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Benign Neonatal Convulsions Medication

  • Author: Nitin C Patel, MD, MPH, FAAN; Chief Editor: Amy Kao, MD  more...
 
Updated: Feb 16, 2016
 

Medication Summary

No specific antiepileptic medication is preferred for the treatment of benign neonatal convulsions. In general, most epileptologists agree that status epilepticus should be treated when it occurs. Most neonates are best treated at this time with phenobarbital because of long experience with the drug, convenient monitoring, and adequate intravenous (IV) and (PO) absorption in the neonate or levetiracetam for its low adverse effect profile and ease of use with either parenteral (IV) or liquid (PO) formulations.[51] However, treatment has not been shown unequivocally to have an effect, except possibly to decrease the duration or severity of the seizures. By definition, the seizures resolve in days (benign idiopathic neonatal convulsions [BINCs]) to weeks (benign familial neonatal convulsions [BFNCs]).

Limit the choice of antiepileptic drug to those with no serious potential adverse effects. Most notably, avoid valproate in this age group if benign convulsions are suspected, because neonates are at the highest risk for liver failure due to valproate. Avoid phenytoin because of cardiac adverse effects, the high possibility of extravasation in neonates, and problems with reliable absorption if administered PO. A trial off the antiepileptic drug(s) should begin soon after the seizures stop and the electroencephalogram (EEG) is normal.

An important factor to remember when treating neonates is that pharmacokinetics and pharmacodynamics are very different than in infants. Do not use infant loading dosages, as they may lead quickly to toxic levels that resolve slowly.

Neonatal pharmacology is complex. Maturation of general liver and renal function is in a period of transition from the fetal to infant state. Stresses or lack of stress on the systems in utero greatly affect the function and maturation of both systems.

Normal glomerular filtration rate (GFR) in the neonate varies in individuals from 1 to 4 mL/min and can increase rapidly as maturation of the renal cortex progresses. Adult values for GFR are not reached before the infant is aged 2.5-5 months.

Blood flow within the hepatic portal system changes at birth with closing of the ductus venosus. Maturation of the glucuronidation pathway is often slowed. Neonates whose mothers have been exposed to drugs (both prescribed and otherwise) may have active cytochrome P-450 enzymes, and unexposed neonates have initial low activities that usually increase rapidly with the introduction of drugs such as phenobarbital.

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Anticonvulsants

Class Summary

Anticonvulsants prevent seizure recurrence and terminate clinical and electrical seizure activity.

Phenobarbital (Luminal)

 

Phenobarbital is the drug of choice for treatment of neonatal seizures. Use care in the dosing of this agent, as toxicity can occur quickly and resolve slowly. Also note doses that are initially adequate may need to be increased quickly as cytochrome P-450 becomes more active.

Fosphenytoin (Cerebyx)

 

Fosphenytoin may initially be used to control status epilepticus in patients with benign neonatal convulsions; however, this agent is unsuitable for long-term therapy.

Topiramate (Topamax)

 

Topiramate is a sulfamate-substituted monosaccharide with a broad spectrum of antiepileptic activity that may have state-dependent sodium channel blocking action. This agent potentiates the inhibitory activity of the neurotransmitter gamma-aminobutyric acid (GABA) and may block glutamate activity.

Levetiracetam (Keppra)

 

The exact mechanism of action is unknown. Stereoselective binding of levetiracetam is confined to synaptic plasma membranes in the central nervous system with no binding occurring in peripheral tissue. Levetiracetam inhibits burst firing without affecting normal neuronal excitability, which suggests it may selectively prevent hypersynchronization of epileptiform burst firing and propagation of seizure activity.

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Benzodiazepines

Class Summary

Alternative intravenous medications used in treating benign neonatal convulsions include benzodiazepines. The disadvantages of benzodiazepines are that they are overdosed easily in the neonate and can be very sedating.

Lorazepam (Ativan)

 

Lorazepam is a benzodiazepine with a short onset of effects and relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, it may depress all levels of the CNS, including limbic and reticular formation.

Diazepam (Valium)

 

Diazepam is a benzodiazepine that is an extremely lipid-soluble agent and enters brain very quickly in first pass and often will stop seizures in 1-2 min. It modulates the postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. It appears to act on part of the limbic system, the thalamus, and hypothalamus, to induce a calming effect.

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Contributor Information and Disclosures
Author

Nitin C Patel, MD, MPH, FAAN Professor of Clinical Pediatrics and Neurology, Southern Illinois University School of Medicine; Private Practice, Columbia Center for Child Neurology

Nitin C Patel, MD, MPH, FAAN is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, Child Neurology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nancy Theresa Rodgers-Neame, MD Assistant Professor, Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine; Director, Florida Comprehensive Epilepsy and Seizure Disorders Program

Nancy Theresa Rodgers-Neame, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Womens Association, Society for Neuroscience, Southern Medical Association

Disclosure: Nothing to disclose.

Robin D Riggins, RN, MSN, CPNP Pediatric Nurse Practitioner, Department of Pediatric Neurology, University of Missouri Health Care Hospitals and Clinics

Robin D Riggins, RN, MSN, CPNP is a member of the following medical societies: National Association of Pediatric Nurse Practitioners, American Association of Neuroscience Nurses

Disclosure: Nothing to disclose.

Harsha N Patel, MD, MPH Assistant Professor, Department of Child Health, University Hospital; Assistant Professor, Department of Pediatrics, University of Missouri-Columbia School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD Attending Neurologist, Children's National Medical Center

Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Child Neurology Society

Disclosure: Have stock from Cellectar Biosciences; have stock from Varian medical systems; have stock from Express Scripts.

Acknowledgements

Robert J Baumann, MD Professor of Neurology and Pediatrics, Department of Neurology, University of Kentucky College of Medicine

Robert J Baumann, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, and Child Neurology Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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