eMedicine Specialties > Neurology > Pediatric Neurology

Neonatal Seizures: Treatment & Medication

Author: Raj D Sheth, MD, Professor of Neurology, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic
Contributor Information and Disclosures

Updated: Nov 16, 2009

Treatment

Medical Care

Acute neonatal seizures should be treated aggressively.6 Controversy exists as to what is the optimal treatment for neonatal seizures.8  

When clinical seizures are present, a rigorous workup to determine an underlying etiologic cause should be initiated quickly. The following points should be attended to:

  • Electrolyte imbalances should be corrected through a central venous site. Hypocalcemia should be treated cautiously with calcium, since leakage of calcium into subcutaneous tissue can cause scarring.
  • Obtain EEG when uncertain as to whether the observed events are epileptic or nonepileptic.
  • When an inborn error of metabolism is suspected, discontinue feeding since feeding may exacerbate the seizures and encephalopathy. Institute intravenous solutions.
  • Once these issues have been addressed, antiepileptic drug (AED) therapy should be considered. Phenobarbital is the initial drug of choice. If seizures persist, the use of phenytoin should be considered.

Consultations

Neurology consultation is recommended to help with the evaluation of seizures, EEG, video EEG monitoring, and management of anticonvulsant medications.

Medication

Antiepileptic medications should be instituted in an orderly and efficient manner (Painter et all 1999). Correct hypoglycemia, if present. Initial treatment with phenobarbital should be considered. If seizures persist, phenytoin should be added. Persistent seizures may require use of an intravenous benzodiazepine such as lorazepam or midazolam.

Anticonvulsants

These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.


Phenobarbital (Luminal, Barbita)

Important to use minimal amount required and to wait for anticonvulsant effect to develop before giving second dose. Start with loading dose and continue with maintenance dosage.

Adult

Pediatric

Loading dose: 20 mg/kg/d IV
Maintenance dose: 5-8 mg/kg/d IV

No known contraindications for use in neonates

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; exercise caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia, since adverse reactions can occur; exercise caution in patients with myasthenia gravis or myxedema


Phenytoin (Dilantin)

Should be added to phenobarbital if seizures persist. May act in motor cortex where may inhibit spread of seizure activity. Activity of brainstem centers responsible for tonic phase of grand mal seizures also may be inhibited.

Adult

Pediatric

Initial dose: 20 mg/kg/d IV
Maintenance dose: 5-8 mg/kg/d IV

Barbiturates may decrease effects

No known contraindications for use in neonates

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hemodynamic stability should be monitored during IV administration; therapeutic levels are often difficult to maintain via enteral administration in neonates


Lorazepam (Ativan)

Benzodiazepine anticonvulsant; use in cases refractory to phenobarbital and phenytoin. By increasing action of GABA, which is major inhibitory neurotransmitter in brain, may depress all levels of CNS, including limbic and reticular formation.

Adult

Pediatric

0.05-0.1 mg/kg IV, followed by 0.05-mg/kg increments until seizures controlled

Barbiturates may increase CNS toxicity

No known contraindications for use in neonates

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

With concurrent phenobarbital, monitor blood pressure and respiration

Vitamins

This agent may be effective in seizures refractory to medications already discussed. It is essential for normal DNA synthesis and cell function.


Pyridoxine (Nestrex)

Should be tried in patients not responding to above regimen. Patients with pyridoxine-dependent seizures respond immediately to pyridoxine.

Adult

Pediatric

50-100 mg IV with EEG monitoring to determine response

No known contraindications for use in neonates

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

None in neonates

More on Neonatal Seizures

Overview: Neonatal Seizures
Differential Diagnoses & Workup: Neonatal Seizures
Treatment & Medication: Neonatal Seizures
Follow-up: Neonatal Seizures
Multimedia: Neonatal Seizures
References
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References

  1. Volpe JJ. Hypoxic-Ischemic Encephalopathy: Biochemical and Physiological Aspects. In: Neurology of the Newborn. 4th ed. Philadelphia: WB Saunders; 2000:217-276.

  2. Scher MS, Trucco GS, Beggarly ME, et al. Neonates with electrically confirmed seizures and possible placental associations. Pediatr Neurol. Jul 1998;19(1):37-41. [Medline].

  3. Silverstein FS, Jensen FE. Neonatal seizures. Ann Neurol. Aug 2007;62(2):112-20. [Medline].

  4. Sheth RD, Hobbs GR, Mullett M. Neonatal seizures: incidence, onset, and etiology by gestational age. J Perinatol. Jan 1999;19(1):40-3. [Medline].

  5. Vigevano F. Benign familial infantile seizures. Brain Dev. Apr 2005;27(3):172-7. [Medline].

  6. Sheth RD, Buckley DJ, Gutierrez AR, et al. Midazolam in the treatment of refractory neonatal seizures. Clin Neuropharmacol. Apr 1996;19(2):165-70. [Medline].

  7. Sheth RD. Electroencephalogram in developmental delay: specific electroclinical syndromes. Semin Pediatr Neurol. Mar 1998;5(1):45-51. [Medline].

  8. Sankar R, Painter MJ. Neonatal seizures: after all these years we still love what doesn't work. Neurology. Mar 8 2005;64(5):776-7. [Medline].

  9. Lombroso CT. Neonatal seizures: gaps between the laboratory and the clinic. Epilepsia. 2007;48 Suppl 2:83-106. [Medline].

  10. Painter MJ, Scher MS, Stein AD, et al. Phenobarbital compared with phenytoin for the treatment of neonatal seizures. N Engl J Med. Aug 12 1999;341(7):485-9. [Medline].

  11. Sheth RD. Electroencephalogram confirmatory rate in neonatal seizures. Pediatr Neurol. Jan 1999;20(1):27-30. [Medline].

  12. Sheth RD. Frequency of neurologic disorders in the neonatal intensive care unit. J Child Neurol. Sep 1998;13(9):424-8. [Medline].

  13. Sheth RD, Bodensteiner JB. Delayed postanoxic encephalopathy: possible role for apoptosis. J Child Neurol. Jul 1998;13(7):347-8. [Medline].

  14. [Best Evidence] Pisani F, Sisti L, Seri S. A scoring system for early prognostic assessment after neonatal seizures. Pediatrics. Oct 2009;124(4):e580-7. [Medline].

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Further Reading

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Keywords

neonatal seizures, benign familial neonatal convulsions, benign neonatal convulsions, fifth day convulsions, fifth day fits, myoclonic seizures, newborn fits, hypoxic-ischemic encephalopathy, intracranial hemorrhage in a newborn, subarachnoid hemorrhage in infants, germinal matrix-intraventricular hemorrhage, subdural hemorrhage, cerebral contusion, metabolic disturbances, hypoglycemia, hypocalcemia, hypomagnesemia, meningitis, encephalitis, herpes encephalitis, toxoplasmosis, cytomegalovirus, CMV infection, lissencephaly, pachygyria, polymicrogyria, linear sebaceous nevus syndrome, benign neonatal seizure syndromes, benign idiopathic neonatal seizures, benign sleep myoclonus

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Contributor Information and Disclosures

Author

Raj D Sheth, MD, Professor of Neurology, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic
Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, and Child Neurology Society
Disclosure: Nothing to disclose.

Medical Editor

Robert Stanley Rust Jr, MD, MA, Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, Director, Child Neurology, University of Virginia; Chair-Elect, Child Neurology Section, American Academy of Neurology
Robert Stanley Rust Jr, MD, MA is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, American Neurological Association, Child Neurology Society, International Child Neurology Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Neurology, Department of Neurology, Oregon Health and Science University; Consulting Staff, Shriners Hospital for Children
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

 
 
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