Dept of Pediatrics
S V medical college
To familiarize the varied presentations of neonatal
To distinguish non seizure states from seizures.
To recognize the unique etiology of neonatal
To familiarize the algorithm of management specific
to neonatal seizures.
To be able to decide the duration of antiepileptic
therapy and followup.
DEFINITION OF SEIZURE
TYPES OF NEONATAL SEIZURES
CAUSES OF NEONATAL SEIZURES
APPROACH TO NEONATAL SEIZURES
DURATION OF ANTICONVULSANT THERAPY
SEIZURE is defined clinically as paroxysmal alteration in
neurologic function ie., motor, behaviour and/or
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
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
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
Why generalised seizures are rare in neonates
Neonatal brain has reduced connectivity due to
incomplete myelination, so electrical discharges
TYPES OF NEONATAL SEIZURES
Four types of neonatal seizures
1. Subtle seizures
2. Clonic seizures
3. Tonic seizures
4. Myoclonic seizures
Most common form(>50%)
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.
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.
Pattern is sustained posture of limbs or
asymmetrical truncal postures.
cause: diffuse neurological injury or IVH in preterm
Usually no EEG changes.
Prognosis is poor except for postasphyxial cases.
Non rhythmic lightning fast contraction.
Seen in diffuse brain damage as in perinatal
asphyxia, inborn errors of metabolism, cerebral
Worst prognosis in terms of neurodevelopmental
outcome and seizure recurrence.
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
Malignant migrating partial seizures in
infancy( coppola syndrome)
NEONATAL SEIZURES – TIME OF ONSET
< 24 hrs HIE, severe birth trauma, hypoglycemia, hypocalcemia,
drug withdrawl, congenital CNS anomalies,
1-3 days All above , subarachnoid hemorrhage, IEM, benign
familial neonatal seizures
> 3 days sepsis ,meningitis, progressive hydrocephalus,
epileptic syndromes, herpes encephalitis, IEM
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.
Intra cranial hemorrhages
Sub arachnoid hemorrhages cause seizures
usually on second day and have a very good
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.
Acute metabolic disorders
Hypocalcemia : Whole blood ionized calcium is the best
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
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.
Eye or facial
Clonic seizures show
rapid alteration of fast
and slow phase of
Rate of movement
is identical in
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
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
Vitals – HR, RR, CRT, Temp, BP.
General examination – gestation , birth wt and wt for
- Seizures in term well baby may be due to SAH.
- Seizures in large for date babies may be due to
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
Hematocrit (if plethoric and/or at risk for
Serum bilirubin (if icteric)
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
NSG - excellent tool for detection of IVH and
CT - diagnostic in SAH and developmental
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
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
Administer phenobarbitone 20mg/kg IV stat
over 20 minutes
Repeat phenobarbitone in 10 mg/kg/dose
aliquots until 40 mg/kg dose is reached
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.
Second line drugs like
Lidocaine[4mg/kg f/b 2mg/kg/hr]
sodium valproate[20-25mg/kg f/b 5-10mg/kg/12h]
exchange transfusion[IEMs,drug toxicity,bilirubin encephalopathy]
Wean AEDs slowly to maintenance
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.
Newborn on anticonvulsant therapy
prior to discharge
Taper drugs over
reassess at 3
Taper drugs over 2
Wean all antiepileptic drugs except phenobarbitone once seizure
Perform neurological examination prior to discharge
Continue phenobarbitone for 1 month
Repeat neurological examination at 1 month
Focal clonic seizures carry the best prognosis.
Myoclonic seizures carry the worst prognosis in
terms of neurodevelopmental outcome and seizure
Seizures due to SAH and late onset hypocalcemia
carry best prognosis in terms of long term
Seizures related to hypoglycemia,cerebral
malformations and meningitis have adverse
Seizures are common in neonatal period than any
other period of life.
Subtle seizures are the most common type of
Hypoxic ischemic encephalopathy is the most
common cause of neonatal seizures.
Phenobarbitone is the drug of choice for neonatal
Focal clonic seizures and seizures due to
subarachnoid hemorrhage and late onset
hypocalcemia carries best prognosis.
AIIMS NICU PROTOCOL -2014
MANUAL OF NEONATAL CARE - CLOHERTY
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