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The neonatal period (birth to 28 days) is a highly
vulnerable time for an infant, who is completing many
of the physiologic adjustments required for
The high neonatal morbidity and mortality rates attest
to the fragility of life during this period; of all deaths
occurring in the 1st yr of life in the USA, two thirds are
in the neonatal period.
A seizure is a transient occurrence of signs and/or
symptoms resulting from abnormal excessive or
synchronous neuronal activity in the brain.
Epilepsy is a disorder of the brain characterized by an
enduring predisposition to generate seizures and by
the neurobiologic, cognitive, psychological, and social
consequences of this condition.
Seizure disorder is a general term that is usually used to
include any one of several disorders including epilepsy
and seizures 2ry to metabolic, infectious, or other
etiologies (hypocalcemia, meningitis).
An epileptic syndrome is a disorder that manifests one
or more specific seizure types and has a specific age of
onset and a specific prognosis.
An epileptic encephalopathy is an epilepsy syndrome
in which the severe EEG abnormality is thought to
result in cognitive and other impairments in the
•Seizures are the most important and common indicator
of significant neurologic dysfunction in the neonatal
•Seizure incidence is higher during this period than in
any other period in life:
57.5/1,000 in infants with birth weights <1,500 g
2.8/1,000 in infants weighing between 2,500 and
3,999 g have seizures.
•More liable for seizures
Defective balance between excitatory and inhibitory
Types of neonatal Seizures
5 main types:
1. Subtle Seizures:
Subtle seizures include:
1.Transient eye deviations, nystagmus, blinking,
3.abnormal extremity movements (rowing, swimming,
bicycling, pedaling, and stepping),
4.fluctuations in heart rate, hypertension episodes.
Subtle seizures occur more commonly in premature than
in full-term infants.
•Tonic seizures can be focal or generalized (generalized
are more common).
•Focal tonic seizures include persistent posturing of a
limb or neck in an asymmetric way often with persistent
horizontal eye deviation.
•Generalized tonic seizures are bilateral tonic limb
extension or tonic flexion of upper extremities often
associated with tonic extension of lower extremities.
3. Clonic Seizures:
•Clonic seizures can be focal or multifocal.
•Multifocal clonic seizures incorporate several body
parts and are migratory in nature.
•Generalized clonic seizures, which are bilateral,
symmetrical, and synchronous, are uncommon in the
neonatal period .
Spasms are sudden generalized jerks lasting 1-2 sec that
are distinguished from generalized tonic spells by their
shorter duration and by the fact that spasms are usually
associated with a single, very brief, generalized
5. Myoclonic Seizures:
•Myoclonic seizures are divided into focal, multifocal,
and generalized types.
•Myoclonic seizures can be distinguished from clonic
seizures by the rapidity of the jerks and by their lack of
•Focal myoclonic seizures affect the flexor muscles of
the upper extremities.
•Multifocal myoclonic movements involve
asynchronous twitching of several parts of the body.
•Generalized myoclonic seizures involve bilateral
2.Drug withdrawal or toxicity
4.Acute metabolic disorders:
•hypo or hyper natremia)
5.Inborn errors of metabolism (ex.
1.Infection ( meningitis , encephalitis)
2.Metabolic ( hypocalcemia, persistent
3.Benign neonatal convulsion.
5. Drug withdrawal
6. Developmental delay, epilepsy, neonatal
1.Infection ( meningitis , encephalitis)
2.Head injury( subdural hemorrhage, child
3.Inherited disorders of metabolism (ex.
4.Malformation of cortical development (ex
5. Tuberous sclerosis.
6. Sturge weber syndrome.
Put them all together..
1. Hypoxic ischemic encephalopathy (50-60)%.. Most
common cause of neonatal seizure.
2. Vascular events (10 -20) %
3. Intracranial infection (5-10)%
4. Brain malformation (5-10)%
5. Metabolic disturbances (↓glycemia, Ca, Mg,↓ ↓
6. Drugs ( withrawal or toxicity)
7. Neonatal seizure syndromes : rare . AD.
1. HISTORY: PRENATAL & POSTNATAL
• History of fetal distress, maternal infection
(TORCH) , preeclampsia and diabetes.
• Delivery history: type, duration, APGAR score,
temperature and b. sugar instability.
• Family history may suggest a genetic syndrome
• Neurological examination.
• Ophthalmological exam: chorioretinitis, coloboma.
• Skin : café au lait spots, shagreen patch, adenoma
Complete blood count.
Serum level of:
Blood urea nitrogen
Blood and urine
Serological tests for
Specific test for
inborn errors of
- is indicated in virtually all neonates with seizures,
unless the cause is obviously related to a metabolic
disorder such as hypoglycemia or hypocalcemia
which usually respond promptly to appropriate
- LP may reveal features of meningitis.. Bloody CSF
may indicate SAH
EEG is considered the
main tool for diagnosis.
Cranial US, CT and MRI.
4. Differential Diagnosis:
• Startle or Moro reflex.
• Sleep myoclonus .
Fast and fine
No eye deviation
HR and BP normal
Immediate: give O2, maintain airway, insert IV, treat
Anticonvulsants: When to start anticonvulsants is
controversial because risks and benefits of
treatment have not been properly evaluated;
usual indication is >3 seizures/hr or single seizure
A. Phenobarbital: drug of choice:
• 20 ml/kg over 5-10 min up to 40 ml/kg.
B. Phenytoin & Fosphenytoin:
• 15-20 ml/kg phenytoin or 15- 20 PE/kg fosphenytoin.
C. Lorazepam :
• 0.05 – 0.1 mg/kg
D. Diazepam and Midazolam:
• 0.1 – 0.3 mg/kg over 3-5 min. Diazepam.
• 0.05 – 0.1 mg/kg . Midazolam.
• Treat Underlying Cause:
•Hypoglycemia : Glucose infusion 2 ml per kg of 10%
glucose, through an I.V. line is given over 2-3 min
•Hypomagnesemia: MgSO4(0.4-0.8 mEq/kg); given IV
every 12 hours until Mg level is normal.
•Infection: Appropriate antibiotics
•Hypocalcemia: I.V administration of 2 ml/kg of Calcium
gluconate given over 5 min.
•Pyridoxine deficiency: IV administration of 50 mg
pyridoxine is effective.
•Mortality ↓ed from 40 to 20%.
•Dep. on EEG and underlying causes:
HIE …. 50% chance of normal development.
Seizure 2ry to hypocalcemia …. Much better prognosis