Introduction
Definition of Neonatal Seizures
Epidemiology of Neonatal Seizures
Etiology of Neonatal Seizures
Clinical Presentation
Classification
Diagnosis of Neonatal Seizures and the Role of EEG/aEEG
Management of Neonatal Seizure
Antiseizure Therapy
Choice of First- and Second-Line Drugs
Medication | Dosage | Common side effects | Remarks |
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Phenobarbitone | Loading dose: 20 mg/kg intravenously, repeated once as needed (consider 10 mg/kg, if notventilated) Maintenance dose: 3–6 mg/kg/d Target level: 40 mcg/mL | Respiratory depression Depressed consciousness Hypotension Hepatotoxic Blood dyscrasia | Prolonged half-life first week of life and preterm (43–217 h) may lead to increased duration of NICU stay Risk of dose error because of available strength [200 mg/mL] Renal and hepatic excretion can be affected in HIE |
Phenytoin/Fosphenytoin | Loading dose: 20 mg/kg PE intravenous, over 20 min or at rate of 3 mg/kg/min PE Maintenance dose: 2.5–5 mg/kg/d in 2 divided doses Target level: 10–20 mcg/mL Administer over 10 min | Infusion site irritation Arrhythmia Rash Hepatotoxic Blood dyscrasia | Cardiac monitoring required Phenytoin poor oral bioavailability Fosphenytoin preferred over phenytoin Levels likely higher in therapeutic cooled infant, and hence, maintenance dose needs to be titrated to drug levels |
Levetiracetam | Loading dose: 40–60 mg/kg/d intravenously Maintenance dose: 30–60 mg/kg/d in 3 divided doses Optimal dosing & target level not known | Mild sedation Irritability | Limited information regarding dosing side effect for the neonatal population Adjust dose in renal impairment |
Midazolam | Loading dose: 0.15 mg/kg as bolus intravenously over 10 min Maintenance dose: Infusion started at 0.06 mg/kg/h and titrated upwards to effect up to maximal 0.3 mg/kg/h | Respiratory depression Depressed consciousness Hypotension | Developing brain may have an excitatory response to benzodiazepines rather than inhibition, hence, can potentiallyworsen seizures. Wean gradually |
Treatment Considerations in Inborn Errors of Metabolism
Stopping Antiseizure Drugs
The Outcome of Neonatal Seizures
EEG Monitoring Systems and the Future in LMICs
Conclusion
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Etiology and comorbidity of neonatal seizures specific to the social, economic, and environmental situation in LMIC.
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Availability of EEG and/or aEEG.
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Availability of monitors and ventilators in limited-resource settings (may influence use of maximal therapeutic doses of some antiseizure drugs, such as phenobarbital, phenytoin, or midazolam).
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Availability of infusion pumps and associated risk of drug errors.
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Availability of pyridoxine (IV and oral perpetrations), pyridoxal-5 phosphate, and folinic acid.
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Availability and costs of metabolic and genetic testing.