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  • Updated 03.16.2023
  • Released 10.18.1993
  • Expires For CME 03.16.2026

Neonatal seizures



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 or may not 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 (08). 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 (64; 62; 53).

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