This document discusses neonatal seizures. It begins by defining seizures and noting that they are not uncommon in neonates and often indicate an underlying neurological condition. It then reviews epidemiological data on seizure incidence. The main causes of neonatal seizures are identified as hypoxic ischemic encephalopathy, intracranial hemorrhage, infections, metabolic disorders, and genetic conditions. The document outlines the various clinical presentations and classifications of neonatal seizures and diagnostic workup. Treatment involves identifying and treating the underlying etiology, maintaining glucose and electrolyte levels, and administering anti-seizure medications like phenobarbital. Careful monitoring is needed to determine when anti-seizure drugs can be safely discontinued.

1. NEONATAL SEIZURE
Dr Chandan Barnwal MD (Pediatrics)

2. INTRODUCTION
 SEIZURE:- Paroxysmal alteration in neurological
function i.e. motor, sensory and autonomic
function
 Not uncommon
 Almost always due to some underlying cause
 Idiopathic
 Often first sign of neurological disorder
 Predicts long term cognitive and developmental
impairment
Dr Chandan Barnwal MD (Pediatrics)

3. EPIDEMIOLOGY
 A/c to NNPD (2002-03)
Incidence at India:-
 10.3 per 1000 live birth
 Higher in Pre-Term and VLBW BABY
 Term baby:- 8.4 per 1000 live birth
 Pre-Term baby:- 20.8 per 1000 live birth
 VLBW baby:- 36.1 per 1000 live birth
 No Racial but slightly Male predisposition
Dr Chandan Barnwal MD (Pediatrics)

4. DIAGNOSTIC DILEMNA
 Because
 Usually brief and subtle in clinical appearance
 Unusual behaviors i.e. difficult to differentiate from
seizure activity
 Differential ability of parents and even medical
personnel to recognize neonatal seizure
Dr Chandan Barnwal MD (Pediatrics)

5. OBJECTIVE
 To familiarize the various presentations of neonatal seizure
 To distinguish non-seizure state from seizure
 Early recognition of etiology
 To decide management specific to neonatal seizure
 To decide:- Duration of anti-epileptic therapy,
:- Duration of follow up
:- Prognosis
Dr Chandan Barnwal MD (Pediatrics)

6. PATHOPHYSIOLOGY
Immature Brain
More excitable
More liable to seizure
Dr Chandan Barnwal MD (Pediatrics)

7. PATHOPHYSIOLOGY
Defective balance between Excitatory NT e.g.
Glutamate & Inhibitory NT e.g. GABA
Excitatory NT
Inhibitory NT
Dr Chandan Barnwal MD (Pediatrics)

8. Immaturity of Brain
1. Delay in maturation of Na+ - K+ ATPase
2. Increased density of NMDA & AMPA receptor
3. Increased GLUR2 AMPA receptor:-
Increases permeability of Ca++
4. Delay in Inhibitory function of GABA:-
GABA receptor becomes excitatory instead of
inhibitory in immature brain d/t reversal of chloride
channel
Dr Chandan Barnwal MD (Pediatrics)

9. Reversal of chloride channel
.
NKCC1
KCC2
Bumetanide
Dr Chandan Barnwal MD (Pediatrics)

10. Types of Neonatal Seizure
• Based on corresponding EEG finding:-
1. Epileptic seizure:-
Seizure with corresponding EEG
e.g. spasm, focal tonic , focal clonic, generalised myoclonic
seizure
2. Non-Epileptic seizure:-
Seizure without corresponding EEG
e.g. subtle, generalised tonic, multifocal myoclonic
3. EEG Seizure:-
Only EEG Seizure without any clinical seizure
Dr Chandan Barnwal MD (Pediatrics)

11. Types of Neonatal Seizure
• Based on clinical features:-
1. Subtle seizure
2. Tonic seizure
3. Clonic seizure
4. Spasm
5. Myoclonic seizure
Dr Chandan Barnwal MD (Pediatrics)

12. Subtle Seizure
Now k/a- Motor automatism and Bucco-Lingual Movements
More common in Pre-mature baby
C/F:-
1. Eye:- transient eye deviations, nystagmus, blinking
2. Mouth:- mouthing, tounuge thursting
3. Extremities:- swimming, rowing, bicycling, pedaling, stepping
4. ANS:- fluctuations in HR and RR, hypertensive episodes
5. Apnea
Dr Chandan Barnwal MD (Pediatrics)

13. Tonic Seizure
2 types:-
 Generalised Tonic seizure:-
1. Bilateral tonic extension or flexion of upper limb with or
without tonic extension of lower limb
2. Non-epileptic seizure :-
 Focal Tonic seizure:-
1. Persistent posturing of limb or trunk or neck in asymmetrical
way with or without persistent horizontal deviation of eye
2. Epileptic seizure :-
 Generalised tonic seizure is more common than Focal tonic
seizure
Dr Chandan Barnwal MD (Pediatrics)

14. Clonic seizure
3 types:-
 Focal Clonic seizure:-
1. Repetitive and rhythmic contractions of group of muscles
2. Epileptic seizure-
 Multifocal Clonic seizure:-
1. k/a Fragmentary seizure
2. migratory in nature
3. migration follows Non- Jacksonian trend i.e. jerking of left
arm is a/w jerking of right leg
 Generalised clonic seizure:-
1. Very rare in neonate
Dr Chandan Barnwal MD (Pediatrics)

15. Spasm
1. Sudden generalised jerk that last for 1-2 seconds
2. Single jerk per episode
3. Epileptic seizure :-
Dr Chandan Barnwal MD (Pediatrics)

16. Myoclonic seizure
3 types:-
 Focal myoclonic seizure :-
It involves flexor group of muscles of upper extremities
 Multifocal myoclonic seizure :-
It involves synchronous twitching of several parts of body
 Generalised myoclonic seizure :-
There is bilateral jerking a/w flexon of upper limb and/or lower
limb
Dr Chandan Barnwal MD (Pediatrics)

17. ETIOLOGY
A/c to age of onset:-
1st day
1. Hypoxic Ischemic Encephalopathy
2. Cerebral Contusion
3. 1st day Hypocalcaemia
4. Accidental injection of local anesthetic into fetal scalp
5. Pyridoxine dependency
Dr Chandan Barnwal MD (Pediatrics)

18. 1-3 days
1. Hypoglycemia
2. Inborn error of metabolism:- Galactosemia, Urea
cycle disorder, Hyperglycinemia
3. Intracranial hemorrhage
4. Drugs withdrawal:- maternal use of narcotics and
barbiturate
Dr Chandan Barnwal MD (Pediatrics)

19. .
4-7 days:-
1. Meningitis
2. TORCH infections
3. Kernicterus
4. Brain malformations
5. Benign Neonatal Seizure
6. Tetany
Dr Chandan Barnwal MD (Pediatrics)

20. 1-4 weeks
1. Late onset Hypocalcaemia
2. Sepsis
3. Epileptic syndrome
4. Cerebral dysgenesis:- lissencephaly, focal cortical
dysplasia, Aicardi syndrome
5. Herpes encephalitis
6. Inborn error of metabolism:- Galactosemia, Urea
cycle disorder, Hyperglycinemia
7. Progressive Hydrocephalus
8. Neurocutaneous syndrome:- Tuberous sclerosis,
Sturge weber syndrome
Dr Chandan Barnwal MD (Pediatrics)

21. Etiology
HIE 50-60%
Vascular 10-20%
Infections 5-10%
Brain malformation 5-10%
Metabolic
Rest etiology
Dr Chandan Barnwal MD (Pediatrics)

22. .
Hypoxic ischemic encephalopathy
1. m/c etiology of neonatal seizure
2. onset within first 12-24 hr
3. types:- subtle(m/c), focal clonic, multifocal clonic
4. typically of short duration i.e. < 1 minutes, may be
very frequent but refractory to treatment specially
in first 24 hr
Dr Chandan Barnwal MD (Pediatrics)

23. .
Intracranial hemorrhage
1 . 10-15% of neonatal seizure
2. SDH, SAH, IVH, Germinal matrix, Parenchymal
hemorrhage
3. SAH:- Term baby, good prognosis, clinically normal
b/w seizure
4. IVH, Parenchymal, Germinal matrix hemorrhage:-
mainly in Pre-Term, poor prognosis
5. SDH:- d/t CPD, breech delivery, instrumentation
Dr Chandan Barnwal MD (Pediatrics)

24. .
CNS infections:-
1. 5-10% of neonatal seizure
2. Congenital infections:-
TORCH, seizure may onset within 2 days, a/w other features
e.g. microcephaly, IUGR, cerebral calcifications, cataract etc
3. Neonatal sepsis:-
Group B Streptococci, E. coli etc,
clinically well for couple of days, then clinical deterioration
with seizure after 48-72 hr
Dr Chandan Barnwal MD (Pediatrics)

25. .Acute metabolic disorder:-
1. Hypoglycemia:-
Definition is controversial- <20 mg/dl for Pre-Term and
<30 mg/dl for term
Threshold for treatment- <40mg/dl for first 24 hr and
<45mg/dl after 24 hr of age
2. Hypocalcaemia:-
<7.5mg/dl for Pre-Term and <8mg/dl for Term baby
ionized fraction <0.6 has more predictable a/w seizure
3. Hypomagnesaemia:-
mostly transient,
must be corrected before correction of Hypocalcaemia
4. Hyponatremia:-
<125meq/l
Dr Chandan Barnwal MD (Pediatrics)

26. .
Inborn error of metabolism:-
1. Initially normal then become encephalopathic
2. Seizure starts after 2-3 days
3. E.g.
 GLUT1 deficiency:- impair glucose transport across BBB
 Non-ketotic hyperglycemia i.e. Glycine encephalopathy
 Pyridoxine deficiency:-
d/t ALDH7A1/antiquitin gene,
l/t accumulation of alpha-AASA in blood, urine and CSF,
so act as biomarker,
diagnosed by a test dose of 100mg pyridoxine iv that l/t cessation
of seizure
 Folinic acid responsive seizure
Dr Chandan Barnwal MD (Pediatrics)

27. .
Epilepsy syndrome:-
Very rare:- e.g.
Benign or Malignant
 Benign Infantile Neonatal Convulsion:-
k/a 5th day fit ? Seizure b/w 4-6 day of life
initially focal clonic, often l/t status epilepticus
may be a/w apnea,
benign ? Cease within 2 weeks
 Benign Familial Neonatal Convulsion:-
family history present
seizure occur up to 6 month
d/t KCNQ2 channel abnormality
Dr Chandan Barnwal MD (Pediatrics)

28. .
 Early Myoclonic Epilepsy:-
presents in 1st few days of life
often with focal motor seizure and myoclonus
refractory to medications
EEG- burst suppression pattern
 Early Infantile Epileptic Encephalopathy:-
k/a- Ohtahara syndrome
early onset of tonic spasm with focal motor seizure
 Malignant Migrating Partial Seizure in Infancy:-
k/a- Coppola syndrome
may present from 1st month to 10th month of life
focal motor seizure and escalate aggressively
shift from side to side:- both clinically and Electrographically
Dr Chandan Barnwal MD (Pediatrics)

29. Investigations
Essential :
• Blood sugar
• Serum calcium and sodium
• CSF
• Cranial ultrasound
• EEG and /or aEEG
Dr Chandan Barnwal MD (Pediatrics)

30. .
• Conventional EEG :
- Gold standard for detecting neonatal seizures
- Recommended for babies at high risk for seizures and/or
paroxysmal events
• Amplitude integrated EEG (aEEG):
- with only 4 electrodes
- Provides continuous monitoring at the bed side
- Lower sensitivity and specificity than cEEG
- Lower sensitivity for brief, focal seizures or distant from
recording electrodes
- Useful for monitoring background brain activity (e.g.
identifying variability as a sign of neurological wellbeing)
Dr Chandan Barnwal MD (Pediatrics)

31. .
Additional investigations :
• Hematocrit ( when child is plethoric or risk for
polycythemia)
• Serum bilirubin ( if icteric)
• ABG and Anion Gap ( if lethargy, vomiting,
family history)
• Work-up for IEM
• TORCH Screen for congenital infection
• IMAGING – CT / MRI
Dr Chandan Barnwal MD (Pediatrics)

32. Flowchart for management of neonatal
seizures :
Neonate with seizures
• Identify and characterize the seizure
• Ensure TABC
• Start OXYGEN if seizures are continuous
• Secure IV access and take samples for baseline investigations.
• Glucostix for immediate glucose estimation
• If Blood sugar <40mg/dl
• No facility to test Glucose
• Administer 10% Dextrose – 2ml/kg bolus followed by continuous
infusion @ 6-8mg/kg/min
Dr Chandan Barnwal MD (Pediatrics)

33. • If no response to dextrose bolus/hypoglycemia ruled out
• If Serum calcium <7mg/dl or QTc > 0.2sec
• 2ml/kg of 10% Calcium gluconate IV over 10 min under strict cardiac
monitoring
• If hypocalcaemia then give 10% Calcium gluconate @8ml/kg /day for 3
days
0.25 ml/kg of 50% Magnesium sulphate IM
• Administer Phenobarbitone- 20mg/kg IV slow over 20min
• If seizure persist repeat it @10mg/kg/dose up to 40mg/kg dose is reached
• Phenytoin – 20mg/kg IV slowly over 20min
• If seizure persist repeat it @ 10mg/kg/dose
Dr Chandan Barnwal MD (Pediatrics)

34. • Lorazepam- 0.05mg/kg IV bolus over 2-5min
• Midazolam- 0.1-0.2mg/kg IV bolus followed infusion of 0.1-
0.4mg/kg/hr
• Lidocaine: 4mg/kg IV bolus f/b infusion @ 2mg/kg/hr
• Paraldehyde: 0.1-0.2ml/kg/dose IM or 0.3ml/kg/dose per
rectal route
• Sodium valproate: 20mg/kg IV bolus f/b 5-10mg/kg every
12hrs
• Leveracitam: 10-30mg/kg/day in divided dose
• Vigabatrin: 50mg/kg/day
• Topiramate: 3mg/kg
• Misc. – Pyridoxine ; Exchange transfusion
Dr Chandan Barnwal MD (Pediatrics)

35. When to discontinue AED :
Newborn on anticonvulsant therapy
Wean all AED in reverse manner except Phenobarbitone once seizure controlled
Neurological examination prior to discharge
Normal Abnormal
Stop Phenobarbitone
Continue Phenobarbitone for 1 month
Repeat neurological examination at 1 month
Normal Abnormal
Evaluate EEG
Taper drugs over 2weeks
Normal EEG
Taper drugs over 2wks
Abnormal EEG
Continue drug
Reassess at 3 monthsDr Chandan Barnwal MD (Pediatrics)

36. Thank you
Dr Chandan Barnwal MD (Pediatrics)