Introduction
Neonatal seizures are epileptic events occurring within the first 28 days of life in term infants or before 44 weeks of gestational age in preterm infants. They represent a neurological emergency and are a clinical manifestation of underlying central nervous system dysfunction.
🔑 Key Point:
The incidence of neonatal seizures is highest in the neonatal period compared to any other time in life, occurring in approximately 1-3.5 per 1,000 live births in term infants and 10-15 per 1,000 live births in preterm infants.
Pathophysiology
The pathophysiology of neonatal seizures is complex and involves multiple interconnected mechanisms. The neonatal brain is particularly vulnerable to seizures due to developmental factors that create an excitation-inhibition imbalance.
Pathophysiological Mechanisms of Neonatal Seizures
The neonatal brain has unique characteristics that predispose it to seizures:
- Enhanced excitability: Greater density of excitatory receptors (NMDA) and more excitatory neurons
- Underdeveloped inhibition: GABA (normally inhibitory) can be excitatory in the immature brain
- Immature connectivity: Limited propagation pathways prevent generalized tonic-clonic seizures but allow for subtle, difficult-to-recognize seizure activity
- Higher metabolic demand: The developing brain requires more energy, making it vulnerable to metabolic insults
📝 Nursing Insight:
Unlike older children and adults, neonates rarely exhibit generalized tonic-clonic seizures due to their incompletely myelinated neural pathways and immature brain connectivity. This makes seizure recognition challenging for nursing staff.
Etiology
Understanding the causes of neonatal seizures is crucial for appropriate management. Several conditions can trigger seizures in the neonatal period:
Mnemonic: “VITAMIN” for Neonatal Seizure Causes
| Etiology Category | Examples | Timing |
|---|---|---|
| Hypoxic-Ischemic Encephalopathy (HIE) | Perinatal asphyxia, placental insufficiency | First 24-48 hours of life |
| Intracranial Hemorrhage | Intraventricular, subarachnoid, subdural | First week of life |
| Metabolic Disturbances | Hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia | Variable, often 24-72 hours |
| Infections | Bacterial meningitis, viral encephalitis, TORCH infections | Variable |
| Inborn Errors of Metabolism | Amino/organic acidopathies, urea cycle disorders | After first feeding, days 2-3 |
| Drug Withdrawal | Maternal opioids, benzodiazepines | 24-72 hours after birth |
| Brain Malformations | Cortical dysplasia, lissencephaly | Variable, may be delayed |
| Genetic Disorders | Benign familial neonatal epilepsy, Early infantile epileptic encephalopathy | Variable, often early |
⚠️ Critical Nursing Alert:
Hypoglycemia is a rapidly treatable cause of neonatal seizures. Always check blood glucose immediately in any neonate presenting with seizure activity.
Clinical Presentation
Neonatal seizures differ significantly from seizures in older children and adults. They are often subtle and can be difficult to distinguish from normal neonatal movements.
Classification of Neonatal Seizures
🔑 Clinical Pearl:
Subtle seizures are the most common seizure type in neonates (approximately 50%) but are easily missed. They include ocular deviation, eyelid fluttering, sucking/chewing movements, and “swimming” limb movements.
Associated Clinical Findings
Several signs and symptoms may accompany neonatal seizures:
- Autonomic changes (tachycardia, fluctuations in blood pressure)
- Respiratory pattern changes or apnea
- Color changes (cyanosis, pallor)
- Altered level of consciousness before, during, or after events
- Feeding difficulties
- Temperature instability
Diagnosis
Diagnosing neonatal seizures requires a combination of clinical observation, electroencephalography (EEG), and laboratory/imaging studies.
Step 1: Clinical Recognition
Careful observation of suspicious movements, differentiating seizures from normal neonatal behaviors and jitteriness.
Step 2: Electroencephalography (EEG)
Gold standard for diagnosis. Options include:
- Conventional EEG (cEEG)
- Amplitude-integrated EEG (aEEG)
- Video EEG monitoring
Step 3: Laboratory Investigations
Essential to identify treatable causes:
- Blood glucose, calcium, magnesium, sodium
- Complete blood count
- Blood cultures
- Cerebrospinal fluid analysis (if infection suspected)
- Metabolic screening (ammonia, lactate, amino acids, organic acids)
- Toxicology screen
Step 4: Neuroimaging
To identify structural abnormalities:
- Cranial ultrasound (bedside, good for hemorrhage)
- CT scan (rapid, good for hemorrhage)
- MRI (preferred, better detail of brain tissue)
📝 Nursing Insight:
Up to 80% of neonatal seizures are subclinical (electrographic-only) and can only be detected by EEG monitoring. Many clinically apparent “seizures” may not have EEG correlates and may represent non-epileptic movements.
| Differentiating Features | Seizures | Jitteriness/Tremors |
|---|---|---|
| Stimulus sensitivity | Not provoked or stopped by stimulation | Can be provoked or stopped by gentle restraint |
| Eye movements | Often present (deviation, staring) | Absent |
| Movement pattern | May involve slow, rhythmic clonic jerking | Rapid, fine tremors of equal amplitude |
| Autonomic changes | Often present (heart rate changes, apnea) | Usually absent |
| Consciousness | May have altered consciousness | Normal consciousness |
Management
Management of neonatal seizures follows a dual approach: treating the underlying cause while providing symptomatic control of seizure activity.
Management Approach for Neonatal Seizures
Pharmacological Management
| Medication | Dosing | Advantages | Disadvantages | Nursing Considerations |
|---|---|---|---|---|
| Phenobarbital | Loading: 20mg/kg IV Maintenance: 3-5mg/kg/day |
First-line agent Long half-life Established efficacy |
Respiratory depression Sedation Hypotension May worsen neuronal injury |
Monitor respiratory status Have resuscitation equipment ready Slow IV administration Monitor levels |
| Levetiracetam (Keppra) | Loading: 20-50mg/kg IV Maintenance: 10-30mg/kg/day |
Minimal sedation No respiratory depression No drug interactions Minimal adverse effects |
Less established efficacy Limited long-term data in neonates |
Adjust dose in renal impairment Monitor for irritability May be preferred for preterm infants |
| Phenytoin/ Fosphenytoin | Loading: 20mg/kg IV Maintenance: 4-8mg/kg/day |
Second-line agent Established use |
Cardiac arrhythmias Hypotension IV infiltration concerns Narrow therapeutic window |
Cardiac monitoring required Incompatible with dextrose Purple glove syndrome Monitor levels Slow infusion rate |
| Midazolam | Loading: 0.15mg/kg IV Continuous: 0.1-0.4mg/kg/hour |
Rapid action Short half-life |
Respiratory depression Hypotension Tolerance develops quickly |
Continuous cardiorespiratory monitoring Reserved for refractory seizures Risk of withdrawal with prolonged use |
Mnemonic: “ABCDE” for Initial Management
⚠️ Critical Nursing Alert:
When administering phenobarbital or phenytoin, always have resuscitation equipment readily available and continuously monitor respiratory status. These medications can cause significant respiratory depression, especially in premature infants.
Nursing Considerations
Comprehensive nursing care for neonates with seizures involves assessment, monitoring, intervention, and family support.
Assessment
- Perform thorough neurological assessment using standardized tools appropriate for neonates
- Document seizure characteristics: type, duration, frequency, associated signs
- Monitor vital signs closely, including temperature, as hypothermia/hyperthermia can trigger seizures
- Ensure timely collection of specimens for diagnostic tests
- Assess for risk factors: maternal history, birth trauma, infection, metabolic disorders
Interventions
- Position infant to maintain airway patency; have suction equipment ready
- Monitor and document response to anticonvulsant therapy
- Ensure accurate medication administration, particularly for weight-based dosing
- Implement seizure precautions: padded side rails, minimal stimulation environment
- Maintain thermoregulation; avoid hyperthermia which can worsen seizures
- Ensure adequate nutrition and hydration
- Implement developmental care principles despite intensive monitoring
🔑 Nursing Pearl:
When documenting neonatal seizures, use objective descriptions rather than interpretations. For example, write “rhythmic jerking of right arm lasting approximately 30 seconds with eye deviation to the right” rather than simply “had a seizure.”
Family-Centered Care
Neonatal seizures are frightening for parents. The nurse plays a crucial role in:
- Educating parents about seizures in clear, understandable terms
- Demonstrating seizure recognition and appropriate responses
- Involving parents in care when appropriate
- Providing emotional support and opportunities to express concerns
- Connecting families with resources and support groups
- Preparing for discharge and home care when applicable
Discharge Planning and Follow-up
Many neonates with seizures require specialized follow-up care after discharge:
- Ensure parents understand medication administration, side effects, and importance of adherence
- Teach parents how to recognize seizures and respond appropriately
- Provide emergency plan for seizure management
- Schedule follow-up appointments with neurology, developmental pediatrics
- Arrange for home health services if needed
- Connect family with early intervention services for developmental support
Nursing Process for Neonatal Seizures
Prognosis and Long-term Outcomes
The prognosis for neonates with seizures varies widely and depends on multiple factors:
| Prognostic Factor | Better Outcome | Poorer Outcome |
|---|---|---|
| Etiology | Transient metabolic disturbances Benign familial seizures |
HIE Structural brain abnormalities Infections |
| Seizure type | Focal clonic | Myoclonic Tonic |
| Gestational age | Term | Extremely preterm |
| EEG findings | Normal background Focal discharges |
Burst suppression Severe background abnormalities |
| Response to treatment | Rapid response to first-line therapy | Refractory seizures |
| Neuroimaging | Normal | Extensive injury Malformations |
Potential Long-term Complications
- Epilepsy: 20-30% of neonates with seizures develop epilepsy later in life
- Cerebral palsy: especially with HIE and certain structural abnormalities
- Developmental delay: cognitive, motor, language impairments
- Learning disabilities: may become apparent as child reaches school age
- Behavioral problems: attention deficits, hyperactivity
- Visual and hearing impairments: particularly with certain etiologies like TORCH infections
📝 Nursing Insight:
Early intervention services can significantly improve outcomes for infants who experienced neonatal seizures. Nurses should facilitate referrals to developmental specialists, physical therapy, occupational therapy, and speech therapy as needed.
Summary
Neonatal seizures represent a significant neurological emergency requiring prompt recognition and management. Key points for nursing students to remember:
- Neonatal seizures often present differently than seizures in older children and adults, with subtle manifestations being most common
- The underlying etiology significantly impacts both immediate management and long-term outcomes
- EEG is essential for diagnosis as many seizures may be subclinical or motor events may not have epileptic correlates
- First-line treatment remains phenobarbital, though levetiracetam is increasingly used
- Family education and support are essential components of comprehensive care
- Long-term follow-up and developmental monitoring are crucial for affected infants
🔑 Final Thoughts:
The nursing role in caring for neonates with seizures extends beyond technical skills to include keen observation, accurate documentation, effective communication with the healthcare team, and compassionate family support. By understanding the unique presentations and management considerations of neonatal seizures, nurses can significantly contribute to improved outcomes for these vulnerable patients.
References
- Glass, H. C. (2018). Neonatal seizures: advances in mechanisms and management. Clinics in perinatology, 45(4), 657-673.
- Soul, J. S. (2018). Acute symptomatic seizures in term neonates: Etiologies and treatments. Seminars in Fetal and Neonatal Medicine, 23(3), 183-190.
- Pisani, F., & Spagnoli, C. (2018). Neonatal seizures: a review of outcomes and outcome predictors. Neuropediatrics, 49(1), 6-11.
- World Health Organization. (2015). Guidelines on neonatal seizures. World Health Organization.
- Pellock, J. M., & Nordli, D. R. (2016). Neonatal seizures. In J. M. Pellock, D. R. Nordli, R. Sankar, & J. W. Wheless (Eds.), Pellock’s Pediatric Epilepsy: Diagnosis and Therapy (4th ed., pp. 285-301).
- Shellhaas, R. A., Wusthoff, C. J., Tsuchida, T. N., et al. (2017). Profile of neonatal epilepsies: Characteristics of a prospective US cohort. Neurology, 89(9), 893-899.
- Srinivasakumar, P., Zempel, J., Wallendorf, M., Lawrence, R., Inder, T., & Mathur, A. (2015). Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury. The Journal of pediatrics, 167(3), 465-470.