What is the initial treatment for convulsions in newborns?

Management of Convulsions in Newborns

Phenobarbital should be used as the first-line treatment for neonatal seizures at a loading dose of 15-20 mg/kg intravenously. 1

Initial Assessment and Management

When managing a newborn with convulsions, follow these steps:

1. Assess circulation, airway, and breathing (CAB)

   • Provide airway protection interventions
   • Administer high-flow oxygen
   • Check blood glucose level immediately 2

2. Immediate Diagnostic Workup

   • Measure blood glucose (hypoglycemia is a common cause of neonatal seizures)
   • Consider lumbar puncture if meningitis is suspected, especially in infants under 12 months 3
   • Consider EEG monitoring for confirmation of seizure activity and treatment response

First-Line Treatment

• Phenobarbital IV: 15-20 mg/kg loading dose 4, 1
  • This achieves therapeutic levels (15-30 μg/ml) within minutes of injection
  • Effects last approximately 48 hours after initial dose
  • Phenobarbital remains the recommended drug for treatment of seizures in term neonates 4

Second-Line Options

If seizures persist after adequate phenobarbital loading (plasma levels >40 μg/ml), consider:

• Phenytoin/Fosphenytoin: 18-20 mg/kg IV (maximum rate of 1-2 mg/kg/min) 2
• Levetiracetam: 40 mg/kg IV bolus (maximum 2,500 mg) 2, 1
• Midazolam: 0.1 mg/kg IV 2, 1
• Lidocaine: Consider as an alternative second-line agent 1

Maintenance Therapy

• Phenobarbital: 3-4 mg/kg/day 4
  • Due to long half-life in neonates (69-165 hours), accumulation may occur
  • Avoid doses exceeding 5 mg/kg/day to prevent toxicity
  • Monitor plasma levels to maintain therapeutic range (15-30 μg/ml)

Special Considerations

• Therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy 1
• Do not administer naloxone to a newborn infant whose mother is suspected of long-term opioid use because of the risk of seizures/acute withdrawal 2
• For neonates with suspected vitamin B6-dependent epilepsy and seizures unresponsive to second-line treatment, consider a trial of pyridoxine 1
• In cases of channelopathy (e.g., due to family history), phenytoin or carbamazepine may be preferred as first-line treatment 1

Duration of Treatment

• Following cessation of acute provoked seizures without evidence of neonatal-onset epilepsy, antiseizure medications should be discontinued before discharge home 1
• In general, early discontinuation after 1-2 weeks should be possible for most neonates 4

Monitoring

• Continuous EEG monitoring is recommended for neonates with seizures, particularly for those with electrographic-only seizures 1
• Monitor respiratory status closely as phenobarbital and other anticonvulsants may cause respiratory depression
• Regular assessment of plasma drug concentrations helps guide dosing adjustments

Prognosis

Treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcomes 1. Early and effective seizure control is critical to minimize the risk of long-term neurological sequelae.