Management of Neonatal Seizures

 

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Types of Seizures History, Examination, and Investigation Indication for Treatment Usual Sequence of Therapy
EEG Maintenance Therapy Duration of Therapy References

The incidence of neonatal seizures in term infants is 0.7-2.8 per 1000 live births and is higher in the preterm population 1-4. In term infants hypoxic-ischemic encephalopathy is the most common cause, but other causes include intracranial haemorrhage, infection, metabolic abnormalities, CNS malformations and drug withdrawal.

Link to Seizure Record Chart

Types of Seizures

The clinical manifestations of neonatal seizures differ from those in older children. Five major varieties are described:

Jitteriness is not a seizure but is frequently confused with one and may be a sign of cerebral irritation.

History, Examination, and Investigation

Indication for Treatment

In general if seizure duration >3 min or frequency or >3 per hour treatment is required.

Usual Sequence of Therapy

1

Phenobarbitone 20 mg/kg loading dose (slow IV infusion over 30 mins)
  • If the initial 20 mg/kg dose is ineffective, additional doses of 5-10 mg/Kg can be administered until either seizures have ceased or a total dose of 40 mg/Kg has been given. 5

2

Phenytoin 20 mg/kg (slow IV infusion over 30 mins, i.e < 1 mg/kg/min)
  • Cardiac rate and rhythm should be monitored during the infusion.

3

Paraldehyde 200-400 mg/kg IV

  • Infuse over 2 hours in a 5% solution made up in 5% dextrose 6.

OR

Clonazepam 100-200 micrograms/kg (intravenously over 30 seconds)

  • and if control not achieved then Clonazepam intravenous infusion 10-30 micrograms/kg/hour.

OR

Midazolam 0.05 to 0.15mg/kg as a slow push over 5 minutes

  • can be repeated 2-4 hourly as required or given as a continuous infusion (10-60micrograms/kg/hour)

EEG

Maintenance Therapy

Duration of Therapy

References

1 Curtis PD, Matthews TG, Clarke TA, et al. Neonatal seizures: the Dublin Collaborative study. Arch Dis Child 1988;63:1065-8.
2 Lanska MJ, Lanska RJ, Baumann, RJ, Kryscio RJ. A population based study of neonatal seizures in Fayette County, Kentucky. Neurology 1995;45:724-32.
3 Lien JM, Towers CV, Quilligan EJ et al. Term early-onset neonatal seizures: obstetric characteristics, etiologic classifications, and perinatal care. Obstet Gynecol 1995;85:163-9.
4 Scher MS, Aso K, Beggarly ME, et al. Electrographic seizures in preterm and full-term neonates: clinical correlates, associated brain lesions, and risk for neurologic sequelae. Pediatr 1993;91:128-34.
5 Gilman JT, Gal P, Duchowny MS, Weaver RL, Ransom JL. Rapid sequential phenobarbital treatment of neonatal seizures. Pediatr 1989;83:674-8.
6 Koren G, Butt W; Rajchgot P, et al. Intravenous paraldehyde for seizure control in newborn infants. Neurology 1986;36:108-11
7 Evans D, Levene M. Neonatal Seizures. Arch Dis Child. 1998;78:F70-75
8 Hellstrom Westas L, Blennow G, Lindroth M, Rosen I, Svenningsen NW. Low risk of seizure recurrence after early withdrawal of antiepileptic treatment in the neonatal period. Arch Dis Child 1995;72: F97-101