Treatment of neonatal seizures
- Renee Shellhaas, MD, MS
Renee Shellhaas, MD, MS
- Clinical Associate Professor, Dept of Pediatrics
- University of Michigan Pediatric Neurology
- Section Editors
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Professor of Neurology and Pediatrics
- Northwestern University Feinberg School of Medicine
- Joseph A Garcia-Prats, MD
Joseph A Garcia-Prats, MD
- Section Editor — Neonatology
- Professor of Pediatrics
- Baylor College of Medicine
The occurrence of neonatal seizures may be the first, and perhaps the only, clinical sign of a central nervous system (CNS) disorder in the newborn infant. Seizures may indicate the presence of a potentially treatable etiology and should prompt an immediate evaluation to determine cause and to institute etiology-specific therapy. In addition, seizures themselves may require emergent therapy, since they can adversely affect the infant's homeostasis or they may contribute to further brain injury. Some types of neonatal seizures are associated with a relatively high incidence of early death and, in survivors, a high incidence of neurologic impairment, developmental delay, and postneonatal epilepsy.
Management of neonatal seizures involves accurate diagnosis of seizures, expedited evaluation and targeted treatment for their etiology, and medication to abolish the electrographic seizures. This topic will discuss the approach to treatment of neonatal seizures. The etiology, clinical features and diagnosis of neonatal seizures are discussed separately. (See "Etiology and prognosis of neonatal seizures" and "Neonatal epileptic syndromes" and "Clinical features, evaluation, and diagnosis of neonatal seizures".)
Both seizures and their subsequent therapy may be associated with changes in respiration, heart rate, and blood pressure. An adequate airway and access to the circulatory system must be insured early in the course of treatment.
Treatment directed at the cause of neonatal seizures is critical since it may prevent further brain injury. This is particularly true for seizures associated with some metabolic disturbances (eg, hypoglycemia, hypocalcemia, and hypomagnesemia) and with central nervous system (CNS) or systemic infections. Furthermore, neonatal seizures may not be effectively controlled with antiepileptic drugs (AEDs) unless their underlying cause is treated.
The most common etiologies of neonatal seizures are reviewed in the Table (table 1).
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- ETIOLOGIC THERAPY
- Neonatal encephalopathy
- CNS infection
- Metabolic disturbances
- - Hypoglycemia
- - Hypocalcemia
- - Hypomagnesemia
- Pyridoxine or PLP responsive seizures
- Biotinidase deficiency
- ANTIEPILEPTIC DRUG THERAPY
- Decision to institute drug therapy
- Drug selection
- - First-line therapy
- - Endpoint of acute therapy
- - Refractory seizures
- Dosing considerations in neonates
- - Phenobarbital
- - Phenytoin
- - Levetiractetam
- - Lidocaine
- - Midazolam
- Duration of therapy
- SUMMARY AND RECOMMENDATIONS