What are the treatment options for neonatal seizures?

From the Guidelines

Neonatal seizures should be treated with lorazepam as the first-line medication at a dose of 0.05 mg/kg (maximum 1 mg) intravenous (i.v.), repeated every 5 minutes as needed, followed by levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus, and if seizures persist, phenobarbital i.v. at a loading dose of 10–20 mg/kg (maximum 1,000 mg) should be added, as recommended by the most recent guidelines 1. The treatment of neonatal seizures is crucial to prevent further brain injury and improve neurodevelopmental outcomes.

• The initial assessment should include checking the airway, breathing, and circulation (CAB) and providing oxygen as needed, as well as evaluating the blood glucose level 1.
• The use of lorazepam as a first-line treatment is supported by recent guidelines, which recommend a dose of 0.05 mg/kg (maximum 1 mg) intravenous (i.v.), repeated every 5 minutes as needed 1.
• If seizures persist, levetiracetam 40 mg/kg (maximum 2,500 mg) i.v. bolus should be added, followed by phenobarbital i.v. at a loading dose of 10–20 mg/kg (maximum 1,000 mg) if necessary 1.
• Maintenance doses of anticonvulsant drugs after resolution of seizures include lorazepam 0.05 mg/kg (maximum 1 mg) i.v. every 8 hours for 3 doses, levetiracetam 15 mg/kg (maximum 1,500 mg) i.v. every 12 hours, and phenobarbital 1–3 mg/kg i.v. every 12 hours 1.
• It is essential to identify and treat the underlying cause of seizures, including hypoglycemia, electrolyte imbalances, infections, or hypoxic-ischemic injury, and to use continuous EEG monitoring to detect subclinical seizures 1.

From the FDA Drug Label

The safety of lorazepam in pediatric patients has not been established.

Pediatric The safety of lorazepam in pediatric patients has not been established.

• Treatment for neonatal seizures: The FDA drug label does not answer the question.

From the Research

Treatment Options for Neonatal Seizures

• Phenobarbital is recommended as the first-line antiseizure medication (ASM) for neonatal seizures, regardless of etiology 2
• In cases where channelopathy is likely the cause of seizures, phenytoin or carbamazepine may be used as the first-line ASM 2
• For neonates with seizures not responding to first-line ASM, second-line options include phenytoin, levetiracetam, midazolam, or lidocaine 2
• Levetiracetam may be the preferred second-line ASM in neonates with cardiac disorders 2

Management Pathways for Neonatal Seizures

• A standardized pathway for the management of neonatal seizures is recommended for each neonatal unit 2
• Prompt EEG confirmation of seizures is a key component of management pathways 3
• Intravenous benzodiazepine administration may be considered if EEG or loading of ASM is delayed 3
• Phenobarbital 20 mg/kg IV is commonly used as the first-line ASM in management pathways 3

Therapeutic Hypothermia and Seizure Burden

• Therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy 2, 4
• Treating neonatal seizures to achieve a lower seizure burden may be associated with improved outcomes 2
• The impact of seizure activity on the developing brain and the most effective way to manage these seizures remain poorly understood 4

Discontinuation of Antiseizure Medications

• Antiseizure medications should be discontinued before discharge home in neonates with acute provoked seizures without evidence of neonatal-onset epilepsy 2
• The timing of ASM discontinuation is variable and requires further research 3

Special Considerations

• A trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM 2
• Informing parents/guardians about the diagnosis of seizures and initial treatment options is an important aspect of care 2