Pediatric & General Neurology | Level: Medical/Professional Residency

The document titled "Neonatal Seizures: Comprehensive Clinical Protocols" is a specialized medical presentation designed for use in a Neonatal Intensive Care Unit (NICU). It provides an evidence-based framework for the evaluation and management of seizures in newborns. Core Medical Concepts Definition & Incidence: It defines neonatal seizures as paroxysmal alterations in neurological function and notes they occur in approximately 3.5 per 1,000 live births, with much higher rates in preterm infants (10–15 per 1,000). The "GABA Paradox": A key clinical point explained is that while GABA is inhibitory in mature brains, it can be excitatory in neonates due to high intracellular chloride levels, which may make standard treatments like Phenobarbital less effective. Subclinical Seizures: The document highlights that up to 80% of neonatal seizures are "electrographic only" (occult), meaning they cannot be detected without an EEG. Clinical Manifestations The presentation categorizes seizure types to assist in bedside diagnosis: Motor Seizures: Includes focal clonic (rhythmic jerking), focal tonic (sustained posturing), and myoclonic (rapid, non-rhythmic jerks). Subtle & Autonomic: Describes non-motor signs like repetitive blinking, lip smacking, "pedaling" movements, and fluctuating vitals such as sudden tachycardia or apnea. Seizure vs. Jitteriness: It includes a dedicated section for differentiating true seizures from jitteriness. Etiology & Timing It provides a timeline to help identify the underlying cause based on when the seizure begins: 0–24 Hours: Typically caused by HIE (Hypoxic-Ischemic Encephalopathy), hypoglycemia, or birth trauma. 24–72 Hours: Often related to stroke, hemorrhage, or inborn errors of metabolism. 72 Hours: Likely due to infections, genetic syndromes, or cerebral malformations. Management & Treatment Hierarchy The protocol outlines a tiered pharmaceutical approach: First-line: Phenobarbital (Loading dose: 20 mg/kg IV). Second-line: Levetiracetam (40–60 mg/kg) or Fosphenytoin (20 mg PE/kg). Refractory/Rescue: Midazolam infusions or a Pyridoxine (B6) trial for suspected vitamin-dependent epilepsy. Diagnostic Investigations Tier 1: Blood work (glucose, calcium, electrolytes), sepsis screen, and cranial ultrasound. Tier 2: Mandatory Lumbar Puncture (LP) if the etiology is unclear, and continuous video-EEG, which is cited as the "gold standard" for diagnosis. Imaging: MRI is the definitive modality once the infant is stable.