What is the protocol for managing convulsions (seizures) in a newborn?

Management of Neonatal Seizures Protocol

For active neonatal seizures, immediately administer lorazepam 0.1 mg/kg IV/IO, followed by phenobarbital 15-20 mg/kg IV loading dose if seizures persist, with levetiracetam 40 mg/kg IV as an alternative second-line agent. 1

Immediate Stabilization (First 2-5 Minutes)

Airway and Breathing:

• Position infant in "sniffing" position to maintain patent airway 1, 2
• Administer high-flow oxygen to prevent hypoxia 1, 2
• Have equipment for airway protection and artificial ventilation immediately available 1, 3
• Consider elective intubation if Glasgow coma score ≤8 1

Circulation and Access:

• Establish IV or intraosseous access immediately 1
• Monitor vital signs continuously, including oxygen saturation 1

Critical Initial Labs:

• Check blood glucose urgently to rule out hypoglycemia 1, 2
• Obtain calcium, magnesium, sodium, complete blood count, and blood culture if infection suspected 1

Temperature Management:

• Place infant under radiant heat source to prevent hypothermia 1
• Maintain normothermia—avoid both hypothermia and hyperthermia 1

Neurological Assessment

Rapid Evaluation:

• Assess level of consciousness using AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) 1
• Check pupillary size and reaction to light—unilateral sluggish or absent responses indicate raised intracranial pressure 1
• Observe for abnormal posturing or convulsive movements 1

Anticonvulsant Medication Protocol

First-Line Treatment:

• Lorazepam 0.1 mg/kg IV/IO given slowly (2 mg/min maximum) 1, 3
• If seizures persist after 5 minutes, repeat lorazepam dose (maximum 2 doses total) 1
• Critical caveat: Monitor for respiratory depression, especially in neonates 1, 4

Second-Line Treatment (if seizures continue):

• Levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) given as slow infusion over 5-10 minutes 1
• Alternative: Phenobarbital 15-20 mg/kg IV loading dose (maximum 1,000 mg) 1, 5, 6
  • Therapeutic plasma levels (15-30 mcg/mL) achieved within minutes 5
  • 77% of neonatal seizures respond to phenobarbital at doses up to 40 mcg/mL serum concentration 6
  • Premature infants (<32 weeks) respond significantly better to phenobarbital 6

Third-Line Treatment:

• If seizures persist despite phenobarbital loading to 40 mcg/mL serum concentration, add a second anticonvulsant rather than escalating phenobarbital further 6
• Additional phenobarbital beyond 40 mcg/mL shows minimal additional benefit (only 10% response rate) 6

Maintenance Therapy After Seizure Control

Dosing Schedule:

• Lorazepam: 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
• Levetiracetam: 15 mg/kg (maximum 1,500 mg) IV every 12 hours 1
• Phenobarbital: 3-5 mg/kg/day IV divided every 12 hours 1, 5, 7
  • Lower doses (3 mg/kg/day) for severe asphyxia 7
  • Higher doses (5 mg/kg/day) for neonates on ECMO support 7
  • Half-life is 59-182 hours in neonates, allowing once-daily dosing after loading 8

Critical Monitoring and Pitfalls

Respiratory Monitoring:

• Major pitfall: Benzodiazepines and phenobarbital cause respiratory depression—have ventilatory support immediately available 1, 3
• Rapid IV injection (<2 minutes) in neonates causes severe hypotension, especially when combined with fentanyl 4

Neurological Monitoring:

• Monitor pupillary responses—most reliable sign of raised intracranial pressure 1
• Document seizure cessation and any recurrence 1

Fluid Balance:

• Maintain fluid balance records 1
• Document vomiting or abdominal distention 1

Underlying Etiology Investigation

Common Causes to Consider:

• Hypoxic-ischemic encephalopathy (most common) 1
• Intracranial hemorrhage 1
• Perinatal ischemic stroke 1
• Infection (meningitis/sepsis)—obtain blood culture 1
• Metabolic disorders (hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia) 1
• Withdrawal-associated seizures (primarily myoclonic, respond to opiates) 2

When to Perform Lumbar Puncture:

• Suspected meningitis based on clinical presentation 9
• Children <12 months with prolonged seizures or incomplete recovery within 1 hour 9
• Contraindication: Comatose infant or signs of raised intracranial pressure—perform brain imaging first 9

Team Coordination

Role Assignment:

• Designate a team leader to coordinate care 1
• Clearly assign roles to team members during resuscitation 1
• Use closed-loop communication to prevent errors 1
• Consider early pediatric neurology consultation 1

Transfer Considerations:

• If specialized center transfer needed, discuss with receiving team early 1
• Use pressure-redistributing mattresses and barrier creams under transport straps 1

Special Populations

Preterm Infants:

• Avoid rapid IV injection (<2 minutes)—associated with severe hypotension and seizures 4
• Reduced organ function increases vulnerability to prolonged respiratory effects 4
• Better response to phenobarbital than term infants 6

Neonates with Renal/Hepatic Disease:

• No acute dose adjustment needed for single doses 3
• Exercise caution with frequent repeated doses over short periods 3