Is it normal for a one-month-old premature newborn, born at 34 weeks of gestation, to have episodes where she stares to the sides and appears unresponsive for 1 to 2 minutes?

Staring Episodes in a One-Month-Old Premature Infant

These episodes of staring to the sides with apparent unresponsiveness lasting 1-2 minutes are NOT normal and require urgent neurological evaluation to rule out neonatal seizures, which can present as subtle behavioral changes including staring spells and altered responsiveness. 1, 2

Why This Requires Immediate Evaluation

Your infant has multiple risk factors that make seizures more likely:

• Prematurity at 34 weeks increases seizure risk, with preterm infants having an incidence of 57-132 per 1,000 live births compared to 3 per 1,000 in term infants 3
• Current age of one month (approximately 38 weeks corrected gestational age) falls within the high-risk window for neonatal seizures 1, 4
• The described behavior - staring with unresponsiveness for 1-2 minutes - is concerning for non-motor seizures, which can manifest as altered consciousness, staring, or autonomic changes without obvious convulsive movements 1

Critical Diagnostic Considerations

Many neonatal seizures are subclinical or lack obvious clinical signs, making them difficult to recognize without electroencephalography (EEG). 1 The staring episodes you describe could represent:

• Non-motor seizures with altered awareness, which are recognized by the International League Against Epilepsy as a seizure type that can occur without obvious motor manifestations 1
• Subclinical seizures that appear only as behavioral changes like staring or decreased responsiveness 1

This is distinctly different from benign conditions that might be confused with seizures:

• Benign myoclonus of early infancy typically involves brief myoclonic jerks lasting only seconds, not prolonged staring episodes of 1-2 minutes 3
• Benign paroxysmal torticollis presents with head tilt, not staring 3
• The duration of 1-2 minutes is too long for normal infant behaviors and too short for most benign movement disorders 3

Immediate Actions Required

Seek urgent pediatric neurological evaluation within 24-48 hours. The evaluation should include:

1. Continuous video-EEG monitoring - This is essential because not all clinical movements have an EEG correlate, and not all EEG seizures have clinical manifestations 1

2. Brain imaging based on clinical stability:

   • Head ultrasound if immediate bedside evaluation is needed 1, 2
   • MRI with diffusion-weighted imaging as the gold standard to identify underlying causes 1, 2

3. Laboratory evaluation to exclude treatable metabolic causes:

   • Point-of-care glucose testing (hypoglycemia must be excluded immediately) 1, 2
   • Electrolytes including sodium, calcium, and magnesium 1, 2
   • Complete blood count and blood culture if infection is suspected 1

Most Likely Underlying Causes in Your Infant

Given the prematurity and current age, the differential diagnosis includes:

• Hypoxic-ischemic injury - accounts for 46-65% of neonatal seizures, though 90% present within the first 2 days of life 1, 4, 2
• Late-onset causes (beyond day 7 of life) including infection, genetic disorders, or malformations of cortical development, which become more likely at one month of age 4, 2
• Intracranial hemorrhage or stroke - accounts for 10-12% of cases and is more common in preterm infants 4, 2
• Metabolic derangements including hypoglycemia, hypocalcemia, or hypomagnesemia 2

Critical Pitfall to Avoid

Do not adopt a "wait and see" approach. Approximately 95% of neonatal seizures have an identifiable cause, and many are treatable if diagnosed promptly. 1, 4 Delayed diagnosis can result in:

• Ongoing seizure activity causing additional brain injury 1
• Missed opportunity to treat reversible metabolic causes 1, 2
• Progression of underlying conditions like infection or metabolic disorders 2

The absence of obvious convulsive movements does not rule out seizures - many neonatal seizures present only as behavioral changes, staring, or autonomic signs without rhythmic jerking. 1