Sean M. Fox, M.D.
Adult and Pediatric Emergency Medicine
Carolinas Medical Center; Charlotte, NC
Neonatal Seizures-Not a Benzo Deficiency!
We are all rather accustomed to managing the patient who is having a seizure. ABCDs… Airway, Breathing, Circulation, and Disrobe… and then Benzos if there is still shaking. This method works pretty well. But one population that deserves some specific attention is the neonate who is having a seizure. As is often the rule, “don’t trust a neonate!”
Neurological dysfunction in a neonate is frequently demonstrated by neonatal seizures.
Neonatal Seizures can be difficult to recognize clinically.
(1) Subtle Sz (50%)
(a) Often overlooked
(b) Can be misconstrued as normal behaviors and reactions.
(c) Ocular movements, oral-buccal-lingual movements, progression movements (ex. rowing, swimming, pedaling, thrashing), Complex Purposeless Movements.
(2) Clonic Sz (25%)
(a) Rhythmic jerking
(b) Todd’s Paresis can follow prolonged hemi-convulsions.
(3) Myoclonic Sz (20%)
(a) Rapid, single or arrhythmic repetitive jerking
(b) May mimic the Moro reflex
(c) Myoclonic Sz is associated with the most severe brain damage; however, can also occur in healthy neonates with abundant myoclonic movements occurring during sleep.
(4) Tonic Sz (5%)
(a) Sustained contraction.
(b) May be focal, multifocal, or generalized.
(c) May mimic decerebrate or decorticate posturing.
(1) Ok, so this is not actually the most common cause, but it is still the one that we must consider first in our initial evaluation.
(2) Meningoencephalitis must be excluded in all neonates with seizures.
(3) In addition to group B Strep (GBS), E. coli, and Listeria, do not forget TORCHeS, which can present as seizures.
(1) Most common cause
(2) Most seizures due to HIE manifest within the first 48hrs of life.
(1) Intraventricular and periventricular hemorrhage (particularly preterm kids)
(2) Subarachnoid, intraparenchymal, or subdural more common in term kids.
(3) May occur “spontaneously” or from trauma (consider NAT always)
(1) Hypoglycemia, hypocalcemia, hypomagnesemia are most common metabolic causes.
(2) Inborn Errors of Metabolism (i.e., amino acid and organic acid disorders, hyperammonemias) can also lead to these derangements and subsequent seizures.
(3) Pyridoxine deficiency should also be considered.
(1) Cerebral malformations
(2) Drug withdrawal and toxicity (i.e., maternal narcotics, intrapartum maternal medications, inadvertent local anesthetic injection into the neonates scalp)
(3) Neurocutaneous syndromes (i.e., tuberous sclerosis)
NOTE: Just because you found one possible etiology, does not mean that another does not exist concurrently. Hypoglycemia may be present along with meningitis. So, do not waver from your initial concern for meningitis when you find out the glucose is 20. Naturally, treat the glucose, consider other inborn errors of metabolism, then perform the lumbar puncture and give antibiotics.
A “rational, initial evaluation” – at least I think so.
(1) Cranial Ultrasound can be done first. It is excellent at showing intraventricular and parenchymal hemorrhage, but cannot detect subarachnoid hemorrhage (SAH) or subdural hematoma (SDH).
(2) Head CT scan or MRI can also be performed (although I’d favor CT scan while in the ED).