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content:neonatal_seizures [2020/02/23 12:59] – [Prognosis] icna | content:neonatal_seizures [2022/04/30 11:32] (current) – changed pubmed syntax administrator@icnapedia.org | ||
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* Neonatal epileptic seizures occur from birth to the end of the neonatal period. | * Neonatal epileptic seizures occur from birth to the end of the neonatal period. | ||
* The neonatal period is defined as the first 28 days of life of a full-term infant. | * The neonatal period is defined as the first 28 days of life of a full-term infant. | ||
- | * Most neonatal seizures are acute (pro-voked, occasional, reactive) | + | * Most neonatal seizures are acute symptomatic seizures caused by an acute illness such as hypoxic–ischaemic encephalopathy, |
* seizures are the most common and important sign of acute neonatal encephalopathy | * seizures are the most common and important sign of acute neonatal encephalopathy | ||
* neonatal seizures are a major risk for death or subsequent neurological disability and, by themselves, may contribute to an adverse neuro-developmental outcome. | * neonatal seizures are a major risk for death or subsequent neurological disability and, by themselves, may contribute to an adverse neuro-developmental outcome. | ||
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===== Classification ===== | ===== Classification ===== | ||
- | * The ILAE Commission (1989)[(: | + | * The ILAE Commission (1989)[(: |
- | * In the ILAE (2010)[(: | + | * In the ILAE (2010)[(: |
===== Clinical features ===== | ===== Clinical features ===== | ||
- | Five main types of seizures are recognised[(: | + | Five main types of seizures are recognised[(: |
* subtle seizures (50%) | * subtle seizures (50%) | ||
* tonic seizures (5%) | * tonic seizures (5%) | ||
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**Myoclonic seizures** | **Myoclonic seizures** | ||
* rapid, single or arrhythmic repetitive jerks. They may affect a finger, a limb or the whole body. They may mimic Moro reflex and startling responses | * rapid, single or arrhythmic repetitive jerks. They may affect a finger, a limb or the whole body. They may mimic Moro reflex and startling responses | ||
- | * more frequently in pre-term than in full-term infants indicating, if massive, major brain injury and poor prognosis[(: | + | * more frequently in pre-term than in full-term infants indicating, if massive, major brain injury and poor prognosis[(: |
* healthy pre-term and, although rarely, full-term neonates may have abundant myoclonic movements during sleep | * healthy pre-term and, although rarely, full-term neonates may have abundant myoclonic movements during sleep | ||
* Neonates have cortical, reticular and segmental types of myoclonus, similar to adult forms (Scher, 1985). | * Neonates have cortical, reticular and segmental types of myoclonus, similar to adult forms (Scher, 1985). | ||
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* autonomic ictal manifestations commonly occur with motor manifestations in 37% of subtle seizures | * autonomic ictal manifestations commonly occur with motor manifestations in 37% of subtle seizures | ||
* paroxysmal changes of heart rate, respiration and systemic blood pressure, salivation, pupillary changes | * paroxysmal changes of heart rate, respiration and systemic blood pressure, salivation, pupillary changes | ||
- | * Apnoea, as an isolated seizure phenomenon unaccompanied by other clinical epileptic features, is rare[(: | + | * Apnoea, as an isolated seizure phenomenon unaccompanied by other clinical epileptic features, is rare[(: |
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* suppression–burst pattern in neonatal epileptic encephalopathies[{{ : | * suppression–burst pattern in neonatal epileptic encephalopathies[{{ : | ||
* relatively common in neonatal period | * relatively common in neonatal period | ||
- | * can be induced by drugs[(: | + | * can be induced by drugs[(: |
* usually transient in ischemic encephalopathy | * usually transient in ischemic encephalopathy | ||
* stable lasting for more than 2 weeks in [[content: | * stable lasting for more than 2 weeks in [[content: | ||
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**Stimulus-evoked electrographic patterns** | **Stimulus-evoked electrographic patterns** | ||
* electrographic seizures are elicited by tactile or painful stimulation (with or without concomitant clinical ictal manifestations) | * electrographic seizures are elicited by tactile or painful stimulation (with or without concomitant clinical ictal manifestations) | ||
- | * represent an abnormal form of cortical reactivity to sensory stimuli in the developing brain[(: | + | * represent an abnormal form of cortical reactivity to sensory stimuli in the developing brain[(: |
* most neonates with these patterns have significant diffuse or multifocal damage to the neocortex | * most neonates with these patterns have significant diffuse or multifocal damage to the neocortex | ||
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* clinical component of a seizure occurs at times with or without an electrical correlate | * clinical component of a seizure occurs at times with or without an electrical correlate | ||
* ‘decoupling response’ - commonly seen after starting AEDs where AEDs may suppress the clinical manifestations of seizures but not the EEG ictal discharge | * ‘decoupling response’ - commonly seen after starting AEDs where AEDs may suppress the clinical manifestations of seizures but not the EEG ictal discharge | ||
- | * may arise from foci not consistently echoed by surface electrodes[(: | + | * may arise from foci not consistently echoed by surface electrodes[(: |
+ | ==== Differential diagnosis ==== | ||
+ | * [[hyperekplexia]] | ||
+ | * [[benign neonatal sleep myoclonus]] | ||
+ | * [[Benign Non-Epileptic Myoclonus of Early Infancy]] ([[benign non-epileptic infantile spasms]]) | ||
+ | * paroxysmal, non-epileptic movement disorder of otherwise healthy infants who have normal EEG and development[(: | ||
+ | * ‘benign non-epileptic infantile spasms’ is descriptively more accurate than myoclonus[(: | ||
+ | * thought to be the same condition as ‘shuddering attacks’[(: | ||
==== Prognosis ==== | ==== Prognosis ==== | ||
* depends on the underlying cause[(: | * depends on the underlying cause[(: | ||
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=== Treatment === | === Treatment === | ||
+ | {{page> | ||
+ | There is limited evidence regarding the best pharmacologic treatment for neonatal seizures. World Health Organisation recommends electrographic seizures should be treated in the same way as clinical seizures[(: | ||
+ | |||
+ | * **phenobarbital** | ||
+ | * often recommended as first-line treatment[(: | ||
+ | * recommended as first line treatment in the UK[(: | ||
+ | * included in RCTs of first-line treatment of neonatal seizure | ||
+ | * most studied anti-epileptic medication in animals | ||
+ | * historical precedence as the first-line antiepileptic drug for neonates | ||
+ | * extremely limited evidence on the effect of phenobarbital on long-term neonatal neurodevelopment | ||
+ | * U.S. Food and Drug Administration (FDA) has never approved phenobarbital for use in any patient population[(: | ||
+ | * animal studies have raised concerns that neonatal phenobarbital exposure induces neuronal apoptosis, disruption of synaptic development in the striatum, and other behavioral deficits[(: | ||
+ | * **Levetiracetam** | ||
+ | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital | ||
+ | * FDA-approved for children as young as one-month of age[(: | ||
+ | * efficacy and safety profile has not been adequately studied in term or preterm neonates within the first month of life | ||
+ | * current literature suggests loading doses of 10 to 20 mg/kg are appropriate and effective in neonates, with a maintenance dose range of 10 to 80 mg/kg/day divided twice daily[(: | ||
+ | * dosing of 40–50mg/ | ||
+ | * a recent open labelled RCT (Level III neonatal unit; 100 neonates) used Levetiracetam (20 mg/kg) or Phenobarbitone (20 mg/kg) intravenously and concluded that Levetiracetam achieves better control than Phenobarbitone for neonatal clinical seizures when used as first-line antiepileptic drug, and is not associated with adverse drug reactions[(: | ||
+ | * phenytoin/ | ||
+ | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital | ||
+ | * requires frequent blood-level monitoring | ||
+ | * erratic oral absorption & needs 6-8hrly oral dosing | ||
+ | * **lidocaine** | ||
+ | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital. | ||
+ | * narrow therapeutic window and the potential to cause cardiac arrhythmias or hypotension | ||
+ | * can induce seizures at high doses | ||
+ | * may be considered in status epilepticus if phenytoin was no previously given | ||
+ | * Benzodiazepines (midazolam) | ||
+ | * sedation is a serious side effect | ||
+ | * may be considered as a second- or third-line therapy choice, especially in already intubated neonates | ||
+ | |||
+ | Other considerations | ||
+ | * consider pyridoxine challenge when other antiepileptics provide no response | ||
+ | * minimal data for many antiepileptics including topiramate, which is being increasingly used in neonates | ||
+ | * steroids and / or [[vigabatrin]] are considered in epileptic spasms | ||
+ | * Low-dose carbamazepine (CBZ) should be considered as first-line treatment for benign familial neonatal epilepsy (BNFE), even in cases of status epilepticus[(: | ||
+ | * there is equipoise on levetiracetam vs phenobarbitone as first line treatment[(: | ||
+ | * The 2011 World Health Organization (WHO) guidelines for neonatal seizures[(: | ||
- | * limited evidence regarding the best pharmacologic treatment for neonatal seizures | ||
- | * | ||