What is the systematic approach to managing neonatal and pediatric seizures?

Systematic Approach to Neonatal and Pediatric Seizures

The management of neonatal and pediatric seizures requires prompt recognition, accurate diagnosis, and appropriate treatment based on age and etiology, with immediate treatment of active seizures using short-acting medications like lorazepam for non-self-limiting seizures. 1

Initial Assessment and Stabilization

Immediate Actions

• Ensure airway, breathing, and circulation
• Position patient on side to prevent aspiration
• Clear area of hazards
• Monitor vital signs including heart rate, blood pressure, temperature, and oxygen saturation
• Establish IV access

Seizure Classification by Age Group

1. Neonatal (0-29 days)

   • Most commonly due to hypoxic-ischemic injury (46-65%), intracranial hemorrhage, or perinatal stroke (10-12%) 1
   • Seizures within first 2 days typically from hypoxic-ischemic encephalopathy
   • Seizures beyond 7 days more likely related to infection, genetic disorders, or cortical malformations

2. Infants and Children

   • Febrile seizures
   • Epilepsy syndromes
   • Acute symptomatic causes (infection, trauma, metabolic)
   • Drug withdrawal (especially in neonates) 1

Diagnostic Approach

Immediate Investigations

• Neonates:

  • Continuous EEG monitoring (ideally within 24 hours) 2
  • Head ultrasound for unstable neonates 1
  • Brain MRI when stable
  • Blood work: glucose, electrolytes, calcium, magnesium, complete blood count

• Infants/Children:

  • EEG (standard or continuous based on clinical presentation)
  • Neuroimaging: Non-contrast CT for emergency situations, MRI preferred when stable 1
  • Laboratory tests: glucose, electrolytes, toxicology as indicated

Special Considerations

• Enhanced EEG monitoring for high-risk populations (neonates, children with stroke) 1
• Consider lumbar puncture if infection suspected
• Evaluate for non-convulsive status epilepticus in patients with unexplained altered consciousness 2

Treatment Algorithm

Acute Seizure Management

Neonatal Seizures

1. First-line:

   • Phenobarbital 20 mg/kg IV loading dose 3, 4
   • Treat underlying cause (hypoglycemia, electrolyte abnormalities)

2. Second-line (if seizures continue):

   • Additional phenobarbital (10 mg/kg) OR
   • Levetiracetam 30-50 mg/kg IV OR
   • Fosphenytoin 20 mg/kg IV 3

3. Third-line:

   • Midazolam continuous infusion for refractory seizures 3
   • Consider additional options: topiramate or lacosamide 3, 5

Pediatric Seizures

1. First-line:

   • Lorazepam 0.05-0.1 mg/kg IV (max 4 mg) for active seizures 2
   • If no IV access: midazolam 0.2 mg/kg buccal/intranasal

2. Second-line (if seizures continue after 5-10 minutes):

   • Levetiracetam 30-60 mg/kg IV OR
   • Fosphenytoin/Phenytoin 20 mg/kg IV (administer at ≤1 mg/kg/min) 2
   • Valproate 20-40 mg/kg IV (avoid in suspected metabolic disorders)

3. Third-line:

   • Phenobarbital 10-20 mg/kg IV for refractory seizures 2
   • Consider continuous midazolam, propofol, or pentobarbital for status epilepticus

Neonatal Drug Withdrawal Seizures

• Follow non-pharmacologic supportive measures first (minimize stimuli, promote rest)
• Use standardized assessment tools to guide therapy
• For withdrawal-associated seizures, pharmacologic therapy is indicated 1
• Options include oral morphine solution or methadone; oral clonidine may be effective as primary or adjunctive therapy 1

Monitoring and Follow-up

During Acute Management

• Continuous cardiorespiratory monitoring
• Frequent neurological assessments
• Monitor for medication side effects, especially respiratory depression with benzodiazepines and barbiturates
• Avoid prophylactic use of anticonvulsants in patients with acute stroke 1

Post-Seizure Care

• Neonates:

  • Consider discontinuation of anticonvulsants after resolution of acute symptomatic seizures 4
  • Observe in hospital for 4-7 days for neonates with known opioid/benzodiazepine exposure 1

• Children:

  • Regular follow-up every 3-6 months to assess seizure control and medication effects 2
  • EEG monitoring as indicated

Special Considerations

Stroke-Related Seizures

• New-onset seizures during acute stroke should be treated with short-acting medications if not self-limiting 1
• Single self-limiting seizures within 24 hours of stroke onset do not require long-term anticonvulsants 1
• Prophylactic anticonvulsants are not recommended and may have negative effects on neurological recovery 1

Therapeutic Hypothermia

• About half of neonates treated with therapeutic hypothermia for encephalopathy have EEG-confirmed seizures 4
• Continuous EEG monitoring is essential as clinical diagnosis may miss subclinical seizures 4

Common Pitfalls to Avoid

1. Failing to recognize non-convulsive status epilepticus
2. Delaying EEG monitoring in high-risk neonates
3. Administering phenytoin in glucose-containing solutions (use normal saline) 2
4. Overdiagnosing non-epileptic events as seizures
5. Prophylactic use of anticonvulsants without clear indication
6. Inadequate dosing of first-line agents before moving to second-line therapy

By following this systematic approach, clinicians can effectively manage neonatal and pediatric seizures while minimizing complications and optimizing outcomes.