SHINU K ANTONY
1ST YEAR MSc NURSING
Neonatal seizures are the seizures
that occur within the first 4 weeks
of life and are most commonly seen
within the first 10 days.
57.5/1,000 in infants with birth
2.8/1,000 in infants weighing
between 2,500 and 3.999g have
1 in 200 healthy newborns
Many seizures are very subtle – go
1.Large group of neurons undergo
excessive, synchronized depolarization
which results from –
a) Increase in excitatory neurotransmitters
b) Decrease in inhibitory neurotransmitters
(gamma amino butyric acid- GABA
c. Disruption of ATP – dependent resting
membrane potentials - Failure of Na - K
pump – flow of sodium into the neuron
& potassium out of neuron
d. Membrane alteration - Increased Na
Inhibitory neurons are selectively
damaged and remaining principal
excitatory neurons became hyper
Aberrant excitatory circuits are formed as
a part of re organization after injury
Immature brain has more excitatory
neurons than matured (excitatory
glutamate containing circuits)
GABA has a paradoxical excitatory nature
in immature brain
Additionally GABA sensitive substantia
nigra pars reticulata neurons play a part
in preventing seizures, but in neonates it
INBORN ERRORS OF METABOLISM
DRUG ASSOCIATED SEIZURES
Primary neuronal injury: intracellular
energy failure occurs, resulting in
immediate cell death by necrosis
Secondary neuronal injury occurs
hours or days after the orginal insult
FOCAL CLONIC SEIZURES
Localized clonic jerking of one limb with
no loss of consciousness.
The electroencephalography is unifocally
Metabolic disturbances like hypocalcemia,
cerebral contusion, focal infarct, or
MULTIFOCAL CLONIC SEZURES
More in term infants.
Characterized by random clonic
movements of limbs. Many muscle groups
are involved simultaneously.
The EEG is multifocally abnormal.
The prognosis is variable
metabolic abnormalities like
Seen in preterm neonates.
May mimic decerebrate or decorticate
posturing. They are often associated with eye
deviation, clonic movements or apnea.
The EEG is multifocally abnormal with a
burst,suppression pattern or can have
extremely attenuated amplitude.
The prognosis is generally poor.
With diffuse cns disease or intraventricular
Synchronous single or multiple jerks of
upper or lower limbs.
Involves distal muscle groups.
The EEG shows burst-suppression pattern
or focal sharp transient waves leading to
Diffuse cns pathology,and development
defects like anencephaly.
The prognosis is poor.
Most common type (>50%)of neonatal
They can be varied in nature and manifest
The EEG is often not associated with an
epileptiform or hypersynchronous EEG.
They are now considered to be brainstem
release phenomenon and not seizures.
Clinical seizure with a
consistent EEG event
Clinical seizures with
inconsistent EEG events
Electrical seizures with absent
These are seizures occurring in well
babies and all investigations are
negative. Causes are
1 Abnormal gaze or eye
2 Movements Exquisitely stimulus-
3 Movements cease Passive flexion or
On their own
4 Predominant movement Tremor Clonic jerking
5 Fast and slow components Absent Present
6 EEG Normal Abnormal
7 Rate or jerks 5 to 6 per second 2 to 3 per second
8 Blood pressure, heart rate Normal Increased
FAMILY HISTORY OF SEIZURES OR
Collect all samples
Glucose 10% - 2-4ml/kg as bolus followed
by 10% glucose as drip @ 8mg/kg/min
IV calcium – gluconate 2ml/kg
If significant seizures persists,
midazolam 0.15mg/kg IV bolus followed
by IV infusion 0.1-0.4mg/kg/hr (0.2-
sodium valporate IV is the usual next drug
in case of resistant seizure (20-
Vigabatrin (50mg/kg/day) and topiramate
(3mg/kg) are experimental at present.
Maintenance dose of anticonvulsants is started
12hours after loading.
Initial maintenance doses are given as intravenous
and later switched over to oral.
If on multiple anticonvulsants and seizures free for
2-3 days then try to taper on to monotherapy
If controlled with calcium gluconate, start
If the baby is seizures free after 1 or 2 episodes
and with normal neurological status or there is a
known cause for seizures then anticonvulsant may
be stopped on discharge.
If the baby had difficult to control seizures or if
baby is neurologically abnormal then
anticonvulsants may be continued and consider a
ANTICONVULSANT DRUG DOSES
DRUG INITIAL DOSE MAINTENANCE
Phenobarbital 20mg/kg IV. Consider further 5-10mg/kg
increments to a total of 40mg/kg
Check drug levels may not
need further doses for many
days 3-4 mg/kg/day
Phenytoin 20mg/kg IV. Fosphenytoin 20mg /kg IV 3-4mg/kg/day divide bid to
benzodiazepines Lorazepam 0.05-0.1 mg/kg IV. Diazepam
PROGNOSIS AND OUTCOME
Level of maturation
Severe grades of IVH and congenital
National Collaborative Perinatal
Apgar <=6 at 5 minutes or longer
The need for positive pressure ventilation > 5
minutes after birth
Early onset of seizures within 24hrs
Hypotonia at 5mts or longer following birth
3 or more days with uncontrolled seizures
Presence of tonic or myoclonic seizures
Seizures lasting longer than 30mts
Need of more than one anticonvulsant drug
for control of seizures
Decreased intracranial adaptive capacity
related to compression of brain tissue due
to increased intracranial pressure
resulting from brain injury
Risk for ineffective (cerebral;) tissue
perfusion related to increased ICP
alteration in blood flow secondary to
hemorrhage, vessel malformation or
Risk for injury related to altered level of
consciousness, weakness, loss of muscle
coordination secondary to seizure activity
Disturbed sensory perception related to
presence of neurologic leisions or
pressure on sensory or motor nerves
secondary to increased ICP as evidenced
by nystagmus, loss of response to stimuli
Risk for infection related to surgical
interventions, trauma to brain, stasis of
pulmonary secretions and urine
Imbalanced nutrition less than body
requirement related to vomiting and
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