What is the recommended method of administration for managing convulsions in newborns?

Management of Convulsions in Newborns

For managing convulsions in newborns, the recommended first-line treatment is intravenous phenobarbital at a loading dose of 20 mg/kg, followed by maintenance doses if seizures persist. 1

First-Line Treatment Algorithm

1. Establish airway, breathing, and circulation

   • Ensure adequate oxygenation and ventilation
   • Monitor oxygen saturation continuously
   • Be prepared to provide respiratory support 2

2. Check blood glucose immediately

   • Treat hypoglycemia if present (common cause of neonatal seizures)
   • Use glucose oxidase strip for rapid assessment 3

3. Administer phenobarbital (first-line)

   • Dosage: 20 mg/kg IV loading dose
   • Administration: Give slowly over 10-15 minutes
   • Monitor for respiratory depression

Second-Line Treatment Options

If seizures persist after phenobarbital administration:

1. Phenytoin/Fosphenytoin

   • Dosage: 15-20 mg/kg IV
   • Administration: Give over 20 minutes
   • Caution: Monitor cardiac function 3, 1

2. Levetiracetam

   • Emerging as preferred second-line agent due to better safety profile
   • Dosage: 20-40 mg/kg IV
   • Advantages: No significant drug interactions, non-hepatic elimination, low protein binding 4, 1
   • Preferred in neonates with cardiac disorders 1

3. Midazolam

   • Dosage: 0.15 mg/kg IV loading dose, followed by continuous infusion (1-5 μg/kg/min)
   • Monitor closely for respiratory depression 2, 1

4. Lidocaine

   • For refractory seizures as third-line treatment
   • Effective when other medications have failed 5, 1

Special Considerations

Route of Administration

• Intravascular (IV) route is preferred for all medications when managing acute seizures in newborns 3
• If IV access is not immediately available, medications may be given via intraosseous route in emergency situations 3
• For epinephrine (if needed for resuscitation during seizure management): IV dose 0.01-0.03 mg/kg; if IV access unavailable, endotracheal dose 0.05-0.1 mg/kg 3

Monitoring

• Continuous cardiorespiratory monitoring
• Continuous EEG monitoring when available (essential for subclinical seizures, which are common in neonates) 5, 1
• Monitor for signs of increased intracranial pressure 3

Duration of Treatment

• Following cessation of acute provoked seizures without evidence of neonatal-onset epilepsy, antiseizure medications should be discontinued before discharge home 1

Refractory Cases

For seizures that don't respond to first and second-line treatments:

1. Consult neurology and consider anesthesia
2. Consider continuous EEG monitoring (if not already in place)
3. Consider additional therapies:
   • Barbiturate coma
   • Hydrocortisone IV (emerging evidence in refractory cases) 6
   • Pyridoxine trial (especially if vitamin B6-dependent epilepsy is suspected) 1

Important Pitfalls to Avoid

1. Delay in treatment - Seizures lasting over 5 minutes are unlikely to stop spontaneously 7
2. Missing subclinical seizures - Many neonatal seizures are subtle or subclinical 5
3. Inadequate dosing - Underdosing of medications is common and reduces efficacy
4. Overlooking treatable causes - Always investigate for underlying etiology (hypoglycemia, electrolyte abnormalities, infection, etc.)
5. Respiratory depression - All anticonvulsants can cause respiratory depression, especially when combined 2

Therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy and should be considered in appropriate cases 1.