Neonatal Seizures

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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.

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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 neonate’s 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.

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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 meliorated
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.

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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.

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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 IV, or PO every respiratory
in divided 12 hours. status during
doses every 12  Begin therapy administration
hours. 12 hours after and assess IV
loading dose. site.
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 Stopping Seizures with Anticonvulsants
(cont)

Drug Dose Comments Side Effects

Phenytoin  Loading dose:  Administer IV at  Do not give IM.

15-20 mg/kg IV a maximum rate  Toxicity is a
over 30 min. of 0.5 mg/kg/min problem with this
 Maintenance: 4- drug.
 8 mg/kg/day by  Cardiac
IV push or PO. arrhythmias
 Divide total dose  Cerebellar
and administer damage
IV every 12
hours.

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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
 Maximum dose is albumin
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

• Worse prognosis with:  Hypoglycemia

 Anoxia
 Brain malformation
• Sequelae:
 Chronic seizures 15-
20%
 Mental retardation
 Cerebral palsy
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