Management of Neonatal Seizures: Step-by-Step Approach
When managing a baby with seizures, immediate intervention is critical as prompt recognition and treatment can significantly improve outcomes and reduce the risk of permanent neurological damage.
Initial Assessment and Stabilization
- Assess circulation, airway, and breathing (CAB) and provide airway protection interventions immediately 1
- Administer high-flow oxygen to ensure adequate oxygenation 1
- Check blood glucose level urgently to rule out hypoglycemia as a cause of seizures 1
- Position the baby in a "sniffing" position to open the airway 1
- Maintain normal body temperature - avoid both hypothermia and hyperthermia 1
- Place the infant under a radiant heat source to prevent heat loss 1
Rapid Diagnostic Assessment
- Perform a quick neurological evaluation using the AVPU scale (Alert, responds to Voice, responds to Pain, or Unresponsive) or children's Glasgow coma scale 1
- Check pupillary size and reaction to light, and observe for abnormal posturing or convulsive movements 1
- Consider possible etiologies of neonatal seizures:
Immediate Management
- Establish vascular or intraosseous access immediately 1
- For active seizures, administer lorazepam 0.1 mg/kg intravenously/intraosseously 1, 3
- If seizures persist after 5 minutes, repeat lorazepam dose (maximum of 2 doses) 1
- Follow with levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1
- If seizures continue, add phenobarbital IV at a loading dose of 10-20 mg/kg (maximum 1,000 mg) 1
- Consider transferring the patient to a pediatric intensive care unit (PICU) if seizures are not controlled 1
Monitoring and Further Management
- Initiate continuous electroencephalography (EEG) monitoring if available, as many neonatal seizures are subclinical 2
- Monitor oxygen saturation continuously 1
- Individualize blood pressure and temperature monitoring requirements 1
- For oxygen monitoring, use soft cotton or silicone dressing between monitor and skin to prevent skin damage 1
- Maintain fluid balance records and document any vomiting or abdominal distention 1
- For patients who remain unconscious (Glasgow coma score ≤8), consider elective intubation and ventilation 1
Maintenance Therapy After Seizure Control
- After seizure control is achieved, maintenance doses should be administered:
Team Management and Communication
- Clearly assign roles to team members during the resuscitation
- Designate a team leader to coordinate care
- Communicate clearly and use closed-loop communication
- Consider early consultation with pediatric neurology if available
- If transfer to a specialized center is needed, discuss with the receiving team and prepare for safe transport 1
- Use pressure-redistributing mattresses during transport and barrier creams underneath transport straps to reduce friction 1
Prognosis and Follow-up
- Mortality following neonatal seizures has improved in recent decades, with current rates around 10% (range: 7-16%) 4
- The prevalence of adverse neurodevelopmental sequelae remains relatively stable at approximately 46% (range: 27-55%) 4
- The strongest predictors of outcome are the underlying cause of seizures and the background electroencephalographic activity 4
- Early identification and treatment are likely important for long-term outcomes in acute symptomatic seizures 5
Common Pitfalls to Avoid
- Delaying treatment while waiting for diagnostic tests - treat empirically while investigations are underway 6
- Missing subclinical seizures - clinical identification of seizures is not reliable in neonates; use EEG when available 6, 2
- Inadequate dosing of anti-seizure medications - seizures are refractory to initial loading doses in >50% of cases 6
- Failing to protect the skin during monitoring and procedures - use appropriate padding and techniques to prevent skin damage 1
- Overlooking the possibility of non-convulsive status epilepticus - maintain a high index of suspicion 1