1. Neonatal Seizure
By Rahul Dhaker
Lecturer, PCNMS, Haldwani

2. Introduction
Neonatal seizures are usually the clinical
manifestation of a serious underlying
disease. Seizures constitute a medical
emergency because they signal a disease
process that may produce irreversible
brain damage.

3. Definition
• A seizure is a paroxysmal behaviour
caused by hyper-synchronous discharge
of a group of neurons.
• Neonatal seizures are the most common
overt manifestation of neurological
dysfunction in the newborn.

4. Classification of
seizures
Subtle Tonic Clonic Myoclonic

5. 1. Subtle
• Specially seen in preterm and term.
• In this clinical manifestation are mild &
frequently missed.
• Usually mild paroxysmal alterations in motor,
behavior or autonomic function that are not
clearly clonic, tonic or myoclonic.
• Commonest type constitute 50% of all
seizures.

6. 2. Tonic
• Primarily preterm.
• Characterized by flexion
or extension of axial or
appendicular muscle
groups.
• May be focal or
generalized
– Decerebrate – tonic
extension of all limbs
– Decorticate – flexion of
upper limbs & extension
of lower limbs.
• No ECG change

7. 3. Clonic
• Primarily term.
• Rhythmic
movement of
muscle groups.
• 1-3 jerk per
second.
• Associated with
EEG changes

8. 4. Myoclonic
Single or multiple lightning fast jerks of
the upper or lower limbs and are usually
distinguished from clonic movements
because of more rapid speed of myoclonic
jerks, absence of slow return and
predilection for flexor muscle groups.

9. Non-epileptic movements
• Jitteriness or tremors
• Normal movements seen more commonly
in preterm infants

10. Causes of neonatal seizures
• Developmental defects
• Hypoxic-ischemic encephalopathy (HIE)
• Intracranial haemorrhage
• Metabolic causes
• Infections
• Miscellaneous

11. Diagnosis/Approach
• Seizure history
• Antenatal history
• Perinatal history
• Feeding history
• Family history

12. Investigations
• Mandatory investigations:
– Blood sugar,
– Hematocrit,
– Bilirubin (if jaundice is present clinically),
– Serum electrolytes (Na, Ca, Mg)
– Arterial blood gas, anion gap,
– Cerebrospinal fluid (CSF) examination,
– Cranial ultrasound (US) and
– Electroencephalography (EEG)
• Specific investigations
– Neuroimaging
– CT,
– MRI

13. • Screening for congenital infections
• TORCH screen and VDRL
• Metabolic screening
– Blood and urine ketones,
– Urine reducing substances,
– Blood ammonia, anion gap,
– Urine and plasma aminoacidogram,
– Serum and CSF lactate/ pyruvate ratio
Electro-encephalogram (EEG)

14. Treatment
• Initial medical management
– Thermoneutral environment
– Ensure airway, breathing and circulation
– O2 inhalation
– IV access & fluid administration
– Blood test for sugar and other investigations.
– A brief relevant history should be obtained
– Quick clinical examination
• Hypoglycemia
• Check glucose level-
If shows hpoglycemia,
– 2 ml/kg of 10% dextrose should be given as a bolus injection
followed by a continuous infusion of 6-8 mg/kg/min.

15. • Hypocalcemia
After treatment of hypoglycemia give 2ml/kg
of 10% calcium gluconate IV over 10 minutes
under strict cardiac monitoring.
If ionized calcium levels are suggestive of
hypocalcemia, the newborn should receive
calcium gluconate at 8 ml/kg/d for 3 days.
If seizures continue despite correction of
hypocalcemia, 0.25 ml/kg of 50% magnesium
sulfate should be given intramuscularly (IM).

16. • Anti-epileptic drug therapy (AED)
Anti-epileptic drugs (AED) should be
considered in the presence of even a single
clinical seizure
Anti-epileptic drugs (AED) should be
considered in the presence of even a single
clinical seizure
AED should be given if seizures persist
even after correction of hypoglycemia/
hypocalcemia.

17. Nursing Management
• Emergency Care & observation during
seizure:-
A nurse should be prepared for first aid
measures & should instruct to the family
members. This includes:
– Lie down the child in a flat surface
– Loosen tight clothes
– Remove dangerous object from the area
– Do not force in to the child’s mouth
– Allow the seizures to run
– After the seizures stop turn the child to one side
to drain the saliva
– Check breathing pattern give CPR if needed
– Observe child until fully conscious
– Treat any injury if had

18. • Psychosocial care of family members:-
Epilepsy caries a stigma in the society.
Child may feel different from their
peers & their parents may not allow
their children to have friendship with
them.
Child will become frustrated, epileptic
child should be encouraged to do their
best in school.
Their seizures should not be used as an
excuse to shirk their responsibilities.

19. AIIMS- NICU protocols 2007
Abstract:-
Seizures in the newborn period constitute a medical emergency. Subtle
seizures are the commonest type of seizures occurring in the neonatal
period. Other types include clonic, tonic, and myoclonic seizures.
Myoclonic seizures carry the worst prognosis in terms of long-term neuro
developmental outcome. Hypoxic-ischemic encephalopathy is the most
common cause of neonatal seizures. Multiple etiologies often co-exist in
neonates and hence it is essential to rule out common causes such as
hypoglycemia , hypocalcemia, meningitis before initiating specific
therapy. A comprehensive approach for management of neonatal
seizures has been described.

20. Conclusion

21. References
1. Marlow.R. Dorothy. TextBook fo Pediatric Nursing.Sixth
Edition2007.Elsevier publisher. Page no. 958-966
2. Mizrahi EM, Kellaway P. Characterization and classification. In
Diagnosis and
management of neonatal seizures. Lippincott-Raven, 1998; pp 15-
35
2. Ellenburg JH, Hirtz DG, Nelson KB. Age at onset of seizures in
young children. AnnNeurol 1984;15:127-34
3. National Neonatal Perinatal Database. Report for year 2002-03.
National NeonatologyForum, India.
4. Volpe JJ. Neonatal Seizures. In Neurology of the newborn.
Philadelphia: WB Saunders,1999; 172-225
5. Painter MJ, Scher MS, Stein MD, Armatti S, Wang Z, Gardner
JC et al. Phenobarbitonec ompared with phenytoin for treatment
of neonatal seizures. N Engl J Med 1999;341:485-9
6. Rennie JM. Neonatal seizures. Eur J Pediatr 1997;156:83-7
7. Nirupama Laroia. Controversies in diagnosis and management of
neonatal seizures.Indian Pediatr 2000;37:367-72