Neonatal Convulsion.pptx

Approach to a neonate / newborn with abnormal body movements ( convulsion/seizure)

1. Neonatal Convulsion / Seizure By:- Jwan Ali Ahmed AlSofi

2. Neonatal Convulsion Seizures are more common in the neonatal period than during any other time throughout life .  The majority of neonatal seizures occur on the first day . Seizures in the neonatal period are also the most common neurological emergency and are associated with high mortality and morbidity . The Incidence of seizures in infants born at term is 0.5-3 per 1000 live births (0.1%) ; the incidence is even higher in preterm infants , ranging from 1-13 % (10%) of Very Low Birth Weight Infants .  70 % of all cases eventually recognized have been diagnosed by the fourth day .

3. Etiology:- In contrast to seizures in infancy and childhood, most neonatal seizures are acute and symptomatic with suspected specific causes . Relatively few seizures are idiopathic or part of a clearly defined epilepsy syndrome . Several decades ago, late hypocalcaemia due to a low calcium:phosphate ratio in baby formula was a frequent cause of neonatal seizures but this is very rare today.  At Term , Hypoxic Ischaemic Encephalopathy (HIE) is the most common underlying factor , typically with onset 6–8 hours after the hypoxic insult but within the first 24 hours of life .  In Preterm Infants , Cerebrovascular Events are the most common cause .  Cause seizures at any gestation :- Meningitis , Focal Cerebral Infarction , Metabolic Disorders Congenital Abnormalities of the Brain

4. Types of Convulsion:-

5. Types of Convulsion:- Focal Clonic: Rhythmic muscle contractions Myoclonic : Random single contractions Focal Tonic: Sustained posturing of limb/trunk Spasms : Flexor or extensor , in clusters   Generalized Tonic: Sustained symmetric posturing Electrographic : By definition no clinical correlate  Motor Automatism: Ocular , oral-buccal-lingual or progression movements of limbs (difficult to diagnose ) Subtle seizures: chewing movements, excessive salivation, alteration in respiratory rates, apnea , blinking eyes, nystagmus, and color changes.

6. Causes of Neonatal Seizures:- Hypoxic-Ischaemic Encephalopathy (HIE ) – ( postasphyxial seizures ):- common cause of seizures in the full-term infant It is an insult that occurs in the fetus or newborn Results in anoxia , hypoxia or ischaemia , may injure any organ of the body, but especially the brain . Cause of around 50% of Neonatal Seizures Intra-Cranial Haemorrhage (ICH ):- Common cause of seizures in premature infants , occurring at 1-3 days of age . Associated with Bulging Fontanelle , Haemorrhagic Spinal Fluid , Anaemia , Lethargy , Coma . Sepsis (Meningitis, Encephalitis) Cerebral Infarction

7. Congenital Brain Malformation Metabolic Causes Hypoglycaemia , occurs when blood glucose level declines to lowest post-natal value (usually at either 1-2 hours of age or 1-2 days of poor feeding ) Hypocalcaemia Hypomagnesaemia Hypo/hypernatremia Hyperbilirubinemia Hyperammonaenia Benign Familiar Seizure Drug Withdrawal Seizure Unintentional Injection of Anaesthetic into fetal scalp during labour Associated with transient bradycardia and fixed dilated pupils Pyridoxine Dependency

8. Seizures vs. Jitteriness Seizures Jitteriness Coarse, Clonic activity Fine, rapid movement May be associated with abnormal eye movement Sensory dependent EEG shows activity Interrupted by holding the extremity

9. Pyridoxine Dependent Seizures Pyridoxine Dependent Seizures are a subgroup of neonatal seizures, which are:- Rare Treatable Can begin in intrauterine life .  Seizures are of multiple types. Usually begin shortly after birth are resistant to conventional antiepileptic drugs (AEDs) .  Associated with cognitive impairment if therapy is delayed . Pyridoxine / Pyridoxal-5 ’-phosphate is required for the synthesis of several neurotransmitters , including ( GABA) , monoamines and others.  When Pyridoxine Dependency is suspected , 100–200 mg of pyridoxine should be given intravenously under EEG control . The seizures will abruptly stop ( within minutes ) The EEG will normalize during the next few hours . Pyridoxine = Vitamin B6

10. Investigation:- Examination of the retina might show the presence of  chorioretinitis , suggesting a congenital TORCH infection. Septic Screen , including Blood Cultures and Lumbar Puncture ( mandatory ).  Laboratory: Always Glucose , Electrolytes , Blood Gas , Packed Cell Volume , If necessary Bilirubin , Ammoniac , Metabolic Screening , TORCH , Screening for Drug Abuse . Always do Cranial Ultrasound Scanning (non-invasive), consider MRI , EEG . The characteristic time of onset of seizures in HIE is 8-36 hours after birth . An EEG obtained shortly after birth in which electrographic seizure activity was already manifest, would strongly suggest an insult over eight hours before delivery . Early background EEG activity is a relatively reliable prognostic indicator for outcome .

11. Treatment after Diagnosis The treatment of neonatal seizures may be specific to the identified cause , such as treatment of : Meningitis Hypoglycemia Hypocalcemia Hypomagnesemia Hyponatremia Vitamin B6 Deficiency or Dependency.

12. Treatment in the absence of an identifiable cause Phenobarbitone remains the 1 st drug of choice in the treatment of neonates .  The initial dose is 20 mg/kg in unventilated babies and 30 mg/kg in those who are ventilator-dependent . Phenobarbitone achieves clinical control in only 30-40 % of cases . Phenytoin and Clonazepam are used as second-line drugs . Only started when the 40 mg/kg of Phenobarbital was ineffective . Phenytoin can cause significant myocardial depression and should be avoided in babies requiring inotropic support . 10–20 mg/kg Clonazepam may achieve better EEG control .  Midazolam  has a shorter half-life than clonazepam and does not accumulate , and it avoids the side effect of increased oropharyngeal secretions . So it has less side effects.

13. There is little experience with Carbamazepine , Vigabatrin and Lamotrigine in the neonatal period . Consider a trial of Pyridoxine , Pyridoxal-5-phosphate and Folinic Acid . Treatment of Status Epilepticus requires repeated doses of Phenobarbital and may require Diazepam or Midazolam .

14. Prognosis:- This is mainly determined by the underlying cause .  The prognosis is excellent ( Best Prognosis ) in:- Hypocalcaemic Seizures Familial Neonatal Seizures Symptomatic Hypoglycemia and Meningitis have a 50% chance of sequelae in the survivor s.  In Hypoxic Ischaemic Encephalopathy the prognosis depends very much on the grade (overall 30-50 % normal ), while CNS malformations are generally associated with poor outcome.  Very Low Birthweight Infants with Clinical Seizures have a higher Incidence of Impairment than preterm infants without seizures.

15. Summary:- The clinician needs to be aware that almost any repetitive, stereotype movement pattern can be a manifestation of neonatal seizure. Neonatal seizure typically signals an underlying significant neurological disease. The most common etiology for neonatal seizure is Hypoxic-Ischaemic Encephalopathy (HIE) Check Blood Glucose in any neonatal seizure. Investigation is required in most babies to establish a diagnosis.

16. Questions Febrile and Neonatal Convulsions

17. Q 1 . Regarding neonatal seizures the following are true except: Hypoxic ischemic encephalopathy is the most common cause. Tonic seizure characterized by alteration of respiratory rate chewing movements and excessive salivation. Examination of retina for chorioretinitis. Incidence may reach up to 30% in VLBW. or Incidence 1.8-3.5/1000 live births.

18. Q 2 . The following statements are true regarding pyridoxin dependent seizures, except: It is one of the rare causes of neonatal seizure. Most of cases respond to a testing of 200mg of vitamin B6. Six weeks trial of 10 mg of vitamin B6 is indicated in suspected cases. Most of cases improved after neonatal period .

19. 2-day-old neonate delivered by CS at 39-week gestation, he is completely normal, but today mother bring her to neonatal care unit with a repeated attack of Rhythmic muscle contractions and some times sustained the posturing of limb/trunk Q. What is your first line of management? Midazolam Phenobarbitone injection  Answer: Phenobarbitone Injection 

20. Thank You References: Nelson Essentials of Paediatrics (8th Ed.) Illustrated Textbook of Paediatrics (6th Ed.)