What is the recommended follow-up care for a newborn who experienced neonatal seizures?

Follow-Up Care for Newborns with Neonatal Seizures

All newborns who experienced neonatal seizures require systematic neuroimaging, developmental monitoring through at least 18 months of age, and discontinuation of antiseizure medications before discharge home unless neonatal-onset epilepsy is confirmed.

Immediate Post-Seizure Neuroimaging

MRI with diffusion-weighted imaging is the gold standard and must be performed when the infant is clinically stable 1, 2. This imaging:

• Identifies the underlying etiology in 39.8% more cases than ultrasound alone 2
• Is most sensitive for detecting hypoxic-ischemic encephalopathy, the cause of 46-65% of neonatal seizures 1, 3
• Provides critical prognostic information, as absence of major cerebral lesions on MRI is highly predictive of normal neurological outcome 2

Head ultrasound may be used as initial bedside imaging if the infant is unstable or MRI is unavailable, though it is less sensitive 1, 2.

Antiseizure Medication Management at Discharge

Antiseizure medications should be discontinued before discharge home in neonates whose seizures have ceased and who do not have evidence of neonatal-onset epilepsy 4. This recommendation applies regardless of:

• MRI findings 4
• EEG background abnormalities 4
• The specific etiology of the acute provoked seizures 4

The rationale is that acute provoked neonatal seizures (such as those from hypoxic-ischemic encephalopathy, metabolic derangements, or infection) do not require long-term anticonvulsant therapy once the acute phase has resolved 5, 4.

Exception for Withdrawal-Associated Seizures

Withdrawal-associated seizures are a special case with favorable prognosis 5:

• These seizures are primarily myoclonic and respond to opiates 5
• They carry no increased long-term risk of poor developmental outcome 5
• EEG normalizes and neurologic development proceeds normally, reflecting recovery of normal neurotransmitter concentrations 5
• Mean Bayley Scales of Infant Development scores are normal by 1 year of age, similar to matched drug-exposed controls without seizures 5

Developmental Monitoring Protocol

Structured neurodevelopmental follow-up through at least 18 months of age is essential, as this population faces substantial risk of adverse outcomes 6:

• 22% develop epilepsy 6
• 12% develop cerebral palsy 6
• 19% have severe neurodevelopmental disabilities 6
• 8.5% mortality within the first 18 months 6

Prognostic Indicators to Guide Follow-Up Intensity

The aEEG background pattern is the strongest predictor of unfavorable neurological outcomes, with an odds ratio of 20.4 6. Additional risk factors include:

• Lower Apgar scores (odds of unfavorable outcomes decrease by 0.7-fold for every point increase) 6
• Preterm birth (statistically significant association with poor outcomes) 6
• Requirement for second-line antiseizure medications during acute phase, which indicates larger seizure burden and worse prognosis 7
• Abnormal background EEG during acute phase 7

Monitoring for Recurrent Seizures

Infants should be monitored for recurrent seizure activity during routine vital signs and neurological status checks during the initial hospitalization 5. However:

• A single, self-limiting seizure at onset or within 24 hours after acute stroke should not be treated with long-term anticonvulsants 5
• Recurrent seizures should be treated according to standard seizure management protocols 5
• Prophylactic anticonvulsants are not recommended and may cause harm with negative effects on neural recovery 5

Critical Pitfalls in Follow-Up Planning

Do not continue antiseizure medications "just to be safe" in neonates with resolved acute provoked seizures 4. The evidence supports discontinuation before discharge unless there is confirmed neonatal-onset epilepsy, as unnecessary medication exposure may impair neural recovery 5.

Do not assume normal early clinical appearance guarantees normal outcome 6. Systematic developmental assessment through 18 months is required, as many disabilities manifest over time rather than immediately 7, 6.

Ensure parents understand the diagnosis and the plan for medication discontinuation 4. This prevents confusion and unnecessary continuation of medications after discharge.