Neonates are more prone to seizures than children of other ages. Ultimately, a cause of seizures is more likely to be identified in the newborn. Neonatal seizures are subtle and careful attention to repetitive motions of the face, arms or legs should be considered worrisome for seizure. Generalized tonic clonic seizures are rare in this patient population.  

Common Causes:  

Hypoxic ischemic encephalopathy (most common), infection, stroke, non-accidental trauma, intracranial hemorrhage (including from vitamin K deficiency), metabolic disorders, and structural abnormalities.  

Guidelines for Treatment:  

Phenobarbital should be used as first line, unless there is concern for channelopathy based on family history. Some literature does suggest possible benefits of a benzodiazepine in conjunction with phenobarbital for seizure cessation, but care should be given due to high risk for respiratory suppression in neonates.  

For seizures that are unresponsive to first line treatment, consider phenytoin, levetiracetam, midazolam, or lidocaine. 

A trial of pyridoxine can be attempted in patients who are unresponsive to initial measures 

Evaluation:  

Neonatal seizures require a full evaluation, including labs, head imaging (MRI preferred), low threshold for LP post imaging, concern for trauma  

Disposition:  

Neonates presenting with seizures require admission to the hospital for ongoing evaluation and monitoring.

References

Pressler RM, Abend NS, Auvin S, Boylan G, Brigo F, Cilio MR, De Vries LS, Elia M, Espeche A, Hahn CD, Inder T, Jette N, Kakooza-Mwesige A, Mader S, Mizrahi EM, Moshé SL, Nagarajan L, Noyman I, Nunes ML, Samia P, Shany E, Shellhaas RA, Subota A, Triki CC, Tsuchida T, Vinayan KP, Wilmshurst JM, Yozawitz EG, Hartmann H. Treatment of seizures in the neonate: Guidelines and consensus-based recommendations-Special report from the ILAE Task Force on Neonatal Seizures. Epilepsia. 2023 Oct;64(10):2550-2570. doi: 10.1111/epi.17745. Epub 2023 Sep 1. PMID: 37655702.