What is the management protocol for neonatal seizures?

Management Protocol for Neonatal Seizures

Phenobarbital is the first-line treatment for neonatal seizures at a loading dose of 20 mg/kg IV, regardless of seizure etiology. 1, 2

Initial Assessment and Stabilization

• Assess circulation, airway, and breathing (CAB) and provide appropriate airway protection 3
• Administer high-flow oxygen to prevent hypoxia 3
• Check blood glucose level immediately to rule out hypoglycemia as a potential cause 3
• Initiate continuous EEG monitoring to confirm seizures and monitor response to treatment 1, 2

First-Line Treatment

• Administer phenobarbital 20 mg/kg IV loading dose 1, 2
• This dose typically achieves therapeutic plasma levels (15-30 μg/mL) within minutes of injection 4
• If seizures persist after 20 minutes, consider giving an additional 10 mg/kg dose of phenobarbital (maximum total loading dose: 40 mg/kg) 2

Second-Line Treatment (if seizures persist after phenobarbital)

• Options include (in order of preference):
  • Levetiracetam 40-60 mg/kg IV (preferred in neonates with cardiac disorders) 1, 2
  • Fosphenytoin/phenytoin 15-20 mg/kg IV (consider as first-line if channelopathy is suspected) 2, 5
  • Midazolam 0.1-0.2 mg/kg IV bolus followed by continuous infusion (0.1-0.4 mg/kg/hour) 1, 2
  • Lidocaine (if available) 2 mg/kg IV bolus followed by continuous infusion (4-6 mg/kg/hour) 1, 2

Third-Line Treatment (for refractory seizures)

• Consider continuous midazolam infusion with escalating doses 1
• For suspected vitamin B6-dependent epilepsy with seizures unresponsive to second-line ASMs, attempt a trial of pyridoxine 2
• Consider consultation with pediatric neurology for further management 2

Maintenance Therapy

• After seizure control is achieved, maintain phenobarbital at 3-4 mg/kg/day divided into 1-2 doses 4
• Due to long half-life (69-165 hours), monitor for drug accumulation; avoid exceeding 5 mg/kg/day 4

Duration of Treatment

• For acute symptomatic seizures without evidence of neonatal-onset epilepsy, discontinue antiseizure medications before discharge home 2
• Early discontinuation after 1-2 weeks is generally possible 4
• This recommendation applies regardless of MRI or EEG findings 2

Special Considerations

• Therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy 2
• Treating electrographic-only seizures to achieve lower seizure burden may improve outcomes 2
• For neonates requiring muscle relaxants, administer phenobarbital before curare to enable more effective mechanical ventilation 4

Important Caveats

• Despite being the standard first-line treatment, phenobarbital controls seizures in fewer than half of neonates (43-45%) 5
• The severity of seizures is a stronger predictor of treatment success than the specific medication used 5
• Continuous EEG monitoring is essential to confirm seizure control, as clinical assessment alone is unreliable 1, 2
• Withdrawal-associated seizures in neonates are primarily myoclonic, respond to opiates, and carry no increased long-term risk of poor outcomes 6