Neonatal Seizure

Aka: Neonatal Seizure, Newborn Seizure, Seizure Disorder in Newborns

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II. Types (Order of decreasing frequency)

  1. Background
    1. Generalized tonic-clonic Seizures do not typically occur in the immature nervous system of a neonate
  2. Subtle findings
    1. Horizontal Eye Deviation
    2. Drooling
    3. Sucking
    4. Lip smacking
    5. Swimming or pedaling motion
  3. Generalized Tonic Seizure (Preterm Infants)
  4. Multifocal Clonic Seizure (Full-Term infants)
  5. Focal Clonic Seizure (Full-Term more then Preterm)
  6. Myoclonic (Both Preterm and Full-Term)
  7. Infantile Spasms (2-3% of childhood Epilepsy)
    1. Associated with serious underlying conditions (e.g. Tuberous sclerosis, Phenylketonuria, Agenesis of the Corpus Callosum)

III. Causes

  1. Asphyxia, HIE (12-24 hours after birth)
  2. Interventricular Hemorrhage
  3. Hydrocephalus
  4. Microcephaly
  5. Hypoglycemia
  6. Electrolyte imbalance
    1. Hyponatremia
    2. Hypocalcemia
    3. Hypomagnesemia
  7. Infection
    1. TORCH Infection (esp. Toxoplasmosis, CMV, HSV)
    2. Coxsachievirus
    3. Escherichia coli
    4. Group B Streptococcus (GBS Sepsis)
  8. Amino Acid disturbance (Inborn Errors of Metabolism)
  9. Drug Withdrawal
  10. Pyridoxine Deficiency (Vitamin B6)
  11. Vitamin K Deficiency
  12. Dysgenic brain
  13. Neonatal sleep Myoclonus
  14. Benign familial Neonatal Seizures
  15. Benign idiopathic Neonatal Seizures (Fifth Day Fits) or familial
    1. Onset in first 3-5 days of life
    2. Resolves in weeks

IV. Labs

  1. Bedside Fingerstick Glucose
  2. Serum Sodium
  3. Serum Calcium
  4. Serum Magnesium

V. Evaluation

  1. Requires broad evaluation (e.g. Neonatal Sepsis, Birth Trauma, inborn error of metabolism)

VI. Management

  1. Seizure abortive measures
    1. See Seizure Emergency Management
    2. Step 1: Diazepam 0.3 mg/kg rectally
    3. Step 2: Phenobarbital 20 mg/kg slow IV push (risk of respiratory depression)
      1. Risk of apnea and Hypotension
      2. Phenobarbital much higher efficacy in newborns than Levetiracetam
      3. Sharpe (2020) Pediatrics 145(6) +PMID:32385134 [PubMed]
    4. Step 3: Phenytoin or Fosphenytoin 18 mg/kg IV over 20 min (10 min for Fosphenytoin)
  2. Reversible cause management
    1. Hypoglycemia Management with D10W 2-4 ml/kg IV
    2. Other measures
      1. Severe Hyponatremia Management (6 ml/kg 3% saline)
      2. Severe Hypocalcemia management (50-100 mg/kg Calcium Gluconate over 10-20 min)
      3. Severe Hypomagnesemia management (2-4 ml 2% MgSO4)
      4. Consider Pyridoxine replacement

VII. References

  1. (2016) CALS Manual, 14th ed, p. I-210

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