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Morning Report: Friday, February 3rd
 Neonatal seizures (NS) result from a rapid
depolarization of brain cells excessive
synchronous electrical activity
 Brain cells of newborns are immature and
vulnerable to insults

Therefore, neonatal seizures often indicate an
underlying neurologic disturbance
 REQUIRE
IMMEDIATE ASSESSMENT TO
DETERMINE THE UNDERLYING CAUSE AND
NECESSARY INTERVENTIONS!!!
 Incidence varies widely
Gestational age
 Weight
 Cause of NS

 Some statistics:
Preterm infants <1,500g: 19-57.5/1000 live births
 Preterm/ term infants >2,500g: 2.8/1000 live births

 Hypoxic-ischemic encephalopathy
 Intracranial infections
 Intracranial hemorrhage

Non-accidental trauma
 Cortical (structural) brain malformations
 Metabolic derangements
 Inborn errors of metabolism
 Genetic epileptic syndromes
 A term 3500g male infant is admitted to the NICU
after precipitous vaginal delivery in the ED to a
G34 P4 24 yo mother without PNC. On PE, the
infant has normal VS, a HC of 35.5cm, and normal
general examination findings. 12h after birth, the
nurse notes brief jerking in one of the infant’s arms.
Thirty minutes later, the other arm jerks, and the
nurse places a hand on the arm, noting the jerking is
not suppressible. Of the following, the most likely
cause of the jerking is:





A. Benign neonatal myoclonus
B. Jitteriness due to drug withdrawl
C. Seizure due to CMV infection
D. Seizure due to hypocalcemia
E. Seizure due to hypoxic-ischemic injury
 Most common cause of NS
 50-60% of cases
 *Seizures usually occur
within the first 24h after
birth

Severity can increase with
time
 *Majority of full term
newborn with NS secondary
to asphyxia do NOT
manifest long-term
neurodevelopmental
sequelae
 Account for 10-20% of NS
 Most common cause in developing countries
 Seizures usually begin during the end of the first
week of life
 Pathogens

Bacteria
Listeria
 GBS
 E.Coli


Viruses
HSV
 CMV
 Rubella

 Accounts for ~10% of NS cases
 Preterm infants

Intraventricular hemorrhage
 Grade I-II usually
asymptomatic
 Grade III-IV symptomatic
• Seizures focal and persistant
 Term infants

Subarachnoid hemorrhage
 Most
common type of ICH
 Birth trauma
 Term infants

Subarachnoid hemorrhage (con’t)
 Not

associated with long-term neurologic sequelae
Subdural hemorrhage
 Birth
trauma
 Consider NAT in an infant who has been d/ed from
the hospital
Intraventricular
hemorrhage
Subdural
Hemorrhage
Subarachnoid
Hemorrhage
 Seizures with variable onset
 Dysmorphic features, microcephaly or
cutaneous lesions may suggest this diagnosis
 Electrolyte abnormalities
Hypoglycemia
 Hypocalemia
 Hyper or hyponatremia

 At risk patients:
IDM (hypoglycemia and hypocalcemia)
 Preterm infants
 SGA infants

 Aminoacidopathies (PKU, MSUD)
 Urea cycle defects (OTC deficiency)
 Mitochondrial disorders
 Beta-oxidation defects (MCAD, LCAD)
 Pyridoxine dependency
 Benign familial neonatal convulsions
 May occur 15-20 times per day
 Outgrown by 1 yo
 “Fifth day fits”
 Observed in term infants during the first postnatal
week
 Resolve within 24h
 Ohtahara syndrome (early infantile epileptic
encephalopathy



?Due to malformations in cortical development
Brief, repetitive tonic spasms
Progressive neurologic deterioration and poor
prognosis
 You are called to the nursery to evaluate a 12h old infant for
episodes of jerking. She had been born following a term
pregnancy. Vaginal birth was attempted after a prior C/S. Fetal
monitoring had shown an apparently reassuring HR and normal
status PTD. After replacing the monitor following transport from
the labor room to the delivery room, the tracing indicated an
abrupt decrease in HR. A stat C/S revealed that the uterus had
ruptured and the infant was out of the uterus and in the
abdominal cavity. The baby required intubation and chest
compressions (no epi). Apgars were 1, 1 and 5 at 1, 5, and 10
mins. You question the parents and nurse about any possible
seizures. Of the following, the description that MOST likely
indicates that the child is having a NS is:
A. Episodes of apnea and bradycardia
B. Fatiguing and vomiting during feeds
 C. Focal jerking in both arms simultaneously but asynchronously
 D. Limb jerking triggered by touching the child
 E. Spontaneous limb jerking that stops when a hand is placed on the
child


 Preterm Infants
 Roving eyes
 Sustained eye opening or fixation
 Bicycling
 Lip smacking
 Unresponsiveness
 Term infants
 Sustained tonic horizontal eye deviation
 +/- Jerking
 +/- Apnea
 Top priority is identifying an underlying
etiology

NEONATAL SEIZURES ARE VERY RARELY
IDIOPATHIC!!
 Detailed history and PE
Maternal RF
 Complications of pregnancy, labor and delivery

 Screening labs
 Acucheck
 Electrolytes
 Ammonia
 Blood gas
 LP
 Additional studies
 Neuroimaging
 Serum AA, lactate, UOA
 Viral titers
 Karyotype
 Tox screen
 Due to the immature myelination of the
neuronal network
Some behavioral or motor manifestations of NS
may not be detected on surface EEG
 Surface EEG findings may be present when there
are no observable clinical manifestations

 ABCs!!
 Treat underlying
problem
 Treat seizures
 A term infant is delivered via emergency C/S
following the acute onset of maternal vaginal
bleeding and profound fetal bradycardia. Apgars are
1, 2, and 3 at 1, 5, and 10 minutes, respectively.
Resuscitation includes intubation and assisted
ventilation, chest compressions, and IV epi. The
infant is admitted to the NICU and has seizures at 6h
of life. Of the following, a TRUE statement about
infants who have seizures following perinatal
asphyxia is that most:





A. Develop epilepsy
B. Develop microcephaly
C. Do not have long-term neurodevelopmental delay
D. Experience hearing loss
E. Require multiple anticonvulsant medications
 Cause is the MOST important factor that
determines the outcome of NS
Patients with self-resolving conditions (i.e.: “fifth day
fits”) do well
 Patients with underlying brain disorders are more
likely to have long-term sequelae

 Other factors that affect prognosis:
 Gestational age and BW
60% of term infants >25oog with NS were later found to
be developmentally normal
 20% of preterm infants <1500g with NS were found to be
normal

 Other factors that affect prognosis (con’t)
 Apgar scores
 Need for mechanical ventilation
 Neurologic findings
 Findings on EEG and U/S
 Overall, high incidence of:
 Early death (24 to 30 percent)
 Neurologic impairments (20 to 60 percent)
 Developmental delay (up to 55 percent)
 Postneonatal epilepsy (20 to 30 percent)
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