Neonatal Seizure

By Rahul Dhaker

Lecturer, PCNMS, Haldwani

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.

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.

Classification of seizures

Subtle Tonic Clonic Myoclonic

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.

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

3. Clonic

• Primarily term.

• Rhythmic movement of muscle groups.

• 1-3 jerk per second.

• Associated with EEG changes

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.

Non-epileptic movements

• Jitteriness or tremors

• Normal movements seen more commonly in preterm infants

Causes of neonatal seizures

• Developmental defects

• Hypoxic-ischemic encephalopathy (HIE)

• Intracranial haemorrhage

• Metabolic causes

• Infections

• Miscellaneous

Diagnosis/Approach

• Seizure history

• Antenatal history

• Perinatal history

• Feeding history

• Family history

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

• 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)

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.

• HypocalcemiaAfter 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).

• 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.

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

• 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.

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.

Conclusion

References

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