Neonatal seizures and Hypoglycemia in infants and childrens.

1. Dr. Nighat Seema

2. LEARNING OBJECTIVES
 Define neonatal seizures
 Discuss the clinical types of neonatal seizures
 Discuss the causes of neonatal seizures
 Discuss the emergency management of neonatal seizures.
 Discuss the investigations for neonatal seizures
 Define neonatal hypoglycemia
 Discuss etiology of neonatal hypoglycemia
 Discuss the diagnosis and management of neonatal
hypoglycemia .
 Define neonatal hypocalcemia
 Discuss etiology of neonatal hypocalcemia
 Discuss the diagnosis and management of neonatal
hypocalcem1a

4. DEFINITION
 A seizure is defined as a paroxysmal alteration in neurologic
function (i.e., behavioral, motor, or autonomic function, or all
three).
 Seizures may be early onset (0-3 days of age) or late onset (after 3
days of age).

6. INCIDENCE
 The incidence ranges from 1.5-14 in 1000 live birth.
 In 10 % of cases no cause is found.

7. TYPES OF SEIZURES IN NEONATES
 Due to incomplete glial proliferation, neuronal migration,
establishment of axonal and dendritic contacts, and myelin deposition
in the neonatal brain, seizures in the neonates are different form those
seen in older children.
 There are no tonic-clonic seizures in neonates.

9. CLINICAL TYPES OF SEIZURES
1. Subtle seizures:
• Constitute 50 % seizures in neonates and are more common in
preterm than in full term infant . They consist of
• tonic horizontal deviation of the eyes with or without jerking
• eyelid blinking
• sucking ,smacking, or drooling movements
• swimming, rowing or pedaling movements
• apneic spells.

10. 2. Clonic seizures:
 These are more common in full-term than in preterm infants. which
are rhythmic jerking movements that may involve the muscles of
the face, tongue, arms, legs, or other regions
3. Tonic seizures:
 These occur primarily in premature infants. which are stiffening or
tightening or muscle groups; the head or eyes may turn to one
side, or the baby may bend or stretch one or more arms or legs
4. Myoclonic seizures:
 These are seen in both full-term and preterm infants. which are
quick, single jerks involving one arm or leg or the whole body

11.  It is important to distinguish jitteriness from seizures. In
jitteriness, abnormal eye movements do not accompany and
movements cease on application of passive flexion..

12. ETIOLOGY
 Perinatal asphyxia, hypoxic ischemic encephalopathy.
 Intracranial hemorrhage.
 Metabolic abnormalities.( Hypoglycemia, Hyponatremia ,
hypernatremia. Hypocalcaemia . Hypomagnesemia.)
 Infections (meningitis, sepsis, TORCH).
 Congenital malformations.
 Kernicterus.
 Tetanus neonatorum.
 Drug withdrawal

14. INVESTIGATION
 Blood glucose,
 Calcium,
 Electrolytes,
 Magnesium,
 Phosphate
 Urea,creatinine
 Complete blood count
 Blood culture
 CSF examination
 Cranial ultrasound or CT scan
 EEG

15. SPECIFIC TREATMENT
 If hypoglycemia, give 10% glucose
 If hypocalcemia give 10% calcium gluconate
 If seizures are still not controlled then anticonvulsants are used
 Anticonvulsants drugs (1st line )
a) Diazepam
b) Phenobarbitone
c) Phenytoin
 Anticonvulsants (2nd line )
a) Levitiracetam
b) Topiramate

17. PROGNOSIS
 The overall prognosis is
 Complete recovery in 50%
 Neurological sequalae in 30%
 Chronic seizure disorder in 15-20%
 Death in 15%
 Varies with the cause
 Hypocalcemic seizures –excellent prognosis
 Congenital malformation-bad prognosis

20. INTRODUCTION
 Common metabolic problem
 Blood glucose in newborn are generally lower than older children
& adult
 Fetal glucose level maintained at 2/3 of maternal B. glucose by
transplacental route

22. DEFINITION
 Hypoglycemia in the first few days after birth is defined as blood
glucose < 55mg/dl.
 Incidence of symptomatic hypoglycemia varies between
1.3 -3/1000 live birth

23. NEONATES AT HIGH RISK OF
HYPOGLYCEMIA

25. ETIOLOGY
 Intra-uterine growth retardation
 Prematurity
 Infant of diabetic mother
 Hypothermia
 Sepsis
 Perinatal asphyxia

26. CLINICAL FEATURES
 Jitteriness,
 Irritability
 Lethargy,
 Seizures,
 Apnea,
 Grunting

28. DIAGNOSIS
 Blood glucose level
 A complete blood count with differential count

29. SCREENING OF AT RISK INFANTS
 Infants at risk for hypoglycemia should be screened by
measuring blood sugar at ages 1, 2, 4, 6, 9 and 12h .

30. MANAGEMENT
 In hypoglycemic infants 2 ml-4 ml/kg of 10% dextrose bolus
should be given followed by an infusion of 10% dextrose.
In case of persistent hypoglycemia, other medicines along with
glucose infusion are given.
 Hydrocortisone
 Prednisolone
 Glucagon
 Growth hormone
 Diazoxide

31. PROGNOSIS
 The prognosis of hypoglycemia is good if therapy is prompt

33. DEFINITION
 Defined as total calcium level <7mg/dl for term neonates and
<8mg/dl for preterm neonates .

34. ETIOLOGY
 Early neonatal hypocalcemia (48-72 hours)
 Prematurity
 Birth asphyxia
 Infant of diabetic mother
 IUGR
 Poor intake

35. ETIOLOGY
 Late neonatal hypocalcemia
 Exogenous phosphate load
 Phosphate-rich formulas / cow’s milk
 Magnesium deficiency
 Transient hypoparathyroidism of newborn

37. NEONATAL HYPOCALCEMIA: PRESENTATION
 Often asymptomatic
 focal clonic seizures
 Jitteriness,
 twitches,
 limb-jerking
 laryngospasm
 Non-specific signs:
 Irritability, apnea, tachycardia, tachypnea, cyanosis,
© American Society for Bone and Mineral Research
Contributed by Thomas O. Carpenter

38. INVESTIGATIONS
 Serum calcium level
 Serum phosphate
 Serum magnesium
 alkaline phosphate

39. TREATMENT OF HYPOCALCAEMIA
Symptomatic hypocalcaemia
 IV Calcium should only be given with close cardiac
monitoring in a dose of 1 ml/kg of 10 % calcium
gluconate
 Mix with NaCl or 5 % D/W (not bicarbonate/lactate
containing solutions)

41. TREATMENT OF HYPOCALCAEMIA
Symptomatic hypocalcaemia
Early neonatal hypocalcaemia
 Neonates: Ca gluconate:10 mg/kg (1 ml/kg of 10% solution) Slowly IV +
monitoring ECG
 Occasionally associated transient hypomagnesaemia
 Treat prior to Ca administration
 Start oral Calcium as soon as possible
 Early neonatal hypocalcaemia normalizes in 2-3 days
 Oral Ca usually necessary for 1 week

42. TREATMENT OF HYPOCALCAEMIA
Symptomatic hypocalcaemia
Late neonatal hypocalcaemia
 Decrease phosphate intake
 Give calcium containing phosphate binder
 Oral calcium (gluconate) supplementation