Neonatal Seizures

Purpose

The purpose of this session is to introduce the knowledge, skills, and competencies required to correctly identify, diagnose, classify, and treat neonatal seizures.

Learning Objectives
1. Define seizures and differentiate between epileptic and non-epileptic seizures. 2. Know the incidence of neonatal seizures. 3. Describe the four types of seizures and their clinical pictures. 4. Identify benign movements that are not seizures.

Learning Objectives (cont)

5. List the causes of neonatal seizures, both common and less common etiologies. 6. Diagnose neonatal seizures. 7. Treat neonatal seizures. 8. Inform parents of the neonates prognosis.
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Definition of Seizure
Seizures are transient disturbances in brain function manifesting as episodic impairments in consciousness in association with abnormal motor or automatic activity.

Epileptic and Non-Epileptic Seizures

Epileptic seizures originate from the cortical neurons and are associated with EEG changes. Non-epileptic seizures are initiated in the subcortical area and are not usually associated with any EEG changes. - provoked by stimuli and ameliorated by restraint and body repositioning.
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Incidence of Neonatal Seizures

The overall incidence is 0.5% of all term and preterm neonates. The incidence is higher in preterm neonates (3.9% if gestational age < 30 weeks).
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Types and Clinical Presentations of Neonatal Seizures

Four types of seizures are frequently encountered in neonates: Tonic Seizures Clonic Seizures Myoclonic Seizures Subtle (Fragmentary) Seizures
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Tonic Seizures
Tonic seizures can be either generalized or focal. Generalized tonic seizures: - Mainly manifest in preterm neonates (< 2500 grams). - Tonic flexion or extension of the upper extremities, neck, or trunk and are associated with tonic extension of the lower extremities. - In 85% of cases are not associated with any autonomic changes such as increases in heart rate or blood pressure, or skin flushing.

Focal Tonic Seizures

Present with asymmetrical posturing of one of the limbs or trunk or with tonic head or eye deviation.
Mostly occur with diffuse central nervous system disease and intraventricular hemorrhage.
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Clonic Seizures
Consist of slow (1-3 /minute) rhythmic jerking movements of the extremities. They may be focal or multi-focal. Each movement is composed of a rapid phase followed by a slow one. Changing the position or holding the moving limb does not suppress the movements. They are commonly seen in full-term neonates >2500 grams
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Clonic Seizures (cont)

There is no loss of consciousness and they are associated with focal trauma, infarction or metabolic disturbances.

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Myoclonic Seizures
Myoclonic seizures can be focal, multi focal or generalized.
Focal myoclonic seizures typically involve the flexor muscles of the extremities. Multi-focal myoclonic seizures present as asynchronous twitching of several parts of the body.
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Myoclonic Seizures (cont)

Generalized myoclonic seizures present as massive flexion of the head and trunk with extension or flexion of the extremities. They are associated with diffuse CNS pathology.

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Subtle (Fragmentary) Seizures

Usually occurs in association with other types of seizures and may manifest with: Stereotypic movements of the extremities such as bicycling or swimming movements. Deviation or jerking of the eyes with repetitive blinking.
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Subtle (Fragmentary) Seizures

(cont)

Drooling, sucking or chewing movements. Apnea or sudden changes in respiratory patterns. Rhythmic fluctuations in vital signs.

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Benign Movements that are Not Seizures

Jitteriness Sleep apnea Isolated sucking movements Benign neonatal sleep myoclonus

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Jitteriness
Jitteriness is often misdiagnosed as clonic seizures. Clinically they differ from clonic seizures in the following aspects:

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Jitteriness (cont)
The flexion and extension phases are equal in amplitude. Neonates are generally alert, with no abnormal gaze or eye movements. Passive flexion or repositioning of the limb diminishes the tremors. Tremors are provoked by tactile stimulation, though they may be spontaneous. No EEG abnormalities.
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Jitteriness (cont)
often seen in neonates with hypoglycemia, drug withdrawal, hypocalcemia, hypothermia and in (SGA) neonates. spontaneously resolve within few weeks.

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Sleep Apnea
Not associated with abnormal movements and is usually associated with bradycardia.
When seizures are present with apnea abnormal movements, tachycardia and increased blood pressure are present as well.
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Isolated Sucking Movements

Random, infrequent and not well sustained sucking movements are not seizures.

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Benign Neonatal Sleep Movements

Predominantly seen in preterm neonates during sleep. They can be focal, multi-focal, or generalized. They do not stop with restraint. resolve spontaneously within a few minutes and require no medication.

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Benign Neonatal Sleep Movements (cont)

They differ from myoclonic seizures in the following:
can be triggered by noise or motion. suppressed by the waking state. not associated with any autonomic changes.
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Most Common Causes of Seizures

HIE Infections (TORCH, meningitis, septicemia) Hypoglycemia, hypocalcemia, hypomagnesemia CNS bleed (intraventricular, subdural, trauma, etc.)
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Less Common Causes of Seizures

Congenital brain anomalies Inborn errors of metabolism Maternal drug withdrawal (heroin, barbiturates, methadone, cocaine, etc.) Kernicterus Pyridoxine (B6) dependency, and hyponatremia

more than one underlying cause

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Diagnosis of Seizures

Obtain a good maternal and obstetric history

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Laboratory Investigations
Primary tests
Blood glucose Blood calcium and magnesium Complete blood count, differential leukocytic count and platelet count Electrolytes Arterial blood gas Cerebral spinal fluid analysis and cultures Blood cultures

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Laboratory Investigations (cont)

TORCH titers, ammonia level, head sonogram and amino acids in urine. EEG Normal in about 1/3 of cases Cranial ultrasound For hemorrhage and scarring CT To diagnose cerebral malformations and hemorrhage
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Management of Seizures
Management goals Achieve systemic homeostasis (airway, breathing and circulation). Correct the underlying cause if possible.

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Medical Management of Seizures

10% dextrose solution (2cc/kg IV) empirically to any seizing neonate. Calcium gluconate (200mg/kg IV), if hypocalcemia is suspected . Magnesuim sulfate 50%, 0.2ml/kg or 2ml Eq/kg. Antibiotics in suspected sepsis. In pyridoxine dependency give pyridoxine 50mg IV as a therapeutic trial. Seizures will stop within minutes .

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Stopping Seizures with Anticonvulsants

Drug Dose Comments Side Effects
Phenobarbital Loading dose:

It is the drug of Hypotension 10-20 mg/kg. choice. Apnea Add 5 mg/kg to Administer IV a maximum of over 5 minutes. 40 mg/kg Therapeutic level: 20-40 g/ml. Maintenance: Administer IM, Monitor 3-5 mg/kg/day respiratory IV, or PO every in divided status during 12 hours. doses every 12 Begin therapy administration hours. and assess IV 12 hours after 32 site. loading dose.

Stopping Seizures with Anticonvulsants (cont)

Drug Dose Comments Side Effects

Phenytoin

Loading dose: Administer IV at 15-20 mg/kg IV a maximum rate over 30 min. of 0.5 mg/kg/min Maintenance: 48 mg/kg/day by IV push or PO. Divide total dose and administer IV every 12 hours.

Do not give IM. Toxicity is a problem with this drug. Cardiac arrhythmias Cerebellar damage

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Stopping Seizures with Anticonvulsants (cont)

Drug Dose Comments Side Effects

Benzodiazepines Lorazepam: Administer IV. Respiratory 0.05 0.1 mg/kg Repeat every 15 depression, Diazepam: 0.1 minutes for 2-3 Interferes with 0.3 mg/kg/dose. doses if needed. bilirubin binding to albumin Maximum dose is 2-5 mg. It can be given once as a PO dose of 0.1-0.3 mg/kg.

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Prognosis
Best prognosis with:
Hypocalcemia Pyridoxine dependency Subarachnoid hemorrhage
Hypoglycemia Anoxia Brain malformation Chronic seizures 1520% Mental retardation Cerebral palsy

Worse prognosis with: Sequelae:

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TERIMAKASIH

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