Neonatal Seizures

Presentation

• Often subtle: lip-smacking, bicycling/pedaling, eye deviation, apnea/staring
• Clonic movements (rhythmic jerking that cannot be suppressed by gentle limb restraint)
• Tonic posturing (stiffening)
• Differentiate from benign neonatal sleep myoclonus or jitteriness (which stops with restraint and has no ocular symptoms)

Acute Workup

• Stat glucose to rule out severe hypoglycemia
• Continuous video EEG (gold standard) because subclinical/electrographic-only seizures are very common
• Basic labs: Serum calcium, magnesium, electrolytes, blood gas
• Head ultrasound (rule out major IVH) and subsequently MRI brain (hypoxia, infarction, malformation)
• Sepsis workup: Consider LP for meningitis if signs of infection present

Acute Management Protocol

• Ensure ABCs: patent airway, adequate oxygenation, normoglycemia
• First-line anti-seizure medication: Phenobarbital (20 mg/kg IV loading dose)
• Second-line medications: Levetiracetam (Keppra), Fosphenytoin, or Midazolam infusion
• Address underlying etiology (e.g., correct calcium, start antibiotics for meningitis, cooling for HIE)
• Pyridoxine (Vitamin B6) trial for refractory seizures (rule out pyridoxine-dependent epilepsy)

Neurocritical Care & Monitoring

• Maintain strict midline head positioning, elevate head of bed 15-30 degrees to optimize venous return and minimize ICP.
• Phenobarbital dosing: 20 mg/kg IV loading dose (push rate < 1 mg/kg/min to avoid cardiovascular collapse).
• Continuous aEEG (Amplitude-integrated EEG) monitoring for minimum 72 hours for all encephalopathic infants.
• Minimal handling protocol: cluster nursing care, restrict visitors, reduce ambient noise and keep isolette heavily shielded from light.
• Assess anterior fontanelle fullness and head circumference daily.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• Neonatal Seizure Protocol: [START] Clinical/EEG confirmed seizures -> [PHARMACOLOGY] Phenobarbital 20mg/kg IV load -> [DECISION] Seizures persist? -> [YES] Phenobarbital repeat 10-20mg/kg -> [DECISION] Refractory? -> [YES] Levetiracetam / Fosphenytoin

References

1. Pressler RM, Cilio MR, Mizrahi EM, et al. The ILAE classification of seizures and the epilepsies: Modification for seizures in the neonate. Position paper by the ILAE Task Force on Neonatal Seizures. Epilepsia.
2. Glass HC, Shellhaas RA, Wusthoff CJ, et al. Contemporary Profile of Seizures in Neonates: A Prospective Registry Study. J Pediatr.