NEONATAL SEIZURE

INTRODUCTION

A neonatal seizure is a seizure that occurs in a newborn baby, typically within the
first 28 days of life. These seizures can be caused by various factors, such as
infection, brain injury, or congenital disorders. They can also be a symptom of an
underlying condition such as hypoglycemia.

DEFINITION

A seizure is a paroxysmal behaviour caused by hypersynchronous discharge of a

group of neurons. Neonatal seizures are the most common overt manifestation of
neurological dysfunction in the newborn.

Seizures-episode of paroxysmal and transient brain dysfunction

Convulsion motor manifestation of seizures

Epilepsy recurrent chronic seizures

Status epilepticus any seizure that lasts for more than 30 min or occurrence of
serial convulsion between which there is no return of consciousness.

Most (80%) neonatal seizures occur in the first 1-2 days to the first week of life.

The duration of neonatal seizures is usually brief (10 s to 1-2 min) and repetitive
with a median of 8 min in between each seizure. Longer seizures and status
epilepticus develop more readily at this age, but convulsive neonatal status
epilepticus is not as severe as that of older infants and children.
ETIOLOGY
Hypoxic-ischemic encephalopathy
Metabolic
 Hypoglycemia
 Hypocalcemia
 Hypomagnesemia (often with Hypocalcemia)
 Hyper/Hyponatremia
Drug Withdrawal
Local Anesthetic Toxicity
 Pyridoxine (Vitamin B6) Dependency
Disorders of Small Molecules
 (Amino Acid, Organic Acid & Urea Cycle Disorders)
 Disorders of Subcellular Organelles
(Mitochondrial & Peroxisomal Disorders)
Intracranial infection
 Bacterial meningitis (E. coli, Group B Strep. Listeria)
 Viral Encephalitis (Herpes Simplex, Enterovirus)
Intrauterine Infection
 (CMV, Toxoplasm., HIV, Rubella, Syphilis
Cerebral Vascular
Intraventricular hemorrhage
 Primary subarachnoid bleed
 Subdural/epidural hematoma
 Focal Ischemic Necrosis (Stroke)
 Sinus Thrombosis.
Developmental defects
Neurocutaneous Disorders (Tuberous Sclerosis Complex)
Epilepsy Syndromes
  Epileptic Encephalopathies (Early Myoclonic Encephalopathy)

Benign Familial Neonatal Convulsions autosomal dominant trait

Epilepsy Syndromes

CAUSES DEPENDING ON DAYS OF LIFE

First day

birth asphyxia

intraventricular hemorrhage

cerebral agenesis/dysgenesis

inborn errors of metabolism

infections.

narcotic withdrawal

metabolic causes

accidental injection of local anaesthetic into foetal scalp

Second and third day

prolonged obstructed labour

difficult forceps or vacuum extraction

hypoglycaemia

infections

Fourth to seventh day

tetany

developmental malformations microcephaly, agenesis of corpus callosum

meningitis

intrauterine infections toxoplasmosis, CMV

tetanus neonatorum Pathophysilogy

Due to etiological factor

Disturbance in brain function

Brain cell become over reactive

Burst electrical activity in the brain

That affect the CNS area

Seizure

Classification
1 -Generalized Seizure: Generalized seizure is a

type of seizure that involves the entire brain(both side of hemisphere).

It have 3 sub types

1. Tonic seizure

2. Clonic seizure

3. Myoclonic seizure

Tonic Seizure: Sudden & Sustained muscle stiffness

rigidity in the body. During a tonic seizure, the muscle o the arm, legs may
become stiff. The baby may become unconscious. It lasts for few seconds to a
minute.

Clonic seizure: Rhythmic, Jerking muscle movement that may affect The entire
body or just one part of the body, such as arm or leg. The movements typically
alternate between contraction & relaxation of the muscles, causing a shaking
trembling motion. This is last for seconds to 3 minutes.

Myoclonic seizure: Sudden, brief muscle contraction that can affect one or more
Part of the body. This is typically last for only a few seconds.

2-Partial seizure: A partial seizure, also known as a focal seizure, is a type of

seizure that affects only one part of the brain or a particular area.

Partial seizures can be further classified into two subtypes: simple partial seizures
and complex partial seizures.

Simple Partial seizure:

Also known as a focal aware seizure, is characterized abnormal electrical activity
in a specific part of the brain. The person experiencing a simple seizure remains
conscious and aware of their surrounding during the seizure. They may
experience abnormal sensations, such as tingling, feeling or a sense of fear.

Complex Seizure:

Complex Seizure is characterized by abnormal electrical activity in a specific part

of the brain that cause a loss of consciousness. During a complex seizure the
person may exhibit unusual behaviours, such as lip smacking and Hand rubbing.

Clinical Manifestation

Twitching of facial muscles

Twitching of the hands and feet

The eye roll or stare

Hallucination

Dizziness

Confusion

Anxiety and fear

Diagnostic Evaluation

Seizure history:

History of associated eye movements

Restraint of episode by passive flexion of the affected limb

Change in colour of skin (mottling or cyanosis)

Whether the infant was conscious/sleeping at the time of seizure should be

elicited. The day of life on which the seizure occurred may provide an important
clue to its diagnosis.

Antenatal history:
History suggestive of intrauterine infection, maternal diabetes and narcotic
addiction should be elicited in the antenatal history. A history of sudden increase
in fetal movements may be suggestive of intrauterine convulsions.

Perinatal history

Perinatal asphyxia is the commonest cause of neonatal seizures and a detailed

history including history of fetal distress, decreased fetal movements,
instrumental delivery, need for resuscitation in the labor room, low Apgar scores
(<3 at 1 and/or 5 minutes) and abnormal cord pH (<7) and base deficit (> 10
mEq/L) should be obtained. Use of a pudendal block for mid-cavity forceps may
be associated with accidental injection of the local anesthetic into the fetal scalp.

Feeding history:

Appearance of clinical features including lethargy, poor activity, drowsiness, and

vomiting after initiation of breast-feeding may be suggestive of inborn errors of
metabolism. Late onset hypocalcemia should be considered in the presence of
top feeding with cows' milk.

Family history:

History of consanguinity in parents, family history of seizures or mental

retardation and early fetal/neonatal deaths would be suggestive of inborn errors
of metabolism. History of seizures in either parent or siblings in the neonatal
period may suggest benign familial neonatal convulsions

Examination

Vital signs:

Heart rate, respiration, blood pressure, capillary refill time and temperature
should be recorded.

General examination:
Gestation, birth-weight and weight for age should be recorded as it may provide
important clues to the etiology of the seizure. Seizures in a term 'well baby' may
be suggestive of sub-arachnoid hemorrhage. Seizures in a large for date baby may
be due to hypoglycaemia. The neonate should be examined for the presence of
any obvious malformation or dysmorphic features.

CNS examination

Presence of a bulging anterior fontanelle may be suggestive of meningitis or

intracranial hemorrhage. A detailed neurological examination should include
assessment of consciousness (alert/drowsy/comatose). tone (hypotonia or
hypertonia) and fundus examination for chorioretinitis.

Systemic examination

Presence of hepatosplenomegaly or an abnormal urine odor may be suggestive of

IEM.The skin should be examined for the presence of any neuro-cutaneous
markers. Presence of hypopigmented macules/ash-leaf spot would be suggestive
of tuberous sclerosis.

Investigations

Mandatory investigations:

Blood sugar, hematocrit, bilirubin (if jaundice is present clinically), serum

electrolytes (Na, Ca, Mg), arterial blood gas.

Cerebrospinal fluid (CSF) examination, cranial ultrasound (US) and

electroencephalography (EEG). CSF examination should be done in all cases as
seizures may be the first sign of meningitis. It should not be omitted even if
another etiology such as hypoglycemia is present, because meningitis can often
coexist. CSF study may be withheld temporarily if severe cardio-respiratory
compromise is present or in cases with severe birth asphyxia (documented poor
cord pH, seizure onset within 12-24 hrs).

An arterial blood gas (ABG) may have to be performed if IEM is strongly

suspected.

Specific investigations:
These may be considered in neonates who do not respond to a combination of
phenobarbitone and phenytoin or earlier in neonates with specific features.
These include neuroimaging (CT, MRI), screen for congenital infections (TORCH)
and for inborn errors of metabolism.

Imaging

Neurosonography is an excellent tool for detection of intraventricular and

parenchymal hemorrhage but is unable to detect SAH and sub-dural hemorrhage.

CT scan should be done in all infants where an etiology is not available after the
first line of investigations. It can be diagnostic in sub-arachnoid hemorrhage and
developmental malformations

MRI scan is indicated only if investigations do not reveal any etiology and seizures
are resistant to usual anti-epileptic therapy. It can be diagnostic in cerebral
dysgenesis, lissencephaly and other neuronal migration disorders.

Screen for congenital infections

A TORCH screen and VDRL should be considered in the presence of hepato-

splenomegaly, thrombocytopenia, growth retardation, small for gestational age
and presence of chorioretinitis.Management

Pharmacotherapy for neonatal seizures

Phenobarbitone

It is the drug of choice in neonatal seizures. The dose is 20 mg/kg/IV slowly over
20 minutes (not faster than 1 mg/kg/min). If seizures persist after completion of
this loading dose, repeat dose of phenobarbitone 10 mg/kg may be used every
20-30 minutes till a total dose of 40 mg/kg has been given. The maintenance dose
is 3-5 mg/kg/day in 1-2 divided doses, started 12 hours after the loading dose.

Phenytoin
Phenytoin is indicated if the maximal dose of phenobarbitone (40 mg/kg) fails to
resolve seizures or earlier, if adverse effects like respiratory depression,
hypotension or bradycardia ensure with phenobarbitone. The dose is 20 mg/kg IV
at a rate of not more than 1 mg/kg/min under cardiac monitoring. The
maintenance dose is 3-5 mg/kg/d (maximum of 8 mg/kg/d) in 2-4 divided doses.
Oral suspension has very erratic absorption from gut in neonates, so it should be
avoided. Thus only IV route is preferred in neonates and it should preferably be
discontinued before discharge.

Benzodiazepines

This group of drugs may be required in up to 15% of neonatal seizures. The

commonly used benzodiazepines are diazepam, lorazepam, midazolam, and
clonazepam. Diazepam is generally avoided due to its short duration of action,
narrow therapeutic index, and because of the presence of sodium benzoate as a
preservative. Lorazepam is preferred over diazepam as it has a longer duration of
action and results in less adverse effects (sedation and cardiovascular effects).
Midazolam is faster acting than lorazepam and may be administered as an
infusion. It requires strict monitoring for respiratory depression, apnea and
bradycardia. The doses of these drugs are given below:

Diazepam: 0.25 mg/kg IV bolus (0.5 mg/kg rectal); may be repeated 1-2 times.

Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes; may be repeated

Midazolam: 0.15 mg/kg IV bolus followed by infusion of 0.1 to 0.4 mg/kg/hour.

Clonazepam: 0.1-0.2 mg/kg IV bolus followed by infusion 10-30 mg/kg/hr.

Other therapies
Pyridoxine:

Therapeutic trial of pyridoxine is reserved as a last resort. IV administration is the

preferred method; however, suitable IV preparations are not available at present
in India. Hence intramuscular (IM) route may have to be used instead (1 ml of
neurobion has 50-mg pyridoxine and 1 ml each may be administered in either the
gluteal region or anterolateral aspect of thigh). It should ideally be done in the
NICU as hypotension and apnea can occur.

Exchange transfusion:

It is indicated in life-threatening metabolic disorders, accidental injection of local

anaesthetic, trans-placental transfer of maternal drugs (e.g. chlorpropamide) and
bilirubin encephalopathy.

Surgical management:

Neurosurgery- Removing area of brain where seizure occurs like tumors.

Callosotomy - Surgery to treat epilepsy seizure when anu seizure medication can't
help. Procedure involve cutting a band of fibres (carpes callosum) in brain
afterward, the nerves can't send seizure signals between the brains to halves.

Focal Resection of parts of cerebral cortex. Such as temporal lobe.

NURSING MANAGEMENT

Early Recognition and assessment of seizure activity.

Monitoring And managing vital signs and oxygenation.

Administering antiepileptic medications.

Providing a safe and supportive environment.

Provide education and support to family.

NURSING MANAGEMENT
Detailed history collection and physical examination

Prevent the newborn from sustaining any harm during seizure

Keep the baby on floor

Place the newborn on side lying position, it facilitates drainage and help to
maintain a patent airway If newborn become cyanotic, administer oxygen

Raise the side rails when newborn is sleeping. Side rails and other hard objects
padded

Identify and avoid triggering factors like sudden loud noises, sudden movements,
dehydration, fatigue, hypoglycaemia, hyperventilation, ete

Educate them about the importance of drug therapy and follow up. Advice them
not to stop medicines abruptly.

Provide psychological support to parents.

NURSING DIAGNOSIS

Nursing Diagnosis

1. Ineffective breathing pattern related to dysfunctional neuro muscular function

 Place nothing into child's mouth during convulsion

 Position the child in recovery position.
 Monitor for adequate oxygenation

2. Ineffective airway clearance related to inability to control secretions during

seizure

 Administer 02
 Place nothing into child's mouth during convulsion
 Position the child in recovery position
 Monitor for adequate oxygenation Administer 02

3. Risk for trauma related to uncontrolled movement of seizure activity

 Protect the baby from injury

  Keep the padded side rails up
 Don't try to make the hands straight while convulsion

4. Anxiety related to unpredictable nature of the disease condition

5. Ineffective therapeutic regimen management related to poor adherence with

6. Potential for aspiration related to inability to control the secretions.

 medication
 Give recovery position
 Put an airway
 Do suctioning
 Don't give water or anything to drink or eat

Complications

Cerebral Palsy

Mental Retardation

njury from falls

Difficulty in learning

CONCLUSION
The prognosis depends on gestational maturity, underlying etiology, EEG,
neurologic examination and presence or absence of abnormalities on imaging
studies. It is important to impress on the family the need to continue the
medication regularly without interruption for as long as required. Nurse should
help parents in dealing with psychological and sociologic problems

BIBLIOGRAPHY

1. Meherban Singh. Care of the newborn. 6th edition: Sagar publications; New
Delhi: 2004

2. Dipak K Guha. Guha's neonatology principles and practice. 3rd edition: Jaypee
publications; 2005

3. Hockenberry M. Wongs. Essentials of paediatric nursing,8th edition: Noida,

2009

4. Marlow D R, Redding B.A. Textbook of paediatric nursing.6th edition: Noida,

2008

5 .Sharma R., "Essential of pediatric nursing". Edition : 3re Edition, jaypee

brothers publishers, pg no. 131-132.