This document discusses neonatal seizures, beginning with an introduction stating they are not uncommon and often the first sign of neurological disorders. It then covers the pathophysiology, incidence, patterns, etiology, diagnosis, management, treatment including anticonvulsants, and prognosis of neonatal seizures over multiple pages with headings and subheadings. Key points include seizures occurring in 1 in 200 healthy newborns, various possible causes like hypoglycemia or infections, treatments involving anticonvulsants like phenobarbital or midazolam, and prognosis varying from normal outcome to neurological sequelae depending on factors like etiology and examination findings.

1. Neonatal Seizures
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. INTRODUCTION
• Not uncommon
•Always due to some underlying cause
•25% cases cause – unknown
•Often first sign of neurological disorders
•Powerful predictors of long term
cognitive and developmental impairement

3. Pathophysiology
1.Large group of neurons undergo
excessive, synchronized depolarization which
results from –
a) Increase in excitatory
neurotransmitters (glutamate)
b) Decrease in inhibitory
neurotransmitters (gamma amino
butyric acid- GABA

4. PROBABLE MECHANISMS
c. Disruption of ATP – dependent resting
membrane potentials - Failure of Na - K
pump – flow of sodium into the neuron
& potassium out of neuron
d. Membrane alteration - Increased Na
permeability

5. Incidence
• 1 in 200 healthy newborns
• 0.5 -0.8% Term babies
• 6-12% <1.5 kg (1 in 4 premature and
LBW
• Many seizures are very subtle – go
undetected

6. SEIZURE PATTERN
1. Subtle seizure: 50%of seizures
- Tonic horizontal deviation of eyes,
staring look,Repetitive blinking /
fluttering of eyelids
- Oro- buccal movements-chewing,
lip smacking, sucking, yawning
- Tonic posturing of a limb
- Apnea
- Swimming/ bycycling movements

7. SEIZURE PATTERN
2.Clonic - Focal / Multifocal –
twitching migrate haphazardly
from one limb to another,
occur due to HIE & birth
trauma
3.Generalised seizure - rare

8. SEIZURE PATTERN
4. Focal clonic –
Localized & often assoc with loss of
consciousness
They are signs of bilateral c’bral disorder
Common in metabolic disorder, birth
trauma and c’bral infarction

9. SEIZURE PATTERN
5. Tonic seizure –
- Stiffening similar to decerebrate
posture but with eye signs and
heavy breathing
- Often associated with apnea
- Seen in IVH, preterm and
Kernicterus

10. SEIZURE PATTERN
6.Myoclonic seizures
• Rare in newborns
• Single/multiple flexion
movements, slow and jerky
• Seen in developmental defects and
anencephaly

11. Features Jitteriness Seizure
Stimulus ++ _
sensitive
Cessation Passive flexion -
Gentle grasp
Rhythmicity Rhythmic Fast & slow
oscillation components

12. Features Jitterine Seizure
ss
Frequency of jerks 5-6 / sec 2-3 / sec
Abnormal gaze-Eye Nil Present
movement
Autonomic disturbance Nil Increase HR, BP)
EEG Normal Abnormal

13. ETIOLOGY
A. Perinatal causes
1. Neonatal encephalopathy - 20-
40% of seizures
2. Intracranial hemorrhages- CNS
trauma, SAH, PVH,

14. B. METABOLIC CAUSES
• Hypoglycemia
• Hypocalcemia – most common metabolic
cause for NNS
• Hypomagnesemia
• Hypo / Hypernatremia
• Pyridoxine dependency
• IEM - Disorders of amino acid
metabolism

15. C. Infections
• Intracranial
- Meningitis
- encephalitis – herpes, coxachie, echo, CMV,
- Toxoplasmosis
Extracranial
– septicemia
- Tetanus
- Severe rep distress

16. D. Developmental defects
– Cerebral Dysgenesis
– Hydrocephalus
– Microcephaly
– Neuronal migration defects-
Lissencephaly,pachygyria,schizenceph
aly

17. Others
E. Drugs- prolonged maternal
administration
- Vit B6-pyridoxin dependancy
- Narcotic withdrawal
- Theophylline
F. Polycythemia
G. Focal infarcts

18. Others
H .Hypertensive encephalopathy
I . Benign familial epilepsy – does not
continue after neonatal period
J .Unknown(Idiopathic : 3-25%

19. Diagnosis – time of onset
• 1st day – birth asphyxia (HIE)
- C’bral trauma
- Pyridoxin dependancy
- Narcotic withdrawal
- IEM

20. Diagnosis – time of onset
• 1-3 days –
- ICH
- Hhypocalcemia
- Hypoglycemia
- Hypo & hypernatremia
- Pyridoxin deficiency
- Cong C’bral malformations
- Narcotic withdrawal

21. Diagnosis – time of onset
• 4-7 days –
- Meningitis
- Encephalitis
- Hypomagnesemia
- TORCH infection
- Developmental malformations
- Kernicterus
- IEM
- Pyridoxin dependancy
- Tetanus

22. Refractory seizures
• IEM –
• Developmental defects of CNS
• Narcotic withdrawal
• Pyridoxin dependancy
• Kernicterus
• Benign familial seizures

23. Investigations
• CBC
• Blood – glucose, calcium, electrolytes, Mg,
bilirubin, ABG
• CSF analysis
• Blood C/S , urine C/S
• Cranial USG

24. Second line investigations
• TORCH screening
• IEM screening – urine organic acids
• - S. amino acid assay
• Imaging – CT scan
- MRI
- EEG brain

25. Management
• Collect all samples
• IV line
• Thermoneutral environment
• Glucose 10% - 2-4ml/kg as bolus followed by
10% glucose as drip @ 8mg/kg/min
• IV calcium – gluconate 2ml/kg

26. ANTICONVULSANTS
Phenobarbitone
15 - 20mg / kg IV loading dose
3.5 - 5mg / kg / day maintenance dose
Phenytoin
15 - 20 mg / kg IV at 1mg / kg / min
4 - 8 mg / kg day maintenance dose
Midazolam 0.02 - 0.4 mg/kg IM
0.02 - 0.1mg/kg IV
0.06 - 0.4mg/kg/hr
Others Lorazepam, diazepam, Paraldehyde

27. ANTICONVULSANTS
• Phenobarbitone
↓↓
• Phenytoin
↓↓
• Lorazepam, midazolam drip – 48 hrs
↓↓

28. ANTICONVULSANTS
↓↓
• Barbiturate coma – pentobarbital& thiopental
on ventilator – try to wean every 24 hrs
↓↓
• GA with isoflurane or halothane +
neuromuscular blockade (muscle paralysis)

29. TREATMENT
1. Optimise ventilation
Maintain CO, BP, Serum electrolytes & pH
2. Treat underlying diseases- Metabolic abnor
malities,meningitis,Narcotic withdrawal
3. Pyridoxine dependency- 50mg IV, repeat
every 10 min till control- maintenance dose –
5mg/kg PO daily
6. Hyperbilirubinemia –phototherapy,
exchange transfusion

30. Benign familial neonatal seizure
• Typically occur in first 48- 72 hrs of life
• Disappear by age 2-6 months
• A family history seizures is usual
• Development - normal

31. Benign idiopathic NNS
• Typically Presents at day 5 of life
• Also called 5th day fits
• Multifocal in type
• No cause detected

32. FOLLOW UP -
ANTICONVULSANTS
1. Stop all others except maintenance PB
2. Maintenance PB : 2wks - 2months
3. Risk of recurrence
Little: transient metabolic abnormalities
30-50% : HIE
High : Cortex malformations

33. PROGNOSIS
Normal Outcome: 56%
Neurological sequelae: 30 - 40%
Death : 15-25%
Chronic seizure disorder: 15-20%
Outcome depends on
1. Level of maturity
2. Etiology
3. Neurological examination
4. EEG / Imaging studies

34. GOOD PROGNOSIS
• Uncomplicated hypoglycemia
• Narcotic withdrawal
• SAH

35. POOR PROGNOSIS
• Low APGAR score ≤ 6 at 5min
• Onset o seizures within 24 hrs of life
• Presence of myoclonic attacks
• Abnormal EEG
• 3 or more days of uncontrolled seizures

36. Thank you
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Medical Post [ www.themedicalpost.net ]