Last updated:
April 1, 2026
Neonatal seizures are seizures occurring in the first 28 days of life. Most seizures occur between 12 and 48 hours of life, and these are associated with ischemia or haemorrhage. Seizures first presenting more than 40 hours of life are more likely to be infectious or metabolic in origin. The most common cause of neonatal seizures is hypoxic-ischemic encephalopathy.
Neonatal epilepsy is recurrent, often unprovoked seizures. This is due to genetic or structural causes.
Types of seizures
| Type | Description |
|---|---|
| Provoked seizures | Acute symptomatic seizures. Due to HIE, infection, metabolic causes, and IVH or stroke. |
| Unprovoked seizures | Due to a structural brain abnormality or a genetic mutation |
Causes of neonatal seizures
| Category | Causes of neonatal seizures |
|---|---|
| Cerebrovascular causes (75%) | Hypoxic-ischemic encephalopathy (60%, MCC), Intracranial hemorrhage (15%), ischemic stroke |
| Infectious causes | Bacterial meningitis, viral meningoencephalitis, intrauterine TORCHES infections (especially toxoplasmosis) |
| Metabolic causes | Hypoglycemia, hypocalcemia, hypomagnesemia, hypo-or hypernatremia, inborn pyridoxine deficiency (difficult to treat these seizures), congenital amino acid or organic disorders |
| Others | Drug withdrawal, cerebral dysgenesis, benign familial neonatal seizures (diagnosis of exclusion) |
Notable neonatal epilepsy syndromes
| Syndrome | Description |
|---|---|
| Self-limited neonatal epilepsy | Day 2–3 onset; brief seizures; normal exam; resolves in weeks–months; good prognosis |
| Ohtahara syndrome | Very early onset; tonic seizures; burst-suppression EEG; poor prognosis |
| Early myoclonic encephalopathy | Neonatal onset; myoclonic seizures; metabolic cause; poor prognosis |
| KCNQ2 encephalopathy | Early seizures + encephalopathy; improves, but severe delay remains |
| Migrating focal seizures | Moving focal seizures; drug-resistant; high mortality |
| DEND syndrome | Seizures + neonatal diabetes; developmental delay |
| Pyridoxine-dependent epilepsy | Refractory seizures; responds to vitamin B6 |
- Causes of neonatal epilepsy
- Channelopathies
- Pyridoxine-dependent epilepsy
- DEND syndrome
- Structural malformations: lissencephaly, polymicrogyria, and hemimegalencephaly
- Nn-ketotic hyperglycinemia
- Organic acidemias
- Mitochondrial disorders
- Pathophysiology
- Neonates are hyperexcitable due to
- Increased excitatory receptors (NMDA and AMPA)
- Reduced inhibitory GABA effects – in neonates, GABA is excitatory
- Immature brain circuits
- Neonates are hyperexcitable due to
- Signs and symptoms
- Focal and subtle signs
- Ocular deviation
- Eyelid fluttering
- “Bicycling” or “swimming” like movement of the arms and legs
- Lip smacking
- Sucking or other oral tics
- Apnoeic episodes
- Rarely tonic-clonic due to incomplete myelination and immature synapses
- Focal and subtle signs
- Differentials
- Jitteriness
- Benign sleep myoclonus
- Hyperekplexia
- Reflux (Sandifer syndrome)
- Investigations
- Lumbar puncture: A CT/MRI can be done before the lumbar puncture to assess for raised intracranial pressure
- Xanthocromia: suggests subarachnoid hemorrhage
- Low glucose: suggests bacterial meningitis
- Positive HSV PCR: suggests viral meningoencephalitis
- Metabolic panel, including serum calcium, blood glucose, and magnesium levels
- TORCH titres
- Serum amino acids
- Urine for organic acids
- Cranial ultrasound for unstable neonates
- MRI
- Video 20-lead EEG
- Echocardiograph
- Lumbar puncture: A CT/MRI can be done before the lumbar puncture to assess for raised intracranial pressure
- Treatment
- ABCs:
- Adequate ventilation and perfusion.
- Monitor pulse oximetry and blood pressure
- Get immediate glucose and electrolyte levels
- Correct hypoglycaemia
- Correct electrolyte abnormalities if present
- Antiseizure medications
- First-line treatment
- IV/IM phenobarbital
- Second-line treatment
- Phenytoin, lorazepam, midazolam, or levitiracetam
- Pyridoxine trial (vitamin B6)
- Na+ channel blockers for channelopathies
- First-line treatment
- Continue anti-epileptic drugs if indicated
- ABCs:
- Indications for stopping anti-epileptic drugs
- For provoked seizures, neonates with normal neurological examination and/or normal EEG, if the neonate has been seizure-free for 72 hours
- Neonates in whom seizure control is achieved with a single antiepileptic drug
- For neonates requiring more than one antepileptic drug for seizure control, stop them one by one, with phenobarbital being the last drug to withdraw
- Complications
- Neurodevelopmental delay
- Cerebral palsy
- Cognitive impairment
- Drug-resistant epilepsy