Benign Neonatal Convulsions Treatment & Management

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

Approach Considerations

Although the seizures are benign, general agreement exists that they should be treated, particularly benign idiopathic neonatal convulsions (BINCs).

Patients should be observed in the inpatient unit, until the physician is satisfied that the patient's condition is stabilized and that the infant is feeding well and is free of seizures that compromise feeding or sleeping. In some situations, patients may be seizure free at discharge, but this is not a requirement. Exclude reasonable alternative diagnoses before discharge.

The choice to continue or discontinue any medications that were started can be tailored to each patient. Consider each of the following:

  • Have the seizures abated to the point that they are no longer interfering with function?
  • What is the family's level of comfort? Fully inform the patient's family of the situation and address their questions and concerns before the infant’s discharge.
  • Is the electroencephalogram (EEG) improved? A normal EEG is not required, but improvement in the EEG indicates that the diagnosis is more likely to be benign and that the prognosis is good for continued improvement at home. Likewise, the typical pattern (ie, theta pointu alternant) indicates a benign course. Conversely, deterioration of the EEG background or development of a less benign pattern may indicate a less benign prognosis.

It is important to keep in mind that other seizure types are often intermixed in families with inherited seizure disorders. This is also observed in families with benign neonatal convulsions. Children (and apparently unaffected siblings) who have benign neonatal convulsions are at an increased risk of seizures in later life.

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Medical Management

Treatment with antiepileptic medications may prevent the occurrence or reduce the length of the period of status epilepticus. Continuing antiepileptic treatment for more than 10 days may not be necessary in benign idiopathic neonatal convulsions. Keep in mind that during treatment although the seizures may abate, the electroencephalogram (EEG) may remain abnormal. In some cases, the EEG may change appearance but remain abnormal nevertheless.

No known antiepileptic medications alter the behavior of the potassium channel. Other drugs known to have an effect on potassium transporters are currently being considered for investigation. No studies have revealed any medications that have any advantage over other medications. Select medications on the basis of the following 2 factors:

  • Appropriateness of the drug in neonates
  • Lack of significant serious adverse effects

The most important consideration in choosing an antiepileptic medication in these patients is to remember that the syndrome is benign. Therefore, any medication chosen should have no risk of serious adverse effects.

The medications used most frequently are benzodiazepines, phenobarbital, levetiracetam, and fosphenytoin, but no particular reason exists for the preferential use of these drugs rather than some of the newer drugs, except for their current availability in intravenous (IV) formulations and the long-term experience with their use in neonates.

The disadvantages of phenobarbital and benzodiazepines are that they are overdosed easily in the neonate and can be very sedating. In addition, ample evidence shows that GABA-A agonists may not be a good choice in the immature brain. Phenobarbital has potential long-term effects on neurocognitive development. [49]

Fosphenytoin may be used acutely, but phenytoin is absorbed unpredictably in the neonate and should not be used as an oral preparation.

Levetiracetam is rapidly absorbed and is eliminated through the renal system. The most reported adverse effects are somnolence and behavior problems. [50]

Valproate and phenytoin are less appropriate choices. Generally, valproate in very young patients is reserved for serious conditions that do not respond to therapy with other medications, because the high risk of hepatic complications must be outweighed by the risk of the seizures themselves, a situation that normally is not under consideration in a benign condition. Phenytoin is less appropriate because of an unpredictable decreased absorption in the neonate when administered orally (PO) and a high possibility of IV extravasation in neonates.

When IV and liquid formulations become available, some of the newer drugs may prove to be of greater benefit in the future, owing to their multiple mechanisms of action and their neuromodulatory/neuroprotective effects.

Special concerns

Gamma-aminobutyric acid (GABA)–A agonists (barbiturates and benzodiazepines) should be used with caution in the neonate.

Use caution when treating status epilepticus with phenobarbital in neonates. Mistaking a normal deep anesthesia EEG in this age group with a burst suppression pattern of status epilepticus is easy.

Do not treat neonates in whom benign convulsions are suspected with valproate because of the increased risk of liver failure with the drug and the benign nature of the syndrome.

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Complications

Patients with benign familial neonatal convulsions have an increased risk of developing seizures in later life; depending on the study, 11-20% of patients develop epilepsy in later life. Some families examined have also demonstrated an increased risk of epilepsy in apparently unaffected siblings.

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Long-Term Monitoring

Follow-up care should consist of a visit soon after discharge to confirm that the patient is physically and neurologically healthy. Perform a repeat electroencephalogram (EEG) at that time.

Provide later follow-up care spaced at intervals consistent with the physician's and parents' level of comfort. In general, at least 2 serial assessments spaced several months apart should demonstrate a normal EEG, normal developmental milestones, and normal findings on neurologic examination.

Currently, the most appropriate medications for neonates that can be given in both intravenous (IV) and oral (PO) formulation after discharge remain phenobarbital and levetiracetam. In the future, other medications may prove more appropriate.

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