How to manage convulsions in newborns?

Management of Convulsions in Newborns

The management of neonatal convulsions requires prompt recognition, identification of underlying causes, and a stepwise treatment approach with phenobarbital as first-line therapy, followed by additional anticonvulsants if seizures persist. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation: Ensure patent airway and adequate ventilation before administering anticonvulsants 2
• Glucose Measurement: Check blood glucose immediately with glucose oxidase strip if the newborn is still convulsing or unresponsive 1
• Recognize Seizure Type: Identify seizure pattern (subtle, clonic, tonic, or myoclonic) 3
• Vital Signs: Monitor heart rate, capillary refill, and blood pressure 2

Diagnostic Evaluation

Immediate Investigations

• Lumbar Puncture: Strongly indicated in:
  • Infants under 12 months
  • Presence of meningeal signs
  • After complex convulsions
  • Unduly drowsy, irritable, or systemically ill infants 1

CAUTION: A comatose child must be examined by an experienced doctor before lumbar puncture due to risk of coning 2

Additional Investigations (As Indicated)

• Neuroimaging: Consider CT or MRI for prolonged seizures (>20 minutes) or incomplete recovery within one hour 2, 1
• EEG: Not routinely recommended after a first seizure but valuable for ongoing seizure management and monitoring 1
• Metabolic Workup: Rule out hypoglycemia, hypocalcemia, and electrolyte abnormalities 2

Treatment Algorithm

First-Line Treatment

• Phenobarbital: 20 mg/kg IV loading dose 4, 5
  • Monitor for respiratory depression and hypotension
  • Still recommended as first-line therapy by International League Against Epilepsy guidelines 5

Second-Line Treatment (If Seizures Continue)

• Additional Phenobarbital: Consider additional 10 mg/kg doses (up to total 40 mg/kg) 6
• Lorazepam: 0.05-0.1 mg/kg IV (maximum 4 mg) 7
  • Administer slowly (2 mg/min)
  • Ensure ventilatory support is readily available

Third-Line Treatment (Refractory Seizures)

• Phenytoin/Fosphenytoin: 18-20 mg/kg IV at 1-2 mg/kg/min 1
• Levetiracetam: Increasingly used as second-line agent (20-40 mg/kg) 6, 5
• Lidocaine: Consider for refractory seizures as third-line treatment 6, 8

Status Epilepticus Management

• Rule out underlying causes requiring specific treatment:

  • Pericardial effusion (pericardiocentesis)
  • Pneumothorax (thoracentesis)
  • Ongoing blood loss (blood replacement)
  • Hypoadrenalism (hydrocortisone)
  • Hypothyroidism (triiodothyronine)
  • Inborn errors of metabolism
  • Cyanotic or obstructive heart disease 2

• Consider ECMO: For term newborns with refractory shock when other causes have been excluded 2

Management of Associated Fever (If Present)

• Antipyretics: Administer paracetamol (acetaminophen) for comfort and to prevent dehydration 2, 1
• Adequate Hydration: Ensure proper fluid intake 2
• Avoid Physical Cooling Methods: Fanning, cold bathing, and tepid sponging cause discomfort and are not recommended 2, 1

Follow-up and Prognosis

• Early Discontinuation: Consider discontinuing anticonvulsant medications prior to discharge if seizures were acute and provoked 5
• Risk Assessment: The risk of developing epilepsy after neonatal seizures depends on underlying etiology 1
• Long-term Follow-up: Necessary to screen for postneonatal epilepsy and support neurodevelopment 5

Common Pitfalls and Caveats

1. Subclinical Seizures: Many neonatal seizures are subclinical and can only be detected with continuous EEG monitoring 6

2. Non-epileptic Movements: Jitteriness, benign neonatal sleep myoclonus, and hyperekplexia can be mistaken for seizures 3

3. Delayed Treatment: Prolonged seizures may cause immediate and long-term adverse consequences on the developing brain 9

4. Overtreatment: Not all abnormal movements are seizures; confirm with EEG when possible before initiating treatment 6

5. Inadequate Dosing: Using insufficient loading doses of phenobarbital may lead to treatment failure 8

6. Medication Side Effects: Monitor for respiratory depression with benzodiazepines and phenobarbital, especially when used together 7, 4

The management of neonatal convulsions requires a careful balance between prompt treatment to prevent neurological damage and avoiding unnecessary medication exposure. Phenobarbital remains the first-line agent despite the emergence of newer anticonvulsants, with a structured approach to escalating therapy for refractory cases.