How do you manage convulsions in newborns?

Management of Convulsions in Newborns

The first-line treatment for neonatal convulsions should be phenobarbital, regardless of etiology, unless a channelopathy is suspected, in which case phenytoin or carbamazepine is preferred. 1

Initial Assessment and Stabilization

• Immediate stabilization of airway, breathing, and circulation is essential before proceeding with anticonvulsant therapy 2
• Measure blood glucose with a glucose oxidase strip in any newborn who is actively convulsing or unrousable 3
• Assess for signs of meningitis, systemic illness, or altered mental status that would necessitate further investigation 3
• For newborns with seizures, a lumbar puncture should almost always be performed, especially if under 12 months of age, to rule out meningitis 4, 3

First-Line Treatment

• Administer phenobarbital intravenously as the first-line anticonvulsant for neonatal seizures 1, 5
• The appropriate dosage should be carefully determined as phenobarbital may require 15 or more minutes to reach peak brain concentrations 5
• Caution should be exercised to avoid excessive barbiturate-induced depression by injecting phenobarbital until convulsions stop 5

Second-Line Treatment Options

• If seizures continue after first-line treatment, consider phenytoin, levetiracetam, midazolam, or lidocaine as second-line agents 1
• For newborns with cardiac disorders, levetiracetam may be the preferred second-line anticonvulsant 1
• In cases of prolonged seizures (status epilepticus), lorazepam may be considered at 0.05 mg/kg (for older children, though specific neonatal dosing requires careful consideration) 6

Special Considerations

• For newborns with hypoxic-ischemic encephalopathy, therapeutic hypothermia may help reduce seizure burden 1
• A trial of pyridoxine should be considered in neonates with seizures unresponsive to second-line anticonvulsants, especially if vitamin B6-dependent epilepsy is suspected 1
• For neonates with suspected metabolic disorders (hypocalcemia or hypoglycemia), correction of the underlying metabolic abnormality is essential 7

Diagnostic Workup

• Perform lumbar puncture if any of the following are present: signs of meningism, complex convulsion, excessive drowsiness/irritability, systemic illness, or age less than 12 months 3, 4
• Brain imaging (CT or MRI) may be necessary before lumbar puncture if the newborn is comatose, to avoid the risk of brain herniation 3
• EEG is not routinely indicated for all neonatal seizures but may be valuable for monitoring treatment response in refractory cases 1, 3

Duration of Treatment

• Following cessation of acute provoked seizures without evidence of neonatal-onset epilepsy, anticonvulsant medications should be discontinued before discharge home 1
• Treatment should aim to achieve the lowest possible seizure burden, as this may be associated with improved outcomes 1

Common Pitfalls and Caveats

• Avoid excessive sedation with anticonvulsants, as this can compromise respiratory function and necessitate ventilatory support 6
• Be cautious with lorazepam in neonates as it contains benzyl alcohol, which may be toxic to newborns 6
• Do not delay treatment of prolonged seizures, as experimental data suggest that prolonged seizures can have immediate and long-term adverse consequences on the developing brain 2
• Recognize that the etiology of neonatal seizures significantly impacts prognosis - infections of the central nervous system carry the highest mortality and morbidity 2