombosis
Intracranial hemorrhage
Metabolic encephalopathy
Transient or inborn error of metabolism
Cerebral dysgenesis / migration disorders / malformations
Trauma (delivery related or nonaccidental)
Idiopathic
Epileptic syndromes including familial epilepsies

25. NEONATAL SEIZURES
acute phase treatment
Depending on etiology :
- Hypoglycemia :glucose 10% 2ml/kg i.v.( mainten. 8mg/kg/min i.v.)
- hypocalcemia :Cagluconate 5% 4ml/kg i.v.(mainten 500 mg/kg/24)
- HypoMg : Mgsulfate 50% 0,2 ml/kg i.m.(mainten. 0,2 ml/kg/24h )
- Pyridoxine 50-100 mg i.v.
Symptomatic anticonvulsive treatment :
- 1°) Phenobarbital: Loading dose 20mg/kg i.v.(max 40mg/kg)
- 2°)Phenytoin (fosphenytoin): 20 mg/kg (1mg/kg/min i.v.)
- 3°)Lorazepam: 0.05-0.10 mg/kg i.v.
J.J.Volpe, Neurology of the newborn,2001

26. Neonatal seizures
AED alternative treatment
Symptomatic anticonvulsive treatment
-levetiracetam*
-valproic acid²
-midazolam°
-lidocaine ° }Status epilepticus
-thiopental#
*Rotemberg J.S. J.Child Neurol ,2007 °Shany E. J. Child.Neu 2007
#Bonati M. Develop. Pharm .Ther.1990 ²Singh B. J. Child
Neurol1996

28. Pharmacokinetics
Is the study of drug absorption, distribution, metabolism, and
elimination: that is, what the body does to a drug.
Pharmacodynamics
is the study of a drug’s biochemical and physiologic effects: that is,
what the drug does to the body. Children, much more than adults, have
widely varying abilities to absorb, distribute, metabolize, and eliminate
drugs

29. In the management of pediatric patients with seizures, there is a
concern with the effects of age and maturation on the
pharmacokinetic profile of the antiseizure drugs.
A drug’s effect on a child’s learning and behavior should also be a
major determinant influencing the choice of an antiseizure drug.

30. As a result of the differences between children and adults, children
require more frequent and larger doses relative to body size to attain
targeted plasma concentrations

31. Neonates
Gastric emptying time is irregular, absorption area is reduced, and biliary
function is underdeveloped for several months or more after birth. These
factors can contribute to erratic drug absorption

32. Neonatal seizures
conclusive remarks
Mostly symptomatic
Prognosis aetiology depending
E.E.Graphic seizures are often understimated in high –risk neonates
Need of long term videoEEG monitoring .

33. THANKYOU