Neonatal convulsion & nursing management

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1. NEONATAL CONVULSION/ SEIZURES Presented by Mr. Abhijit p. Bhoyar M. Sc. nursing Child health

2. INTRODUCTION Neonatal convulsions are common life-threatening emergency in the newborn due to cerebral or biochemical abnormality. Preterm and LBW babies are more prone to this problem. Newborn babies do not manifest febrile convulsion. Common causes of neonatal convulsions are encephalopathy (HIE), hypocalcaemia, hypoglycemia , septicemia with meningitis and polycythemia .

3. DEFINITIONS DEFINITION: A seizure is a paroxysmal behavior caused by hypersynchronous discharge of a group of neurons. Neonatal seizures are the most common overt manifestation of neurological dysfunction in the newborn.

4. Etiology of Neonatal Convulsions Developmental neurological problems : Congenital hydrocephalus, microcephaly , cerebral dysgenesis , porencephaly , polymicrogyria , hydranencephaly , etc. Perinatal complications : HIE, birth asphyxia, birth injuries, intracranial hemorrhage . Perinatal infections : Meningitis, septicemia , intrauterine infections (STORCH). Metabolic problems : Hypocalcemia , hypoglycemia , hypomagnesemia , hypo- or hypernatremia , severe hy perbilirubinemia with kernicterus , inborn errors of metabolism . Drugs : Neonates born to narcotic addicted mothers (Narcotic withdrawal syndrome), theophylline , phenothiazine (used in eclampsia ).

5. Types of Neonatal Convulsions Five major types of seizures are seen in neonates, i.e . SUBTLE, GENERALIZED TONIC MULTIFOCAL CLONIC FOCAL CLONIC AND MYOCLONIC SEIZURES.

6. About 50 percent of all neonatal seizures are subtle type, which may manifest as eye movements (blinking, fluttering, deviation with jerking, eye opening sustained with ocular fixation), buccolingual movements, screaming, rowing and pedalling movements, apneic and bradycardia . Pure tonic and clonic convulsions are not seen in neonates as neonatal seizures are mainly subcortical in origin .

7. Twitching, rolling of eyes, generalized tonic stiffness without clonic phase with apnea and respiratory irregularity or only a change in baby's skin colour and vacant look may indicate convulsive disorders and should be investigated. Jitteriness should be differentiated from seizures. It is initiated by stimulation and aborted by gentle restraint. Prolonged jitteriness can be pathological.

8. subtle Seizures Subtle seizures are far more common than other types of neonatal seizures. They are described as  subtle  because the clinical manifestations are frequently overlooked. They imitate normal behaviours and reactions. These include the following. Ocular movements , Eyelid blinking or fluttering, eyes rolling up, eye opening, fixation of a gaze or nystagmus may occur alone or with other ictal manifestations .

9. Oral– buccal –lingual movements  (sucking, smacking, chewing and tongue protrusions). Progression movements  (rowing, swimming, pedalling , bicycling, thrashing or struggling movements). Complex purposeless movements  (sudden arousal with episodic limb hyperactivity and crying)

10. Tonic seizures  manifest with sustained contraction of facial, limb, axial and other muscles. They may be focal, multifocal or generalised , symmetrical or asymmetrical. Truncal or limb tonic extension imitates decerebrate or decorticate posturing.

11. Myoclonic seizures Myoclonic seizures  are rapid, single or arrhythmic repetitive jerks. They may affect a finger, a limb or the whole body. They may mimic the Moro reflex and startling responses. They are more frequent in pre-term than full-term infants indicating, if massive, major brain injury and poor prognosis. Myoclonic seizures are associated with the most severe brain damage.   However , healthy pre-term and rarely full-term neonates may have abundant myoclonic movements during sleep. Neonates have cortical, reticular and segmental types of myoclonus , similar to adult forms

12. Investigations Blood examination for calcium, sugar, phosphorus, electrolytes, amino acids, organic acid, pH, ammonia, etc. Lumber puncture for CSF study help in diagnosis the cause. Electroencephalogram (EEG), USG brain, CT scan, MRI, ECG Sepsis screen and serology for STORCH infections help to exclude the exact etiology of neonatal convulsions. Time of onset of convulsions, family history of convulsions, history of ma ternal drug addiction and infections are important aspect of investigations.

13. Management The neonate needs special care with airway clearance, oxygen, IV line, thermal protection, prevention of aspiration and injury, respiratory support and anticonvulsive therapy ( phenobarbitone , phenytoin , sodium valproate , etc.). exact cause of convulsions should be detected and treated appropriately, e.g. hypoglycemia , hypocalcemia HIE, Illeningitis , kernicterus , IVH, etc. Follow-up care and re-evaluation are important for future outcome of the child.

14. Pharmacologic Management Selection of the most effective drug depends on correct identification of the clinical seizure type eg . Dilantin , dizepam etc A desirable drug level is one that will prevent seizures without producing undesirable adverse effects. Dosages are adjusted according to blood level and clinical signs. Accurate timing is essential to prevent seizures. This is especially true when the child tends to have seizures at a certain time each day

15. Enteric-coated tablets, which have a delayed effect, should be used for children who are prone to attacks during sleep. Most anticonvulsants are available in liquid form and in capsules or tablets. Some drugs are less well absorbed in liquid form. It may take several months to find the best combination of medications and the best dosages of each to control the child's seizures. Single-drug therapy is attempted initially. If this is not successful, a second drug may be tried or added on. Symptoms may not be controlled 100% in every patient .

16. Dosage adjustment may be required from time to time because of the child's growth. Blood counts, urinalyses, and liver function studies are done at regular intervals in children receiving certain anticonvulsants. Medication is commonly not discontinued until 2 to 3 years after the last attack Weaning from medication should always be gradual, with stepwise reduction of dosage and withdrawal of one drug at a time. There is some evidence to suggest that long-term use of some antiepileptic agents may cause intellectual impairment in children with epilepsy

17. Complications Apnea/hypoventilation . Hypoglycemia in status epilepticus . Injuries sustained during a seizure.

18. Nursing management NURSING ASSESSMENT During a seizure, assess the following: Indications of difficulties with airway or breathing. Significant pre-seizure events, such as noise, excitement, lethargy. Behavior before the seizure, aura. Types of movements observed. Time seizure began and ended. Site where twitching or contraction began .

19. Areas of the body involved. Movements of the eyes and changes in pupil size. Incontinence. Color change pallor , cyanosis, flushing. Mouth teeth clenched, abnormal movements, tongue bitten. Apparent degree of consciousness during the seizure.

20. After a seizure, assess the following: Degree of memory for recent events. Types of speech. Coordination, paralysis, or weakness. Length of time the child is post- ictal . Pupillary reaction. Vital signs.

21. Nursing Diagnoses Risk for Injury related to seizure activity Ineffective Breathing Pattern related to spasms of respiratory musculature Social Isolation related to the child's feelings about seizures or public fears and misconceptions Chronic Low Self-Esteem related to lack of control over seizures

22. Nursing Interventions Ensuring Safety during a Seizure Use preventive measures. Remove hard toys from the bed. Pad the sides of the crib or side rails of the bed. Have a suction machine available to remove secretions during a seizure. Have an emergency oxygen source in the room in case of sudden respiratory difficulty.

23. Make sure the child can be readily observed. During a seizure, monitor vital signs and assess neurologic status frequently. After a seizure, check the child frequently and report the following: Behavior changes. Irritability. Restlessness. Listlessness

24. Preventing Respiratory Arrest and Aspiration During a seizure, take the following emergency actions: Clear the area around the child. Do not restrain the child. Loosen the clothing around the neck. Turn the child on side so saliva can flow out of the mouth. Place a small, folded blanket under the head to prevent trauma if the seizure occurs when the child is on the floor .

25. Suction the child, and administer oxygen as necessary. Do not give anything by mouth or attempt to place anything in the mouth. After the seizure, place the child in a side-lying position.

26. Thank you