How to manage convulsions in a newborn baby?

Management of Neonatal Convulsions

Administer phenobarbital 15-20 mg/kg IV as first-line treatment for neonatal seizures, ensure airway equipment is immediately available, check blood glucose urgently, and perform lumbar puncture in all infants <12 months to exclude meningitis. 1, 2

Immediate Acute Seizure Control

• Phenobarbital is the first-line anticonvulsant with an IV loading dose of 15-20 mg/kg administered slowly to achieve therapeutic levels within minutes and control seizures in most cases 1, 2, 3
• Equipment to maintain a patent airway must be immediately available before IV administration, as respiratory depression is a significant risk 4, 2
• If seizures persist after adequate phenobarbital levels, administer second-line agents: phenytoin, levetiracetam, midazolam, or lidocaine 1, 3
• Rectal diazepam 0.5 mg/kg may be used if IV access is unavailable, though IV route is strongly preferred 1
• Exception: If channelopathy is suspected (e.g., positive family history), use phenytoin or carbamazepine as first-line instead of phenobarbital 3

Critical Diagnostic Evaluation (Perform Simultaneously with Treatment)

• Check blood glucose immediately during or after seizure to rule out hypoglycemia, as this is a rapidly correctable cause 5, 1
• Perform lumbar puncture in all infants <12 months with seizures, as meningeal signs may be absent in this age group despite serious bacterial meningitis 5, 1
  • Additional indications: complex convulsion lasting >20 minutes, unduly drowsy/irritable infant, systemically ill appearance, or incomplete recovery within 1 hour 5, 1
  • Critical pitfall: A comatose infant must be examined by an experienced physician before lumbar puncture due to herniation risk; brain imaging may be needed first 5
• Obtain urinalysis to exclude urinary tract infection, the most common serious bacterial infection in febrile infants 1, 6
• MRI head with diffusion-weighted imaging is the most sensitive modality for detecting hypoxic-ischemic injury 1
• Head ultrasound can serve as initial bedside imaging for unstable neonates to identify hemorrhage or hydrocephalus, though it has low sensitivity for hypoxic-ischemic injury 1

Identify Underlying Etiology

• Hypoxic-ischemic encephalopathy accounts for 46-65% of neonatal seizures and is the most common cause 1, 7
• Approximately 90% of infants with hypoxic-ischemic encephalopathy develop seizures within the first 2 days after birth 1
• Intracranial hemorrhage and perinatal ischemic stroke account for 10-12% of cases 1
• Timing matters: Seizures occurring after day 7 of life are more likely related to infection, genetic disorders, or malformations of cortical development 1
• Consider pyridoxine trial in neonates with seizures unresponsive to second-line ASM and clinical features suggesting vitamin B6-dependent epilepsy 3

Supportive Care

• Correct hypoglycemia promptly by checking and maintaining blood glucose levels 1
• Start IV infusion, monitor vital signs continuously, maintain unobstructed airway, and have artificial ventilation equipment immediately available 4, 2
• Therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy 3

Fever Management (If Present)

• Use paracetamol (acetaminophen) as the preferred antipyretic for comfort, not to normalize temperature 1, 6, 8
• Do not use physical cooling methods (tepid sponging, cold bathing, fanning) as they cause discomfort without proven benefit 5, 6, 8
• Ensure adequate hydration to prevent dehydration 5, 6
• Critical point: Antipyretics do not prevent febrile seizures and should not be used for this purpose 8

Hospitalization Criteria (All Neonatal Seizures Require Admission)

• All infants <3 months with fever and seizures must be hospitalized due to immature immune systems and high risk of serious bacterial infection 1, 6
• Neonates with seizures lasting >20 minutes or who have not fully recovered within 1 hour require admission 1
• Any neonate with toxic appearance, abnormal CSF findings, or difficulty feeding requires hospitalization 1

Anticonvulsant Discontinuation Strategy

• After cessation of acute provoked seizures without evidence of neonatal-onset epilepsy, discontinue ASMs before discharge home, regardless of MRI or EEG findings 1, 3, 9
• Only continue treatment beyond the neonatal period if seizures persist after the neonatal period or if severe electroencephalographic changes are present 10

Common Pitfalls to Avoid

• Do not routinely perform EEG, serum electrolytes, or chest X-ray unless specific clinical indication exists 1, 8
• Do not restrain the seizing infant or place anything in the mouth 8
• Do not inject phenobarbital continuously until convulsions stop, as it may require 15+ minutes to reach peak brain concentrations, leading to severe barbiturate-induced depression 2
• Do not delay lumbar puncture in infants <12 months; review the decision not to perform LP within a few hours if initially deferred 5, 8

Parent Education

• Provide specific information on seizure nature, recurrence risk (approximately 30%), and warning signs requiring immediate return 5, 8
• For febrile seizures, parents may be given rectal diazepam for home administration at seizure onset to prevent prolonged recurrent episodes 5, 8
• Reassure parents that simple febrile seizures have excellent prognosis for normal neurological development, with only 2.5% risk of subsequent epilepsy after a single simple febrile convulsion 5, 8
• Reevaluate within 24 hours if managed as outpatient, though most neonatal seizures require inpatient management 1, 6