Seizaure neonatal

Question 1

Neonatal Seizures

Answer 1

Paroxysmal alterations of neurologic functions including motor, behavioral and / or autonomic changes

Question 2

Cause of seizures👶🏻👶🏻

Answer 2

A. Central nervous system

o Incidence: the commonest causes, includes:

• Hypoxic-ischemic encephalopathy (the commonest cause in term babies).
• Intra cranial hemorrhage ( intraventricular, parenchymal, subarachnoid or

subdural)

• Sepsis ( meningitis, encephalitis, tetanus, TORCH)
• Congenital brain malformations e.g. cerebral dysgenesis (5%).
• Bilirubin encephalopathy (Kernicterus)
• Neuro-cutaneous syndromes e.g. tuberous sclerosis, incontinentia pigmenti

B. Metabolic

1. Hypoglycemia

o blood glucose 2.6 mol (45 mg / dl)

o Causes: infant of diabetic mother (IDM), preterm, asphyxia ,

hypopituitarism, Erythroblastosis fetalis, galactosemia

2. Hypocalcaemia

o Serum calcium less than 7mg/dl which either:

• Early onset (in 1 st 3 days) p due to IDM, preterm, & asphyxia.
• Late onset (after end of 1 st week) p due to decrease calcium intake,

hyper phosphatemia, and hypoparathyroidism.

3. Hypomagnesemia (< 1.5 mg/dl) p often associated with hypocalcaemia
4. Hyponatraemia (< 135 meq/L) or hypernatraemia (> 150 meq/L)
5. Inborn errors of metabolism: e.g.
   - Galactosemia
   - Hyperammonemia
   - Organic acidemia

C. Other causes

• Pyridoxine or pyridoxal (vitamin B6) dependency (essential for GABA)
• Drug withdrawal e.g. maternal narcotics or addiction
• Theophylline toxicity
• Benign neonatal seizures (normal neonate ;diagnosed by exclusion)

Question 3

How to differentiate the causes of neonatal seizures

Answer 3

• In the 1 st 4 days of life: e.g. HIE, drug withdrawal, or metabolic causes. * After the 4 th day: e.g. intra cranial hemorrhage and metabolic causes.
• After the 1 st week: e.g. sepsis (meningitis).

Question 4

Differential diagnosis of neonatal seizure

Answer 4

Seizures should be differentiated from Jitteriness which is characterized by:

• Tremor like movements of limbs
• Precipitated by sensory stimuli.
• Stopped by holding the limb.
• No associated autonomic changes, ocular phenomena or EEG changes
• Seen in normal infant, drug withdrawal, hypocalcemia & hypoglycemia

Question 5

Neonatal seizures tx

Answer 5

o Maintain ventilation which may be compromised during seizures and following anti convulsants o Rapidly identify and treat reversible causes of seizures

• Hypoglycemia➡️ Glucose 10% I.V 2- 4 ml/kg
• Hypocalcemia➡️ May require continuous glucose infusion
• Hypomagnesemia➡️ Magnesium sulphate 50% I.M 0.2 ml/kg

o Start parenteral antibiotics (± acyclovir) if there is any concern of sepsis

o Anti convulsants

_ 😱Lorazepam and Other Benzodiazepines

The dose is 0.1 mg/kg when used for acute treatment of seizures,

• phenobarbital may be first-line (loaded 20 mg/kg IV then low maintenance dose of 2-4 mg/kg/day), phenytoin can also be used, often as second-line (loaded as phenobarb

Phenytoin

• Loading dose 20 mg/kg slow IV over 30 minutes
• Monitor heart rate and blood pressure closely
• Better avoided in babies with poor cardiac function

Question 6

Investigations for neonatal seizures

Answer 6

Investigations o Check initially for blood glucose, calcium, magnesium, sodium, blood gases o Sepsis Screen: complete blood picture, CRP, blood culture.

o CSF analysis: - For glucose, protein, Gram stain, culture and viral PCR

• Delay lumbar puncture if the baby is unstable o TORCH Screen for suspected cases o Neuro imaging : - Cranial ultrasound excludes intra cranial hemorrhage
• CT/MRI for brain malformations, and infarcts o Electroencephalogram (EEG) o Metabolic Screen if acidotic or family history: e.g. ammonia, amino acids, lactate, urine amino acids and organic acids o Karyotyping for dysmorphic babies