Neonatal Seizures: Treatment Practices Among Term and Preterm Infants

Abstract

Neonatal seizures are common clinical conditions in both term and preterm neonates, yet no clinical management guidelines for direct care exist. We surveyed 193 international neurologists, neonatologists, and specialists in neonatal neurology or neonatal neurocritical care to assess management practices for seizures in preterm and term neonates. We found high reported rates of electroencephalogram and amplitude-integrated electroencephalogram (aEEG) monitoring to detect neonatal seizures, prevalent use of older anticonvulsant agents, and high rates of neuroimaging. Overall, responses were similar for term and preterm neonates. However, term neonates were likelier to be more heavily investigated, with higher use of magnetic resonance imaging and of electroencephalogram and aEEG monitoring of at-risk neonates. Continuous monitoring and cranial imaging of neonatal seizures now comprise the standard of care in many centers, although management practices vary widely. Early recognition and management of neonatal seizures and possible underlying injury may lead to increased opportunities for stopping seizures, protecting the brain, and improving developmental outcomes in at-risk neonates. The need for collaboration among neonatologists and neurologists is urgent, to address gaps in knowledge regarding management of neonatal seizures in term and preterm neonates.

Introduction

The risk of seizures, and particularly acute symptomatic seizures, is highest within the first year of age [1]. This elevated seizure risk likely reflects both developmental stage-specific mechanisms that lead to relative excitability in the neonatal brain [2], and the high risk for brain injury during the perinatal period. In term neonates, seizures occur in approximately 1-3.5 per 1000 live births, and the reported rate is even higher among children born preterm [3], [4], [5], [6], [7], [8], [9]. Clinical and electrographic neonatal seizures frequently reflect serious underlying brain injury. Clinical seizures are often one of the first signs of neurologic dysfunction, and acutely encephalopathic neonates frequently manifest electrographic seizures without clinical signs [10].

In the past few decades, several factors have influenced a burgeoning interest in optimizing the management of neonatal seizures, with a focus on reducing seizure burden. First, electrographic seizures are becoming easier to detect in this population. Advances in technology permit continuous brain monitoring with digital recording and storage for remote, real-time recognition of seizures. In addition, simplified electroencephalogram trending (e.g., an amplitude-integrated electroencephalogram, or aEEG) permits bedside seizure detection by practitioners with limited training in neurophysiology. Second, evidence from animal studies suggests that seizures may alter brain development and lead to long-term deficits in learning, memory, and behavior [11], [12], [13], [14]. Third, observational and randomized studies suggest that rapid, protocol-driven therapy leads to reduced seizure burdens [15], [16].

Although no definitive evidence exists that minimizing seizure burden improves childhood neurodevelopment, many experts are moving toward early and aggressive seizure therapy. However, some clinicians maintain concern that the potential neurotoxic risks of commonly used seizure medications [17] may outweigh any benefit of treating seizures. Despite recognition that the timely diagnosis and management of neonatal seizures are critical, little evidence guides investigation and treatment. As such, management practices vary widely [18].

The objective of this study was to assess management practices for seizures in preterm and term neonates among neurologists, neonatologists, and specialists in neonatal neurology or neonatal neurocritical care.