*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 Objectives1. 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.

*

Seizures are transient disturbances in brain function manifesting as episodic impairments in consciousness in association with abnormal motor or automatic activity.

Definition of Seizure

*Epileptic and Non-Epileptic SeizuresEpileptic 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.

*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).

*Types and Clinical Presentations of Neonatal SeizuresFour types of seizures are frequently encountered in neonates:Tonic SeizuresClonic SeizuresMyoclonic SeizuresSubtle (Fragmentary) Seizures

*Tonic SeizuresTonic 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.

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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.

*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

*Clonic Seizures (cont)There is no loss of consciousness and they are associated with focal trauma, infarction or metabolic disturbances.

*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.

*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.

*Subtle (Fragmentary) SeizuresUsually 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.

*Subtle (Fragmentary) Seizures (cont)

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

*Benign Movements that are Not Seizures

JitterinessSleep apneaIsolated sucking movementsBenign neonatal sleep myoclonus

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

*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.

*often seen in neonates with hypoglycemia, drug withdrawal, hypocalcemia, hypothermia and in (SGA) neonates.spontaneously resolve within few weeks.

Jitteriness (cont)

*Sleep ApneaNot 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.

*Isolated Sucking Movements

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

*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.

*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.

*Most Common Causes of SeizuresHIEInfections (TORCH, meningitis, septicemia)Hypoglycemia, hypocalcemia, hypomagnesemiaCNS bleed (intraventricular, subdural, trauma, etc.)

*Less Common Causes of SeizuresCongenital brain anomaliesInborn errors of metabolismMaternal drug withdrawal (heroin, barbiturates, methadone, cocaine, etc.)Kernicterus Pyridoxine (B6) dependency, and hyponatremia

more than one underlying cause

*Diagnosis of Seizures

Obtain a good maternal and obstetric history

*Laboratory InvestigationsPrimary tests

Blood glucoseBlood calcium and magnesiumComplete blood count, differential leukocytic count and platelet countElectrolytesArterial blood gasCerebral spinal fluid analysis and culturesBlood cultures

*Laboratory Investigations (cont)TORCH titers, ammonia level, head sonogram and amino acids in urine.EEG Normal in about 1/3 of casesCranial ultrasound For hemorrhage and scarringCT To diagnose cerebral malformations and hemorrhage

*Management of SeizuresManagement goalsAchieve systemic homeostasis (airway, breathing and circulation).Correct the underlying cause if possible.

*Medical Management of Seizures10% 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 .

*Stopping Seizures with Anticonvulsants

Drug

Dose

Comments

Side Effects

Phenobarbital

Loading dose: 10-20 mg/kg. Add 5 mg/kg to a maximum of 40 mg/kg

Maintenance: 3-5 mg/kg/day in divided doses every 12 hours.

It is the drug of choice.

Administer IV over 5 minutes.

Therapeutic level: 20-40 (g/ml.

Administer IM, IV, or PO every 12 hours.

Begin therapy 12 hours after loading dose.

Hypotension

Apnea

Monitor respiratory status during administration and assess IV site.

*Stopping Seizures with Anticonvulsants (cont)

Drug

Dose

Comments

Side Effects

Phenytoin

Loading dose: 15-20 mg/kg IV over 30 min.

Administer IV at a maximum rate of 0.5 mg/kg/min

Maintenance: 4-8 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

*Stopping Seizures with Anticonvulsants (cont)

Drug

Dose

Comments

Side Effects

Benzodiazepines

Lorazepam: 0.05 0.1 mg/kg

Diazepam: 0.1 0.3 mg/kg/dose.

Administer IV.

Repeat every 15 minutes for 2-3 doses if needed.

Maximum dose is 2-5 mg.

It can be given once as a PO dose of 0.1-0.3 mg/kg.

Respiratory depression,

Interferes with bilirubin binding to albumin

*PrognosisBest prognosis with:

Worse prognosis with:

Sequelae:

HypocalcemiaPyridoxine dependencySubarachnoid hemorrhage

HypoglycemiaAnoxiaBrain malformation

Chronic seizures 15-20%Mental retardationCerebral palsy

* TERIMAKASIH

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