Neonatal seizures

Elissa G Yozawitz MD (Dr. Yozawitz of the Albert Einstein College of Medicine has no relevant financial relationships to disclose.)
Emma Laureta MD (Dr. Laureta of Hofstra North Shore-LIJ School of Medicine has no relevant financial relationships to disclose.)
Solomon L Moshé MD (

Dr. Moshé of Albert Einstein College of Medicine received consulting fees from Pfeizer, Malinckrodt, and UCB.

)
Jerome Engel Jr MD PhD, editor. (Dr. Engel of the David Geffen School of Medicine at the University of California, Los Angeles, has no relevant financial relationships to disclose.)
Originally released October 18, 1993; last updated July 31, 2019; expires July 31, 2022

This article includes discussion of neonatal seizures, which includes acute reactive seizures, electroclinical seizures in the newborn period, electrographic seizures in the newborn period, neonatal convulsions, newborn seizures, seizure patterns in newborn infants, seizures in newborn babies, and neonatal onset epilepsy syndromes. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Neonatal seizures are seizures occurring within the first 28 days in a full-term infant and extending to the 44 completed weeks gestational age in the preterm infant. The neonatal period is the most vulnerable of all periods of life for development of epileptic seizures. Most neonatal seizures are acute reactive (structural/metabolic) seizures. In term babies, the most common cause is hypoxic-ischemic encephalopathy, stroke, or infection. The age at onset of the seizure typically depends on the etiology. Determining the etiology requires immediate attention in order to diagnose and treat if appropriate. The seizures typically resolve once the underlying trigger subsides. Neonatal seizures, depending on etiology, may be associated with adverse neurodevelopmental sequelae or death, with possible long-term motor and cognitive problems, or with post-neonatal epilepsy.

Key points

 

• The neonatal brain is more prone to seizures than the mature brain.

 

• Most neonatal seizures are acute reactive seizures, the most common cause in term infants being hypoxic-ischemic encephalopathy, stroke, or infection. Neonatal onset epilepsy syndromes also exist but are less common.

 

• The most commonly used current classification of neonatal seizures divides the seizures into clonic, tonic, myoclonic, and motor automatisms/subtle. A new classification is being proposed by the International League Against Epilepsy Task Force on Neonatal Seizures.

 

• About 60% to 70% of neonatal seizures are subclinical and would not be diagnosed/recognized without continuous EEG monitoring.

 

• Phenobarbital is a first-line treatment for neonatal seizures. Fosphenytoin/phenytoin can also be used or added for additional benefit, as well as midazolam. Additional medications that may be used as an off-label medication include levetiracetam or topiramate. There is a need for new treatments that are age specific.

Historical note and terminology

More than 50 years ago, seizures in the neonatal period were known for their strong relation to permanent handicap in the survivors (Burke 1954). Our understanding of neonatal seizures has evolved over the years, and the methods of recording seizures by EEG have become more refined (digital EEG and continuous video-EEG monitoring). Conventional EEG is the current gold standard to detect neonatal seizures (Shellhaas et al 2011; Shellhaas 2015; Pisani and Pavlidis 2018).

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