PubMed: September 2023

Seizures are common in neonates, but there is substantial management variability. The Neonatal Task Force of the International League Against Epilepsy (ILAE) developed evidence-based recommendations about antiseizure medication (ASM) management in neonates in accordance with ILAE standards.

Seizures are the most common neurological emergency in the neonatal period. Most seizures in newborns are acute provoked (or symptomatic), typically related to hypoxic–ischemic brain injury, intracranial hemorrhage, arterial ischemic stroke, or intracranial infection. In 10%–15% of infants, seizures are the manifestation of neonatal epilepsy,

Electroencephalography (EEG) is required for seizure diagnosis, because most seizures in neonates have no clinical manifestations (electrographic-only), and differentiating between seizures and other abnormal movements is difficult.

TAKE-HOME MESSAGE

The International League Against Epilepsy's Neonatal Task Force developed evidence-based guidelines for managing seizures in neonates, addressing six priority questions through a systematic review and meta-analysis following the PRISMA 2020 standards.

Evidence-based recommendations encouraged that phenobarbital should be used as the first-line antiseizure medication (with certain exceptions) and that therapeutic hypothermia may reduce seizure burden in neonates with hypoxic–ischemic encephalopathy.

Other recommendations were based on expert consensus and included advice about second-line agents, neonates with channelopathies or cardiac disorders, and when antiseizure medications can be discontinued at discharge.

Seizures are challenging to manage and are among the more common neurological problems neonates face in the ICU. Guidelines are helpful, especially when the literature lacks significant evidence-based outcomes.

RECOMMENDATIONS

This article provides guidelines and consensus-based recommendations for six priority questions related to neonatal seizure management. Recommendations include choice of first- and second-line medication, treatment duration, effect of therapeutic hypothermia on seizures, and use of pyridoxine.

A systematic literature review and meta-analysis were performed, and results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 standards.

There were six main recommendations.

First, phenobarbital should be the first-line ASM (evidence-based recommendation) regardless of etiology (expert agreement), unless channelopathy is likely the cause for seizures (e.g., due to family history), in which case phenytoin or carbamazepine should be used.

Second, among neonates with seizures not responding to first-line ASM, phenytoin, levetiracetam, midazolam, or lidocaine may be used as a second-line ASM (expert agreement). In neonates with cardiac disorders, levetiracetam may be the preferred second-line ASM (expert agreement).

Third, following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings (expert agreement).

Fourth, therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy (evidence-based recommendation).

Fifth, treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcome (expert agreement).

Sixth, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM (expert agreement).

Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options.