This document discusses neonatal seizures. It begins by defining seizures and describing the different types seen in neonates. The most common type is subtle seizures. Hypoxic ischemic encephalopathy is usually the most common cause, especially within the first 24 hours. Other common causes include intracranial hemorrhage and metabolic disorders. Phenobarbital is the first-line treatment, with phenytoin and benzodiazepines as second-line options. Seizures from subarachnoid hemorrhage or late-onset hypocalcemia typically carry a good prognosis, while those associated with hypoxic ischemic encephalopathy, cerebral malformations or meningitis usually have a poorer neurological outcome.
Presentation with extensive details of neonatal seizure. Covering its etiology, diagnosis and treatment . Neonatal seizure is one of the commonest clinical situation faced by any one working in a neonatal unit. Furthermore it is a favourite topic of many examiners in MD/DCH/DNB Pediatrics exams.
Neonatal seizures, dr amit vatkar, pediatric neurologistDr Amit Vatkar
In the presentaion i will give you a brief idea to apprach, diagnosis and management of neonatal seizures.
The most prominent feature of neurologic dysfunction in the neonatal period is the occurrence of seizures. Determining the underlying etiology for neonatal seizures is critical. Etiology determines prognosis and outcome and guides therapeutic strategies.
Neonatal seizures, dr amit vatkar, pediatric neurologist
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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2. OBJECTIVES
To familiarize the varied presentations of neonatal
seizures.
To distinguish non seizure states from seizures.
To recognize the unique etiology of neonatal
seizures.
To familiarize the algorithm of management specific
to neonatal seizures.
To be able to decide the duration of antiepileptic
therapy and followup.
3. OVERVIEW
DEFINITION OF SEIZURE
TYPES OF NEONATAL SEIZURES
CAUSES OF NEONATAL SEIZURES
SEIZURE MIMICS
APPROACH TO NEONATAL SEIZURES
DURATION OF ANTICONVULSANT THERAPY
GUIDELINES
PROGNOSIS
4. SEIZURE is defined clinically as paroxysmal alteration in
neurologic function ie., motor, behaviour and/or
autonomic function.
It includes
1. Epileptic seizures - phenomenon associated with
corresponding EEG seizure activity.
Eg: clonic seizures.
2. Nonepileptic seizures - clinical seizures without
corresponding EEG correlate.
Eg: subtle and generalised tonic seizures.
3. EEG seizures - abnormal EEG activity with no clinical
correlation.
5. EPIDEMIOLOGY- INDIA(NNPD;2002-03)
Incidence : 10.3 per 1000 live births
The incidence is high in PRETERM
neonates (2 fold), VLBW( 4 fold) compared
to TERM neonates.
Term neonates- 8.4
Preterm neonates-20.8
VLBW-36.1
6. Why seizures are common in neonatal period ?
Seizures are common in neonatal period than any other
time in life due to decreased seizure threshold.
Transient overdevelopment of excitatory system than
inhibitory system.
7. Why generalised seizures are rare in neonates
?
Neonatal brain has reduced connectivity due to
incomplete myelination, so electrical discharges
spread incompletely.
8. TYPES OF NEONATAL SEIZURES
Four types of neonatal seizures
1. Subtle seizures
2. Clonic seizures
3. Tonic seizures
4. Myoclonic seizures
9. SUBTLE SEIZURES
Most common form(>50%)
It includes
a) Ocular - tonic horizontal deviation of eyes or sustained
eye opening with ocular fixation or cycled fluttering.
b) Oral facial lingual movements - chewing, tongue
thrusting, lip smacking etc.
c) Limb movements - cycling, paddling, boxing etc.
d) Autonomic phenomena-tachycardia or bradycardia.
e) Apnea may be a rare manifestation of seizure.
10. CLONIC SEIZURES
Rhythmic movements of muscle groups.
Have both fast and slow movements with frequency of 1-
3 jerks per second.
Commonly associated with EEG changes.
May be unifocal or multifocal.
Focal clonic has good prognosis.
11. TONIC SEIZURES
Pattern is sustained posture of limbs or
asymmetrical truncal postures.
cause: diffuse neurological injury or IVH in preterm
or postasphyxial.
Usually no EEG changes.
Prognosis is poor except for postasphyxial cases.
12. MYOCLONIC SEIZURES
Non rhythmic lightning fast contraction.
Seen in diffuse brain damage as in perinatal
asphyxia, inborn errors of metabolism, cerebral
dysgenesis.
Worst prognosis in terms of neurodevelopmental
outcome and seizure recurrence.
16. ETIOLOGY
5.MISCELLANEOUS
Passive drug withdrawl
Accidental injection of local anesthetic
into fetal scalp.
Neonatal epileptic syndromes
Benign familial neonatal convulsions
Benign idiopathic neonatal convulsions
(fifth day fits)
Early myoclonic encephalopathy
Early infantile epileptic encephalopathy
(Ohtahara’ssyndrome)
Malignant migrating partial seizures in
infancy( coppola syndrome)
17. NEONATAL SEIZURES – TIME OF ONSET
Time of
onset
Etiology
< 24 hrs HIE, severe birth trauma, hypoglycemia, hypocalcemia,
drug withdrawl, congenital CNS anomalies,
intracranial hemorrhage
1-3 days All above , subarachnoid hemorrhage, IEM, benign
familial neonatal seizures
> 3 days sepsis ,meningitis, progressive hydrocephalus,
epileptic syndromes, herpes encephalitis, IEM
18. SPECIFIC ETIOLOGIES
Hypoxic Ischemic Encephalopathy
Most common cause of neonatal seizures usually
in the first 24 hours.
In perinatal asphyxia, seizures occur in context of
history of difficulty during labour , delivery with fetal
HR alterations, low Apgar scores.
19. Intra cranial hemorrhages
Sub arachnoid hemorrhages cause seizures
usually on second day and have a very good
outcome.
In preterm infant, seizures occur with extension
of germinal matrix hemorrhage to parenchyma
typically after 3 days of life and it is not
assosciated with good outcome.
20. Acute metabolic disorders
Hypoglycemia
Hypocalcemia : Whole blood ionized calcium is the best
measure.
ionised calcium < 1.1 mmol/lit in > 1500gm.
ionised calcium < 1 mmol/lit in < 1500gm.
Hypomagnesemia: Levels < 1.4mg/dl (0.6 mmol/lit ) are
considered low.
Hypo/Hypernatremia
22. SEIZURE MIMICS
1. Jitteriness – suppress with passive flexion,
increases with stimulation, not associated with
autonomic accompaniments and eye movements.
2.Epileptic apnea – associated with tachycardia.
3.Benign neonatal sleep myoclonus - occur as
synchronus myoclonic jerks during non REM sleep
disappear when baby is awake, EEG is normal and
spontaneously resolve by 2 months of age.
23. Clinical
character
seizures jitteriness
Increases with
stimulation
rare common
Suppress with
passive flexion
absent present
Autonomic
phenomena
present absent
Eye or facial
movements
present absent
Rate of
movement
Clonic seizures show
rapid alteration of fast
and slow phase of
movements
Rate of movement
is identical in
either direction.
EEG
abnormalities
Yes No
25. HISTORY
Seizure history – regarding type of seizure , associated
movements , day of onset.
Antenatal history - intrauterine infection , maternal
diabetes , narcotic addiction.
Perinatal history - H/o fetal distress, instrumental
delivery, need for resuscitation in labour room, apgar
scores .
26. Feeding history – appearance of lethargy, poor activity
and vomiting after initiation of breast feeding may be
suggestive of IEM.
Family history – H/o consanguinity in parents , family
h/o seizures or MR , early fetal or neonatal deaths would
be suggestive of IEM.
H/o seizures in either parent or sibling in neonatal period
may be suggestive of benign familial neonatal
convulsion.
27. EXAMINATION
Vitals – HR, RR, CRT, Temp, BP.
General examination – gestation , birth wt and wt for
age
- Seizures in term well baby may be due to SAH.
- Seizures in large for date babies may be due to
hypoglycemia.
28. CNS examination – presence of bulging AF may be
suggestive of meningitis or ICH
- consciousness (alert /drowsy/comatose).
- tone (hypo/hyper).
- fundus examination for chorioretinitis.
Systemic examination – presence of
hepatosplenomegaly or abnormal urine odour may
be suggestive of IEM
- skin should be examined for neurocutaneous
markers .
30. Additional
Hematocrit (if plethoric and/or at risk for
polycythemia)
Serum bilirubin (if icteric)
Serum magnesium
Arterial blood gas and anion gap (lethargy,
vomiting, family history, etc.)
Imaging: CT and/or MRI (if no etiology found
after essential investigations)
TORCH screen for congenital infections
Work-up for inborn errors of metabolism
31. NSG - excellent tool for detection of IVH and
parenchymal hemorrhage.
CT - diagnostic in SAH and developmental
malformations.
MRI - diagnostic in cerebral dysgenesis, lissencephaly
and other neuronal migration disorders.
EEG - diagnostic and prognostic role in seizures and
should be done in all neonates who need anticonvulsant
treatment.
33. Neonate with seizures
•Identify and characterize the seizure
• Secure airway and optimize breathing, circulation, and temperature
• Secure IV access and take samples for baseline investigations
•If hypoglycemic : administer 2 ml/kg of 10% dextrose as
bolus followed by a continuous infusion of 6-8 mg/kg/min
• If serum calcium is abnormal, 2 ml/kg of calcium gluconate
(10%) should be given IV under cardiac monitoring
Seizures persist
34. Administer phenobarbitone 20mg/kg IV stat
over 20 minutes
Repeat phenobarbitone in 10 mg/kg/dose
aliquots until 40 mg/kg dose is reached
Seizures
continue
Seizures continue
Administer phenytoin 20 mg/kg IV slowly
over 20 minutes under cardiac monitoring
Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated
Midazolam: 0.15 mg/kg IV bolus followed by infusion of 1-7 mcg/kg/min
Clonazepam 0.1mg/kg;Consider ventilation.
Seizures continue
Seizures continue
35. Second line drugs like
Lidocaine[4mg/kg f/b 2mg/kg/hr]
Paraldehyde[0.1-0.2ml/kg/dose IM]
sodium valproate[20-25mg/kg f/b 5-10mg/kg/12h]
Topiramate(20mg/kg/day)
Levetiracetam(10-30mg/kg/day)
Vigabatrin(50mg/kg/day) Pyridoxine(100mgIVtestdose)
exchange transfusion[IEMs,drug toxicity,bilirubin encephalopathy]
Wean AEDs slowly to maintenance
phenobarbitone
Seizures controlled
36. MAINTENANCE DOSE
Phenobarbitone or phenytoin after
loading dose maintenance dose 3-5
mg/kg/day in two divided doses.
Wean slowly in a way, taper the last
given anti convulsant first and first
given phenobarbitone in last.
38. Newborn on anticonvulsant therapy
Stop
phenobarbitone
prior to discharge
Evaluate EEG
Normal
Normal examination
Taper drugs over
2 weeks
Abnormal EEG
Continue drug;
reassess at 3
Normal EEG
Taper drugs over 2
weeks
Wean all antiepileptic drugs except phenobarbitone once seizure
controlled
Perform neurological examination prior to discharge
Abnormal
Continue phenobarbitone for 1 month
Repeat neurological examination at 1 month
Abnormal examination
39. PROGNOSIS
Focal clonic seizures carry the best prognosis.
Myoclonic seizures carry the worst prognosis in
terms of neurodevelopmental outcome and seizure
recurrence.
Seizures due to SAH and late onset hypocalcemia
carry best prognosis in terms of long term
neurodevelopmental outcome.
Seizures related to hypoglycemia,cerebral
malformations and meningitis have adverse
outcome.
41. SUMMARY
Seizures are common in neonatal period than any
other period of life.
Subtle seizures are the most common type of
neonatal seizures.
Hypoxic ischemic encephalopathy is the most
common cause of neonatal seizures.
Phenobarbitone is the drug of choice for neonatal
seizures.
Focal clonic seizures and seizures due to
subarachnoid hemorrhage and late onset
hypocalcemia carries best prognosis.
42. REFERENCES
AIIMS NICU PROTOCOL -2014
MANUAL OF NEONATAL CARE - CLOHERTY
NELSON TEXTBOOK OF PEDIATRICS
CARE OF THE NEWBORN – MEHARBAN SINGH
IAP TEXT BOOK OF PEDIATRICS