neonatal pneumonia

1. Neonatal seizures
By;
Dr Syeda Sumaiya(2019-2022)
Pg scholar Dept of OBG
NIUM, Bengaluru-91 Under the guidance of: Prof Wajeeha Begum
HOD dept
of OBG NIUM, Bengaluru-91.

2. Contents
 Diagnosis
 Management
 Prognosis

4. Approach to an infant with neonatal seizures:
History:
 Seizure history: A complete description of the seizure should be obtained from the
parents/attendant. History of associated eye movements, restraint of episode by
passive flexion of the affected limb, change in color of skin (mottling or cyanosis),
autonomic phenomena, and whether the infant was conscious or sleeping at the time
of seizure should be elicited. The day of life on which the seizures occurred may
provide an important clue to its diagnosis. While seizures occurring on day 0-3 might
be related to perinatal asphyxia, intracranial hemorrhage, and metabolic causes, those
occurring on day 4-7 may be due to sepsis, meningitis, metabolic causes, and
developmental defects.
 Antenatal history: History suggestive of intrauterine infection, maternal diabetes,
and narcotic addiction should be elicited in the antenatal history. A history of sudden
increase in fetal movements may be suggestive of intrauterine convulsions.

5.  Perinatal history: Perinatal asphyxia is the commonest cause of neonatal
seizures and a detailed history including history of fetal distress, decreased fetal
movements, instrumental delivery, need for resuscitation in the labor room, Apgar
scores, and abnormal cord pH (10 meq/l) should be obtained. Use of a pudendal
block for mid-cavity forceps may be associated with accidental injection of the
local anesthetic into the fetal scalp.
 Feeding history: Appearance of clinical features including lethargy, poor activity,
drowsiness, and vomiting after initiation of breast-feeding may be suggestive of
inborn errors of metabolism. Late onset hypocalcaemia should be considered in
the presence of top feeding with cow’s milk.
 Family history: History of consanguinity in parents, family history of seizures or
mental retardation and early fetal/neonatal deaths would be suggestive of inborn
errors of metabolism. History of seizures in either parent or sib(s) in the neonatal
period may suggest benign familial neonatal convulsions (BFNC).

6. Examination:
 Vital signs: Heart rate, respiration, blood pressure, capillary refill time and
temperature should be recorded in all infants.
 General examination: Gestation, birth weight, and weight for age should be
recorded as they may provide important clues to the etiology – for example,
seizures in a term ‘well baby’ may be due to subarachnoid hemorrhage while
seizures in a large for date baby may be secondary to hypoglycemia. The
neonate should also be examined for the presence of any obvious
malformations or dysmorphic features.

7.  CNS examination: Presence of a bulging anterior fontanel may be
suggestive of meningitis or intracranial hemorrhage. A detailed neurological
examination should include assessment of consciousness
(alert/drowsy/comatose), tone (hypotonia or hypertonia), and fundus
examination for chorioretinitis.
 Systemic examination: Presence of hepatosplenomegaly or an abnormal
urine odor may be suggestive of IEM. The skin should be examined for the
presence of any neuro-cutaneous markers. Presence of hypopigmented
macules or ash-leaf spot would be suggestive of tuberous sclerosis.

8. Investigations:
 These are done at
the time of
convulsions, as the
investigations done
will help in the
immediate
management.
Immediate
PCV
Acid- base
gas
analysis
Blood
glucose
Serum
electrolyte
s- sodium,
potassium
Serum
calcium

9.  This is done once
the baby has stopped
convulsing.
 This will help to
find out the cause
Early
CT scan
CBC
Blood
culture
Lumbar
puncture

10.  These are not always
necessary. This is
indicated when the
convulsions are
recurrent, etiology has
not been established by
routine investigations.
Late
Urine for
drug
screening
EEG
MRI
Arterial
blood gas
TORCH
Serum
magnesiu
m
Amino
acid
chromato
graphy

11. Electroencephalogram (EEG)
 A background abnormality in both
term and preterm neonates indicates a
high risk for neurological squeal.
 These changes include burst-
suppression pattern, low voltage
invariant pattern and electro-cerebral
inactivity.

13. Amplitude integrated EEG (aEEG)
 Seizure activity on aEEG is
characterized by a rapid rise in
both the lower and upper margins
of the trace.
 Some seizures that are focal or
relatively brief are, however,
missed by this technique.

14.  Screen for congenital infections: TORCH screen and VDRL should be
considered in the presence of hepatosplenomegaly, thrombocytopenia,
intrauterine growth restriction, small for gestational age, and presence of
chorioretinitis.
 Metabolic screen: This includes blood and urine ketones, urine reducing
substances, blood ammonia, anion gap, urine and plasma amino acidogram,
serum and CSF lactate/ pyruvate ratio.

15. Management:
Initial medical management:
TABC
Start Oxygen
IV
Collect blood sample
Brief history and clinical examination

16. Correction of hypoglycemia and hypocalcaemia:
 If GRBS shows hypoglycemia or if there is no facility to test blood sugar
immediately, 2 ml/kg of 10% dextrose should be given as a bolus injection
followed by a continuous infusion of 6-8 mg/kg/min.
 If hypoglycemia has been treated or excluded as a cause of convulsions, the
neonate should receive 2 ml/kg of 10% calcium gluconate IV over 10
minutes under strict cardiac monitoring.
 If serum calcium levels are suggestive of hypocalcaemia, the newborn
should receive calcium gluconate at 8 ml/kg/d for 3 days.
 If seizures continue despite correction of hypocalcaemia, 0.25 ml/kg of
50% magnesium sulfate should be given intramuscularly.

17. Anti-epileptic drug therapy (AED)
Phenobarbitone (the WHO guidelines on neonatal seizures recommend phenobarbitone as the
first-line agent for management of neonatal seizures)
 May be diluted to 10 mg/ml in 0.9 % sodium chloride.
 May be diluted 1:10 with water for injections.
 Loading dose: 20 mg/kg IV over 15–30 minutes.
Maintenance:
 Commence only if seizures continue after the loading doses. 3–4 mg/kg IV per day.
 Commence 12–24 hours after loading dose
 Daily dose (not required)
 (Controls seizures in 43–85 % of babies ·A second line drug is often required)
Side effects
include
respiratory
depression,
depressed level
of consciousness,
hypotension and
hypotonia

18. Phenytoin:
 Second line anticonvulsant for seizures refractory to
Phenobarbital.
 Loading dose: 15–20 mg/kg IV over 30–60 minutes.
 Maintenance: 5 mg/kg per day58 or 2 mg/kg every 8–12 hours.
 Administration (loading and maintenance)
 Dilute to 5 ml with 0.9% sodium chloride and precede and follow
injection with 0.9% sodium chloride flush to avoid contact with
glucose solution.
 Administer directly into large peripheral or central vein through
large bore catheter
Dose related adverse
events include
nystagmus (level 15–
25 mg/ml) and ataxia
and mental statues
changes (level
greater than 30
mg/ml)

19. Midazolam:
 Based on the available evidence, the WHO guidelines on
neonatal seizures recommend either midazolam or lidocaine
as the second-line AED in neonatal seizures.
 Second line anticonvulsant for seizures refractory to
Phenobarbital
 Loading dose: 0.15 mg/kg (150 micrograms/kg) IV over
five minutes · Maintenance IV infusion: 60–400
micrograms/kg/hour.
 Administration (loading and maintenance)
 Dilute in 0.9% sodium chloride or 5% glucose.
 Do not administer by rapid infusion as may cause
respiratory depression, severe hypotension and seizures.
May cause myoclonic
jerking, respiratory
depression and
hypotension when
used in conjunction
with narcotics

20. Lidocaine:
 It is usually administered as a bolus dose of 4
mg/kg IV followed by an infusion rate of 2
mg/kg/hr. It is tapered over several days.
AE include
arrhythmias,
hypotension, and
seizures. It should not
be administered with
phenytoin.

21. Paraldehyde:
 A dose of 0.1-0.2 ml/kg/dose may be
given IM or 0.3 ml/kg/dose mixed
with coconut oil in 3:1 may be used
by per rectal route.
 Additional doses may be used after
30 minutes and q 4-6 hourly.
AE include
pulmonary
hemorrhage,
pulmonary
edema,
hypotension, and
liver injury.

22. Pyridoxine (vitamin B6):
 Vitamin B6 is a required enzyme in the biosynthesis of dopamine and
serotonin.
 Used to treat inborn error of metabolism due to antiquitin deficiency
dehydrogenase deficiency.
 Consider pyridoxine dependency in any baby with severe seizures even if
there is a clear cause (e.g. birth asphyxia).
 Classic presentation is intractable seizures that appear within hours of birth
and are resistant to conventional AEDs
 Baby responds rapidly to IV pyridoxine ·
 May present with frequent multifocal and erratic or generalized myoclonic
jerks.

23.  May also present with tonic seizures, spasms, abnormal eye movements,
grimacing or irritability.
 Seizures may occur without ictal changes on the EEG.
 Maternal history may report sensation of sustained hammering lasting 15–
20 minutes by fetus in-utero.
 Used for diagnosis and treatment of pyridoxine dependent seizures.
 50–100 mg IV injection, over 20 minutes or IM
 If required may be repeated after 10 minutes up to a total maximum dose of
500 mg.
 If responsive then administer 50–100 mg orally, once per day.

24. Treatment for refractory seizures:
 If the seizures are refractory, 40mg/kg of initial dose of phenorbarbitone,
then phenytoin at the dose of 20mg/kg is administered. Then if the seizures
remain unresponsive, benzodiazepine (diazepam, lorazepam) or
paraldehyde is used. Simultaneous EEG should be performed to document
cessation of seizures activity.
 Magnesium sulphate at the dose of 0.2 ml/kg/dose of 50 % solution can be
used. Pyridoxine is also tried at the dose of 50-100 mg IV.
 If the convulsions are intractable and baby is in states convulsions,
clonazepam 50 µg/kg IV slowly for 2-3 min is given. Alternatively
clonazepam 100-200 µg/kg can be given IV over 30 sec. Benzodiazepam
can be repeated as and when needed. Midazolam 0.05-0.15 mg/kg/ dose is
effective when given IM.

25. Follow up of anticonvulsant therapy:
 All the medications which are used to control the seizures can be stopped.
The only maintenance dose of Phenobarbitone is continued. (indications for
stopping anticonvulsants are: normal examination findings, absence of
recurrent and nonepileptiform seizures.)
 The duration of therapy is guided by neurological status of the infant, cause
of the seizures and EEG findings. The infant is evaluated at 6-8 wks. If
there is no recurrence of seizures, CNS examination and EEG is normal, the
Phenobarbitone is stopped.
 When the Phenobarbitone is continued the child is evaluated at the age of 6
months.
 The infant is treated like the case of epilepsy if the seizures are recurrent or
if there are any evidence of neurological disabilities.

26. Prognosis:
 Neonatal seizures can cause both acute effects and long term sequelae.
Acute and long term adverse effects result from energy failure,
excitotoxicity, neuronal death, apoptosis and status epilepticus. These all
contribute to cognitive, motor and behavioral problems.
Normal outcome: 56%
 Neurological sequelae: 30-40 %
 Death: 15-25%
 Chronic seizure disorder: 15-20 %

27. Outcome depends on :
 Level of maturity
 Etiology
 Neurological examination
 EEG/ imaging studies
Good prognosis:
 Uncomplicated hypoglycemia
 Narcotic withdrawal
 SAH

28. Poor prognostic factors:
 Apgar score- less than 6 at 5 minutes
 5 minutes IPPV following birth
 Early onset of seizure
 Seizures lasting more than 30 minutes
 Hypotonia at 5 minutes following birth
 Uncontrolled seizures for 3 or more days
 Presence of tonic or myoclonic seizures.

29. References:
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2019;32:100768.
 2. Soul JS. Acute symptomatic seizures in term neonates: Etiologies and treatments. Semin Fetal
Neonatal Med 2018;23:183-90.
 3. Kang SK, Kadam SD. Neonatal Seizures: Impact on Neurodevelopmental Outcomes. Front Pediatr
2015;3:101.
 4. Kaushal S, Tamer Z, Opoku F, Forcelli PA. Anticonvulsant drug-induced cell death in the developing
white matter of the rodent brain. Epilepsia 2016;57:727-34.
 5.Tekgul H, Gauvreau K, Soul J, Murphy L, Robertson R, Stewart J, et al. The current etiologic profile
and neurodevelopmental outcome of seizures in term newborn infants. Pediatrics 2006;117:1270-80. 2.
 6. National Neonatal Perinatal Database. Report for the year 2002–03.
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 8.Care of the newborn. Singh M (ed), 9th edition, New delhi sagar publication : (2010)