content:neonatal_seizures

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content:neonatal_seizures [2020/02/23 15:39] – [Neonatal seizures] icnacontent:neonatal_seizures [2022/04/30 11:32] (current) – changed pubmed syntax administrator@icnapedia.org
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 ===== Classification ===== ===== Classification =====
  
-  * The ILAE Commission (1989)[(:cite:2502382>{{pubmed>2502382}})] broadly classifies the neonatal seizures among ‘epilepsies and syndromes undetermined as to whether they are focal or generalised’ under the subheading ‘with both generalised and focal seizures’ +  * The ILAE Commission (1989)[(:cite:2502382>{{pmid>2502382}})] broadly classifies the neonatal seizures among ‘epilepsies and syndromes undetermined as to whether they are focal or generalised’ under the subheading ‘with both generalised and focal seizures’ 
-  * In the ILAE (2010)[(:cite:20196795>{{pubmed>20196795}})] revised classification neonatal seizures are no longer regarded as a separate entity.+  * In the ILAE (2010)[(:cite:20196795>{{pmid>20196795}})] revised classification neonatal seizures are no longer regarded as a separate entity.
  
 ===== Clinical features ===== ===== Clinical features =====
  
-Five main types of seizures are recognised[(:cite:2671912>{{pubmed>2671912}})]+Five main types of seizures are recognised[(:cite:2671912>{{pmid>2671912}})]
     * 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[(:cite:7124705>{{pubmed>7124705}})].+  * more frequently in pre-term than in full-term infants indicating, if massive, major brain injury and poor prognosis[(:cite:7124705>{{pmid>7124705}})].
   * 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[(:cite:7124705>{{pubmed>7124705}})]+  * Apnoea, as an isolated seizure phenomenon unaccompanied by other clinical epileptic features, is rare[(:cite:7124705>{{pmid>7124705}})]
    
  
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   * suppression–burst pattern in neonatal epileptic encephalopathies[{{ :content:ch5f4.jpg?direct&100|suppression-burst pattern}}]   * suppression–burst pattern in neonatal epileptic encephalopathies[{{ :content:ch5f4.jpg?direct&100|suppression-burst pattern}}]
     * relatively common in neonatal period     * relatively common in neonatal period
-    * can be induced by drugs[(:cite:11727229>{{pubmed>11727229}})]+    * can be induced by drugs[(:cite:11727229>{{pmid>11727229}})]
     * usually transient in ischemic encephalopathy     * usually transient in ischemic encephalopathy
     * stable lasting for more than 2 weeks in [[content:ohtahara_syndrome|Ohtahara syndrome]] and [[early myoclonic encephalopathy]]     * stable lasting for more than 2 weeks in [[content:ohtahara_syndrome|Ohtahara syndrome]] and [[early myoclonic encephalopathy]]
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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[(:cite:9546495>{{pubmed>long:9546495}})]+  * represent an abnormal form of cortical reactivity to sensory stimuli in the developing brain[(:cite:9546495>{{pmid>long:9546495}})]
   * 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[(:cite:1764139>{{pubmed>1764139}})]+  * may arise from foci not consistently echoed by surface electrodes[(:cite:1764139>{{pmid>1764139}})]
 ==== Differential diagnosis ==== ==== Differential diagnosis ====
   * [[hyperekplexia]]   * [[hyperekplexia]]
   * [[benign neonatal sleep myoclonus]]   * [[benign neonatal sleep myoclonus]]
   * [[Benign Non-Epileptic Myoclonus of Early Infancy]] ([[benign non-epileptic infantile spasms]])   * [[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[(:cite:889296>{{pubmed>889296}})][(:cite:889296>{{pubmed>889296}})][(:cite:10937134>{{pubmed>10937134}})][(:cite:11292215>{{pubmed>11292215}})] +    * paroxysmal, non-epileptic movement disorder of otherwise healthy infants who have normal EEG and development[(:cite:889296>{{pmid>889296}})][(:cite:889296>{{pmid>889296}})][(:cite:10937134>{{pmid>10937134}})][(:cite:11292215>{{pmid>11292215}})] 
-    * ‘benign non-epileptic infantile spasms’ is descriptively more accurate than myoclonus[(:cite:3960282>{{pubmed>3960282}})]  +    * ‘benign non-epileptic infantile spasms’ is descriptively more accurate than myoclonus[(:cite:3960282>{{pmid>3960282}})]  
-    * thought to be the same condition as ‘shuddering attacks’[(:cite:11118798>{{pubmed>11118798}})].+    * thought to be the same condition as ‘shuddering attacks’[(:cite:11118798>{{pmid>11118798}})].
 ==== Prognosis ==== ==== Prognosis ====
   * depends on the underlying cause[(:cite:panayitopoulos2005>Panayiotopoulos CP. (2005). **The Epilepsies: Seizures, Syndromes and Management**. Oxfordshire (UK): Bladon Medical Publishing)]   * depends on the underlying cause[(:cite:panayitopoulos2005>Panayiotopoulos CP. (2005). **The Epilepsies: Seizures, Syndromes and Management**. Oxfordshire (UK): Bladon Medical Publishing)]
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   * **phenobarbital**   * **phenobarbital**
-    * often recommended as first-line treatment[(:cite:16777818>{{pubmed>16777818}})] +    * often recommended as first-line treatment[(:cite:16777818>{{pmid>16777818}})] 
-    * recommended as first line treatment in the UK[(:cite:25824891>{{pubmed>25824891}})] +    * recommended as first line treatment in the UK[(:cite:25824891>{{pmid>25824891}})] 
     * included in RCTs of first-line treatment of neonatal seizure     * included in RCTs of first-line treatment of neonatal seizure
     * most studied anti-epileptic medication in animals     * most studied anti-epileptic medication in animals
     * historical precedence as the first-line antiepileptic drug for neonates     * historical precedence as the first-line antiepileptic drug for neonates
     * extremely limited evidence on the effect of phenobarbital on long-term neonatal neurodevelopment     * 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[(:cite:17342837>{{pubmed>17342837}})] +    * U.S. Food and Drug Administration (FDA) has never approved phenobarbital for use in any patient population[(:cite:17342837>{{pmid>17342837}})] 
-    * animal studies have raised concerns that neonatal phenobarbital exposure induces neuronal apoptosis, disruption of synaptic development in the striatum, and other behavioral deficits[(:cite:29315524>{{pubmed>29315524}})]+    * animal studies have raised concerns that neonatal phenobarbital exposure induces neuronal apoptosis, disruption of synaptic development in the striatum, and other behavioral deficits[(:cite:29315524>{{pmid>29315524}})]
   * **Levetiracetam**   * **Levetiracetam**
     * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital     * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital
     * FDA-approved for children as young as one-month of age[(:cite:fda>U.S. Dept. of Health and Human Services. [cited 2012 Oct 5];Food and Drug Administration Center for Drug Evaluation and Research. Application Number NDA 21505/S-026 [Internet] Available from: http://www.accessdata.fda.gov)]     * FDA-approved for children as young as one-month of age[(:cite:fda>U.S. Dept. of Health and Human Services. [cited 2012 Oct 5];Food and Drug Administration Center for Drug Evaluation and Research. Application Number NDA 21505/S-026 [Internet] Available from: http://www.accessdata.fda.gov)]
     *  efficacy and safety profile has not been adequately studied in term or preterm neonates within the first month of life     *  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[(:cite:25964725>{{pubmed>25964725}})] +    * 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[(:cite:25964725>{{pmid>25964725}})] 
-    * dosing of 40–50mg/kg bolus has also been suggested [(:cite:21397167>{{pubmed>21397167}})] +    * dosing of 40–50mg/kg bolus has also been suggested [(:cite:21397167>{{pmid>21397167}})] 
-    * 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[(:cite:31477643>{{pubmed>31477643}})]+    * 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[(:cite:31477643>{{pmid>31477643}})]
   * phenytoin/fosphenytoin   * phenytoin/fosphenytoin
     * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital     * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital
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   * minimal data for many antiepileptics including topiramate, which is being increasingly used in neonates   * minimal data for many antiepileptics including topiramate, which is being increasingly used in neonates
   * steroids and / or [[vigabatrin]] are considered in epileptic spasms   * 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[(:cite:27888506>{{pubmed>27888506}})] +  * Low-dose carbamazepine (CBZ) should be considered as first-line treatment for benign familial neonatal epilepsy (BNFE), even in cases of status epilepticus[(:cite:27888506>{{pmid>27888506}})] 
-  * there is equipoise on levetiracetam vs phenobarbitone as first line treatment[(:cite:31992265>{{pubmed>31992265}})]+  * there is equipoise on levetiracetam vs phenobarbitone as first line treatment[(:cite:31992265>{{pmid>31992265}})]
   * The 2011 World Health Organization (WHO) guidelines for neonatal seizures[(:cite:who2011)] and the 2010 Queensland Maternity and Neonatal Clinical Guidelines for neonatal seizures[(:cite:queensland2013>Queensland Department of Health. Queensland Clinical guidelines. Translating evidence into best clinical practice: maternity clinical guidelines. http://www.health.qld.gov.au/qcg/html/publications.asp#Neonatal. Accessed March 10, 2013)] recommend phenobarbital as the first-line agent for treatment of neonatal seizures, followed by phenytoin, and then benzodiazepines   * The 2011 World Health Organization (WHO) guidelines for neonatal seizures[(:cite:who2011)] and the 2010 Queensland Maternity and Neonatal Clinical Guidelines for neonatal seizures[(:cite:queensland2013>Queensland Department of Health. Queensland Clinical guidelines. Translating evidence into best clinical practice: maternity clinical guidelines. http://www.health.qld.gov.au/qcg/html/publications.asp#Neonatal. Accessed March 10, 2013)] recommend phenobarbital as the first-line agent for treatment of neonatal seizures, followed by phenytoin, and then benzodiazepines
  
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