How to manage neonatal seizure?
How to manage neonatal seizure?
In this article, we are gonna talk about how to tackle a neonate suffering from seizure? In the very first let’s know what’s seizure?
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Seizure: is a paroxysmal disturbance in neurological function (behavioral, motor or autonomic functions).
Causes:
1-Birth asphyxia HIE the most common cause >50%.
2-Metabolic disturbances:
a-Hypoglycemia RBS<40mg/dl in day 1 or <50 after day 1.
b-Hypocalcemia ionized Ca++ <4.4 mg/dl or total Ca++ <tmg/dl.
c-hypomagnesemia <1.6mg/dl.
d-hyponatremia <130mEq/L or hypernatremia >150mEq/L.
3-CNS or systemic infections.
4-Intracranial hemorrhage & malformations of CNS.
5- A lot of other conditions see textbook…..
Manifestation:
Unlike older children, the neonatal seizure is not generalized rather it is uni or multifocal. They might present with subtle seizure (abnormal eye movement, lip-smacking, swimming or pedaling movements or apnea), so any vague movement in the neonatal period should be taken into consideration.
It’s highly crucial to recognize seizure and differentiate it from conditions that mimic seizure especially jitteriness and neonatal apnea. See below.
*How to differentiate between seizure and jitteriness?
| Clinical feature | Seizure | Jitteriness |
|---|---|---|
| abnormal eye movements | Yes | No |
| induced by stimuli | No | Yes |
| stopped by restraint | No | Yes |
| predominant movement | Clonic jerking | Tremor |
| autonomic changes: tachycardia, flushing, salivation… | Present | Absent |
Look at these videos to see how is seizure in neonates?
How to approach?
Just like any other condition, you gotta take a good history, do a thorough physical examination, send for necessary investigations and lastly provide adequate treatment. It’s crucial to remember when you are receiving a neonate who is convulsing you should not kill time with history and performing examination but rather instantly you gotta have an action which is ABC then after having the neonate stabilized you will get back to history, examination and investigations.
What shall I do while a neonate is convulsing?
ABC, put the neonate on the resuscitator and secure the Airway, if there is any secretion suction the mouth and nose with sucker using appropriate size NG tube, go about 4 cm deep in mouth and 2 cm in each nostril, open mouth, provide O2 if low SPO2. Establish IV access.
Be sure during resuscitation don’t forget to check RBS, if it’s low instantly correct it. See below
History in Neonatal seizure: what questions we’re gonna ask?
Ask the mother to narrate what happened in detail, ask for video record if they did. Does the neonate have fever (meningitis or CNS infection), diarrhea or vomiting (dehydration and electrolyte disturbance), jaundice (kernicterus), ask about history of fetal distress, difficult labor, traumatic delivery, prolonged resuscitation and ask about or look at papers to know about APGAR score in case if available (birth asphyxia), maternal diabetes (hypoglycemia and hypocalcemia), maternal use of drugs during pregnancy (passive narcotic addiction in neonate), family history of epilepsy…etc.
Physical examination:
Uncover the neonate and do a complete examination. Do neonatal reflexes (poor or absent reflexes in birth asphyxia and electrolyte disturbances), hypotonic, hypertonic (birth asphyxia, kernicterus), examine fontanel if it bulged (meningitis, Intracranial hemorrhage or hydrocephalus), examine CVS, Respiratory system, abdomen, and skin.
Investigations:
RBS, CBC, CRP, Serum electrolytes including serum calcium, TSB if jaundiced (kernicterus), Brain Ultrasound. Other investigations like CSF exam with culture, Brain imaging, and others might be ordered if needed.
Treatment of seizure in neonates divides into two parts:
- Treatment of seizure episode itself
- Treatment of underlying conditions
1-Treatment of seizure:
-
- Anticonvulsant drug of choice in the neonatal period is Phenobarbital (LuminalTRN). The loading dose is 20mg/kg slow IV infusion (if no response another loading of 10-20mg/kg can be repeated), followed by maintenance 5mg/kg in 2 divided doses given 24hr after loading dose.
- Phenytoin: if there was no response to two loading doses of Phenobarbital, Phenytoin will be added in a dose of 15-20mg/kg.
- Lorazepam can be given during the attack in a dose of 0.05mg/kg.
- Diazepam: unlike older infants and children Diazepam is not recommended in neonatal seizure but still can be used in a dose of 0.1-0.3mg/kg slow IV over 3-5 minutes
2.Treatment of underlying conditions:
Recognition and correction of the causes are essential and should be dealt with correctly.
1-correction of hypoglycemia: 4ml/kg GW10% followed by IV glucose infusion.
To read more on management on neonatal hypoglycemia click here
2-correction of hypocalcemia: 2-4ml/kg 10%Calcium gluconate inside 10ml GW5% over 10 minutes.
3-treatment of meningitis or CNS infection just in case.
4-treatment of Birth asphyxia just in case.
5-In intractable neonatal seizure a dose of Vitamin B6 100-200mg IV must be given if Pyridoxine dependency is suspected.
*Undoubtedly all neonates with IV cannula need prophylactic antibiotics even in the absence of infection. So in summary if a 1 day-old term, 3 kg neonate presents with convulsion, his RBS and serum calcium are normal, after history taking, physical examination and sending for investigations treatment will be:
1-Incubator (if birth asphyxia set on low temperature) & O2 on need
2-Intravenous fluid according to age and GA, in our case will be GW10% 240ml/24hr.
To know how to calculate IVF in neonates, click here
3-Double antibiotics e.g. Ampicillin vial (100mg/kg/2)150mg*2 & Gentamicin amp (5mg/kg/2) 7.5mg*2.
4-Phenobarbital 3*20=60mg slow IV followed by 3*5=15mg/2 = 7.5mg*2 slow IV 24hr after loading dose. If no response another loading 60mg will be given.
5-If still convulsing Phenytoin 60mg inside 50cc NS over 20minutes will be given.
No need for loading dose of GW10% or Calcium because investigations are normal.
