This document discusses neonatal seizures. It begins by defining seizures and explaining their increased prevalence in the neonatal period due to birth factors and immature brain development. It describes different types of neonatal seizures and their clinical manifestations. Subtle seizures are easily missed without EEG correlation. The document lists various causes that must be investigated and explains that outcomes depend on the underlying cause and presence of clinical and electrographic seizures. It provides guidelines for seizure management including use of antiepileptic drugs and considerations for maintenance therapy. The document emphasizes that prognosis correlates with abnormal EEG findings and brain injury.

1. NEONATAL SEIZURES
NUR FARRA NAJWA
082015100035

2. LEARNING OBJECTIVES
At the end of seminar student should be able to
1. Understand what is neonatal seizures
2. Know type of neonatal seizures and it
mimickers
3. List the causes and investigation
4. Understand the outcome and prognosis of
neonatal seizures
5. The current guideline management for
neonatal seizures

3. INTRODUCTION
• Seizure
– Is a paroxysmal behavior caused by
hypersynchronous discharge of a group of
neurons.
• The neonatal period is the most frequent time
to have seizures.

4. Cont.
• Seizures = most common manifestation of
neurological dysfunction in the newborn.
• The increased susceptibility to seizures may be
explained by
– Birth factors (e.g. Hypoxia ischemia, birth trauma)
– Developmental factors (excitatory effect of
gamma-amino butyric acid (GABA) in immature
brain).

5. Cont.
• Neonates may also exhibit paroxysmal non-
epileptic events than can mimic seizures
• It is important to differentiate
JITTERINESS
• Stimulus sensitive
• Aborts with gentle limb flexion
BENIGN NEONATAL SLEEP
MYOCLONUS
• Only occurs in sleep
• Aborts with arousal
STARTLE DISEASE
(HYPEREKPLEXIA)
• Excessive startle, stimulus
sensitive
• Jerks and generalized muscle
rigidity

7. CLASSIFICATION OF NEONATAL
SEIZURES
1. Subtle
2. Clonic
3. Tonic
4. Myoclonic

8. CLINICAL SEIZURES EEG SEIZURES MANIFESTATION
SUBTLE Common Ocular phenomena
• Tonic horizontal deviation of eyes
common in term infants.
• Sustained eye opening with fixation
common in preterm infants.
• Blinking.
Oral-buccal-lingual movements
• Chewing common in preterm
infants.
• Lip smacking, cry-grimace.
Limb movements
• Pedaling, stepping, rotary arm
movements
Apnoeic spells
• Common in term infants

9. CLINICAL SEIZURES EEG SEIZURES MANIFESTATION
CLONIC
• Focal
• Multifocal
• Common
• Common
• Well localized clonic
jerking, infant usually
not unconscious
• Multifocal clonic
movements;
simultaneous, in
sequence or non-
ordered (non-
Jacksonian) migration

10. CLINICAL SEIZURES EEG SEIZURES MANIFESTATION
TONIC
• Focal
• Generalized
• Common
• Uncommon
Sustained posturing of a limb,
asymmetrical posturing of trunk or
neck
• Tonic extension of upper and
lower limbs (mimic decerebrate
posturing)
• Tonic flexion of upper limbs and
extension of lower limbs (mimic
decorticate posturing)
• Those with EEG correlates;
autonomic phenomena, e.g.
increased BP are prominent
features.

11. CLINICAL SEIZURES EEG SEIZURES MANIFESTATION
MYOCLONUS
• Focal, multifocal
• Generalized
• Uncommon
• Common
• Well localized, single or
multiple, migrating jerks
usually of limbs
• Single/several bilateral
synchronous jerks or
flexion movement more
in upper than lower
limbs.

12. Note:
• Subtle seizures
– Easily missed and requires correlation with EEG
• Focal clonic seizures
– May suggest a localized cerebral injury
– Eg. perinatal stroke
• Generalized tonic seizures
– are the commonest seizure type in preterm IVH

18. MANAGEMENT

19. Thorough history, physical examination and
neurophysiological assessment with amplitude
integrated EEG (aEEG)/ continuous video
electroencephalography (cEEG) is often required in
newborns at risk for seizures.
Abnormal initial EEG background may predict higher
seizure risk in newborns with HIE.
It is very important to delineate whether the abnormal
movements/ paroxysmal events are seizures.
Where applicable correlation with aEEG is desirable as
this avoids unnecessary and potential side effects with
antiepileptic drugs (AED).

20. Controversies regarding extent of treatment
(i.e. whether to stop all clinical or
electrographic seizures) exist.
It is desirable to eliminate electroclinical and
electrographic graphic seizures especially if
they:
1) Are prolonged –more than 2-3 minutes.
2) Are frequent– more than 2-3 per hour.
3) Disrupt ventilation and/or blood pressure
homeostasis

21. IN ACUTE SETTING
Administer antiepileptic drugs intravenously to
achieve rapid onset of action and predictable
blood levels in order to achieve serum levels in
the normal therapeutic range.
MAINTENANCE THERAPY
Usually not required if loading doses of
anticonvulsant drugs are able to control
seizures.

22. A prolonged duration of AED maintenance (6-12
weeks) following acute neonatal seizures may be
considered in the following circumstances:
1) Higher probability of seizure recurrence
(stroke and hemorrhage)
2) Abnormal neonatal neurological examination
upon discharge
3) Abnormal EEG background upon discharge
Routine maintenance AED is not recommended
as some AEDs (phenobarbitone and phenytoin)
have neuro-apoptotic properties

23. In neonate with normal
neurological examination
and/or EEG findings
Consider stopping AED if
seizures free >72 hrs
The drug should be
reconstituted in case of
seizures recurrences

24. OUTCOMES

25. OUTCOME FOLLOWING NEONATAL
SEIZURES
• Depends primarily on the underlying cause.
• The presence of both
– Clinical (except focal clonic) and
– Electrographic seizures
• Often indicates brain injury and coupled with
– Abnormal EEG background
• Are important determinants for adverse
outcome

27. INVESTIGATIONS

29. Neonatal Amplitude-integrated
EEG (aEEG)

30. POINTS TO CONSIDER
1. Continuity
2. Amplitude of lower margin (Normal > 5μV) &
upper margin (Normal>10μV)
3. Sleep-wake cycling
4. Seizures
http://www.jcnonweb.com/article.asp?issn=2249-
4847;year=2016;volume=5;issue=1;spage=18;epage=30;aulast=Gucuyener

32. GUIDELINE

36. 1.Sugar
2.B6
3.Phenobarbitone
• 20
• 10
• 10
4.Midazolam
5.Phenytoin or levetiracetam or topiramate

37. LEARNING OBJECTIVES
At the end of seminar student should be able to
1. Understand what is neonatal seizures
2. Know type of neonatal seizures and it
mimickers
3. List the causes and investigation
4. Understand the outcome and prognosis of
neonatal seizures
5. The current guideline management for
neonatal seizures

38. REFERENCES
• Paediatrics Protocol For Malaysian Hospital,
4th Edition, Kementerian Kesihatan Malaysia,
Chapter 21: Neonatal Seizures, Page: 127
• Nelson Textbook Of Pediatrics, 19th Edition,
Chapter 593.7 Neonatal Seizures Mohamad A.
Mikati And Abeer J. Hani, Page: 4096

39. THANK YOU