NEUROLOGY · NEONATAL CONDITIONS
Neonatal Seizures
A practical guide for SCN clinical staff · Often subtle, usually symptomatic - check the glucose, find the cause, treat early
THEN FIND
THE CAUSE
An excitable brain
The newborn brain favours excitation: glutamate receptors mature early, and inhibitory circuits mature late.
GABA can excite
Immature neurons have high intracellular chloride (high NKCC1, low KCC2), so GABA can depolarise rather than inhibit. One reason phenobarbitone and benzodiazepines often only partly work.
Focal, not generalised
Poorly myelinated connections limit spread, so seizures are focal or multifocal. Generalised tonic-clonic seizures do not occur in newborns.
Electroclinical uncoupling
Many seizures are electrographic only. After phenobarbitone the visible signs often stop while EEG seizures continue.
Seizures add injury
A high seizure burden is linked to worse outcome independent of the cause. Treating early to reduce burden is the aim.
Timing points to cause
First 24-48h: HIE, haemorrhage, infection, hypoglycaemia. Days 2-3 in a well term baby: think stroke. After day 3: metabolic disorders, genetic epilepsy, late hypocalcaemia.
WHAT SEIZURES LOOK LIKE
- Clonic: rhythmic jerking of one limb or one side, often migrating - the most reliable sign
- Tonic: sustained stiffening or posturing of a limb or the trunk
- Automatisms: lip smacking, chewing, cycling, eye deviation or staring
- Autonomic: apnoea, desaturation, tachycardia or BP change, especially with other signs
- Stereotyped and the same each time; not stopped by holding the limb
INVESTIGATIONS
- Now: bedside glucose; blood gas with Na, K, ionised Ca, lactate
- Bloods: FBC, CRP, blood culture, UEC, Ca, Mg, phosphate, LFTs, ammonia
- Lumbar puncture when stable (include HSV PCR)
- Imaging: cranial ultrasound early; MRI is the key test for stroke and injury
- EEG/aEEG via NICU; metabolic and genetic tests guided by NICU and neurology
RED FLAGS
- Encephalopathy after a difficult birth: assess for cooling now (6-hour window)
- Unwell, febrile or abnormal CSF: treat as meningitis or HSV until proven otherwise
- Seizures after feeds start, with poor feeding or vomiting: think inborn error (check ammonia)
- Recurrent or prolonged seizures despite a first drug
- Apnoea or loss of airway after loading doses
SEIZURE
- Not stimulus-sensitive; not stopped by gentle restraint
- Clonic jerks with a fast and slow phase
- May have eye deviation, apnoea or autonomic change
- Can occur awake or asleep
JITTERINESS
- Triggered by handling or noise; stops when the limb is held
- Fine, even tremor with no fast and slow phase
- No eye or autonomic signs; baby otherwise alert
- Common and usually benign - still check glucose and calcium
BENIGN SLEEP MYOCLONUS
- Jerks only during sleep; stop when the baby is woken
- Often repetitive clusters in a well, normal baby
- Normal examination and EEG
- Resolves in the first months; no treatment
MANAGEMENT
Stabilise, check the glucose, treat with phenobarbitone, and look for the cause. Most babies with seizures need NICU care and EEG, so involve the consultant and NETS early.
First 15 minutes
- Airway, breathing, circulation; oxygen and monitoring
- Bedside glucose - treat hypoglycaemia (10% glucose 2 mL/kg IV)
- Gas with electrolytes; correct low calcium or magnesium per local protocol
- Video the event if parents consent; call the consultant
Antiseizure treatment
- First line: phenobarbitone 20 mg/kg IV over 20 minutes
- If seizures continue: further 10 mg/kg, to a total of 40 mg/kg
- Second line on NICU/NETS advice: levetiracetam, phenytoin or midazolam
- Watch for apnoea and hypotension; be ready to support the airway
Find the cause & refer
- Start antibiotics and aciclovir if infection is possible
- Assess for cooling if HIE is possible
- Call NETS: most babies with seizures need NICU, EEG and MRI
- Stop antiseizure drugs before discharge once provoked seizures settle (ILAE)
- Note the time, duration and exact movements; video if parents consent.
- Check a bedside glucose straight away and tell the doctor.
- Gently hold the limb: jitteriness stops, a seizure does not.
- After phenobarbitone, watch breathing, saturations and BP closely.
- Parents are often the first to notice - take their concern seriously and keep them informed.
How do you tell jitteriness from a seizure at the cot side?
Which causes of seizures can you treat in the first 15 minutes?
Why can a baby still be seizing after the visible movements stop with phenobarbitone?
A well term baby has focal clonic seizures on day 2. What is the likely cause and the key test?
Take-home message: Neonatal seizures are usually a sign of an acute problem - most often HIE, stroke, haemorrhage, infection or a metabolic upset. They are often subtle and easy to over- or under-call. Check the glucose, correct what you can, give phenobarbitone, look for the cause, and involve the consultant and NETS early.
For educational purposes only. Doses are a guide only - check your local formulary. Always align management to your local SCN/NICU or NETS protocols.