Neonatal Seizures

Table Of Contents
  1. Causes of Neonatal Seizures
  2. Manifestation
  3. Management

The MCC of neonatal seizures is HIE. The lifespan risk of seizures is highest in the neonatal period and premature infants are at an increased risk of developing seizures.

Causes of Neonatal Seizures

Most seizures occur between 12-48 hours of life and are associated with ischemia or hemorrhage

Seizures first presenting >48 hours of life are more likely to be infectious or metabolic in origin

  • Cerebrovascular causes (75%)
    • HIE (60%, MCC)
    • Intracranial hemorrhage (15%)
    • Ischemic stroke
  • Infectious causes (12%)
    • Bacterial meningitis
    • Viral meningoencephalitis
    • Intrauterine TORCH infection (esp. toxoplasmosis)
  • Metabolic causes
    • Electrolyte disturbances
      • Hypoglycemia
      • Hypocalcemia
      • Hypomagnesemia
      • Hypo- or hypernatremia
    • Inborn pyridoxine deficiency (difficult to treat these seizures)
    • Congenital amino acid or organic disorder
  • Others causes
    • Drug withdrawal
    • Cerebral dysgenesis
    • Benign familial neonatal seizures (dx of exclusion)

Manifestation

Manifestation of neonatal seizures is significantly different from those in older children and adults (extremely subtle and can be missed hence the need for EEG monitoring). Neonates rarely have tonic-clonic seizures

  • Signs and symptoms
    • Ocular deviation
    • Eyelid fluttering
    • “Bicycling” or “swimming”-like movement of the arms and les
    • Lip smacking
    • Sucking or other oral tics
    • Apneic episodes

Management

While the first line Tx of seizures in adults and most pediatric seizures is benzo (Lorazepam), this is NOT the case in newborns (≤ 1 yo)

  • Investigations
    • Lumbar puncture: get a CT/MRI before LP to assess
      • Xanthocromia: suggests SAH
      • Low glucose: suggests bacterial meningitis
      • Positive HSV PCR: suggests viral meningoencephalitis
    • Metabolic panel: serum Ca and Mg levels
    • TORCH titres
    • Serum amino acids
    • Urine for organic acids
    • Cranial sonography (followed by MRI)
    • Video 20-lead EEG
    • Echocardiograph
  • Treatment
    • ABC: adequate ventilation and perfusion. Monitor pulse ox, BP
    • Immediate Glucose and electrolyte levels
      • Correct glucose w 2ml/kg D10W infusion, then drip 6ml/kg/min
      • Correct electrolyte abnormalities present
    • First line treatment
      • IV Phenobarbital 20ml/kg, additional dosages in 5ml/kg increments upto 40m/kg
    • Second-line treatment
      • Fosphenytoin or Lorazepam or Levitiracetam
    • Consult neonatology and paediatric neurology