the
newborn.
Today's program,
seizures with
DR Richard Shrider,
neonatologist at the James Whitcomb Riley
Hospital for Children in Indianapolis
indiana.
Welcome to the newborn series
on the Medical Educational Resource program.
What 21.
Uh today we're gonna talk a little bit about
seizures in the newborn.
Uh I realize seizures are not
real common in the newborn period,
but it's very important to understand a few
basic things about seizures.
There are a number of misconceptions.
Many people have about seizures in the newborn because
they kind of think of them like they think of seizures
and older infants and Children and adults,
and it's a little bit different in the newborn.
So we're just gonna spend maybe a half hour or so today talking
about uh neonatal seizures.
One of the hardest and most difficult
uh problems in neonatal seizures is
diagnosing the fact that they are seizures.
Usually we think uh in the
older person of typical
grand mall tonic clonic
seizures or even petty mall seizures or
temporal lobe seizures.
Well,
it's not like that at all in the newborn,
in the newborn,
seizures can be extremely
subtle and it's very difficult and takes an
experienced person many times to tell whether
or not a newborn is having seizures.
So the first of all,
we're just gonna talk about how do you recognize seizures in the
newborn?
Now,
these first couple slides.
1st 3 slides,
in fact,
will list how seizures can
present in the newborn.
Now,
some of them can be the typical tonic clonic
seizures,
but these are less common.
You can have tonic seizures just where the arms
or legs an extension or mile clonic
seizures or just chronic movements of one
extremity or likeness.
Now there,
let's get back to me for just a second.
I just want to go through some of these,
uh,
what do we mean by clonic seizures?
Well,
we mean just where say one extremity is doing this.
Okay,
that's chronic extremity,
clonic seizures.
What about tonic seizures?
Well,
that's where one extremity say is just out like this.
Or both extremities.
Or maybe the leg.
Uh and then mild chronic
uh jerks can be the whole body
going into a mile,
chronic jerk or even just one extremity,
uh having one mile chronic jerk.
Okay,
the next slide now list some more uh
apnea or transient alterations of
respiratory rate can be a manifestation of
seizures.
Tremors and we'll spend a little bit more time talking about
tremors in a minute or just Veysel,
motor changes,
like the infant turning a little pale or modeled can
be seizures very common in seizures are
just eye blinking or eye opening.
Next slide,
uh Nystagmus or deviation of the eyes to one
side or the other,
facial twitching,
chewing or sucking,
drooling an abnormal cry.
Now,
these are all the different ways that seizures of the newborn
can,
can present.
And most of the time,
seizures are not the typical
tonic clonic activity
that you see in older people with seizures.
Most of the time,
seizures of the newborn are very subtle,
like just a little bit of
uh smacking of the lips or a little bit of deviation of
the eyes or a little bit of facial
twitching,
uh maybe a little ticket
nia or or slow respiratory
rate.
Uh so you really have to be a pro and you have
to really keep your keep alert in order
to pick up seizures in the newborn.
Now,
sometimes you have to differentiate seizures also
from,
from normal activity while an infant sleeping.
Sometime while an Infinite sleeping,
just like when you're sleeping,
you will have a few mild chronic jerks and I'm sure all of
you have experienced these and you have to,
sometimes it's difficult when an infinite sleeping to tell whether or not a
seizure activity or just normal activity that occurs
during,
during sleep.
Now,
the other problem uh in the newborn,
that is totally different than in the
adult or older child is jitteriness.
How do we separate the jittery
baby from the baby with seizures?
And is it important to?
Well,
it probably is important.
Jitteriness is fairly unique to the newborn.
Uh It's probably normal in the newborn,
although we still worry about all the different things
that can cause seizures that might also cause jitteriness,
but jitteriness probably is normal and
probably does not carry with it.
Uh uh the
bad prognostic
implications that some forms of seizures
have in the newborn,
uh and it's important to
differentiate jitteriness from seizures and
we get a number of babies every year referred in who
referred in procedures,
but really are jittery.
Now,
there are a number of ways you can differentiate that
jitteriness from seizures and this next slide will show those.
There are basically four ways.
First of all with jitteriness,
you do not have any abnormality of the
eyes,
Okay with jitteriness,
you can stimulate it.
That is a stimulus sensitive
jitteriness is a tremor,
not a chronic activity and
jitteriness ceases with passive flexion.
Now let's just go through those because I think they're very important.
I'm sure all of you to take care of babies uh have done
this for very long,
have had the experience of not sure,
not being sure whether babies having seizures or jitteriness and let's just
go through those again,
I activity okay.
If a baby is having the stagnant jerking of his
eyes or his eyes are deviated,
way to one side,
that's probably seizure activity.
That's probably not jitteriness.
Okay,
if the baby is quiet and by
clapping or making a little bit of noise or
uh snapping
your fingers or just stimulating the baby,
you can have the baby start having jitteriness,
that activity.
That's probably jitteriness,
not seizures.
If the baby is having these movements and you hold his arm and
it stops right away,
that's probably jitteriness and probably not seizures.
One of the most helpful things I found to differentiate the
two.
He's the type of movement.
Now,
when we talk about differentiating jitteriness from
seizures,
the type of seizure activity will worry about is chronic
activity.
Okay.
And chronic activity always has a
fast component and a slow component.
Okay,
fast and slow and I think you can
appreciate that.
Okay,
Whereas jitteriness,
the movement is just as fast in each
direction.
Okay,
It's a tremor.
Okay.
You don't have a fast and a slow
component.
Okay.
It's all fast.
Okay.
And that is one of the most helpful means I've found at least in
differentiating jitteriness from seizures.
Okay,
now let's go on to the causes of seizures.
Okay,
and this is most important.
The most important aspect of approaching the
newborn with seizures is finding the cause
of the seizures.
Not treating the seizures with
Fiona barbara Dilantin that comes second or third.
The most important aspect about approaching the
newborn with seizures is finding the cause and
treating the cause of the seizure,
not giving Dilantin or PHENobarbital.
That comes second or third in the next slide shows
some of the causes of seizures And
I'm gonna go through all the different causes first and then we'll talk about the more
common ones hypoglycemia.
That is a blood sugar.
That's less than 30,
say in the full term.
In less than 20 in the premature,
in the first few days of life,
or less than 40 after the first few days of life,
low calcium.
Both of these are fairly common causes of seizures,
low magnesium,
low sodium.
Uh this is more common in premature babies.
Low magnesium frequently occurs in babies
who also have a low calcium.
And that's and if you have a baby that has a low calcium
not responding to calcium therapy,
you ought to think of a low magnesium
paradox in deficiency and dependency are
very rare,
but they do occur inborn errors of
metabolism,
like amino acid disorders,
maple syrup,
urine disease,
your branch chain keto acid disorders like meth a
moronic acid urea,
all those very rare metabolic disorders,
but also things like black toxemia,
fennel,
Keaton area,
hypothyroidism.
These can also cause seizures,
hypothyroidism not very commonly.
Uh jOHN does with connectors,
brain damage from jOHN this
hypothermia or hypothermia where the baby is
too cold or too warm.
All of these are causes of
seizures,
the most common on that slide being
hypoglycemia and hippo calc me.
Um but you also have to think of the other is also okay.
The next slide shows,
I think infectious causes sepsis and
meningitis,
fairly common causes of seizures.
Encephalitis like viral infections in the brain,
like herpes,
simplex infection and congenital
infections like talk so
toxoplasmosis,
rubella,
uh syphilis and
cytomegalovirus.
Next slide shows some other causes of seizures,
hemorrhage in the brain.
Subarachnoid hemorrhage or peri
ventricular and intra ventricular hemorrhage and we'll talk a
little bit more about these in a few minutes.
Next light and other causes,
okay,
developmental anomalies like cysts in the
brain,
uh encephalitis,
seals,
uh,
anencephaly,
etcetera,
trauma due to birth,
trauma as fix CIA,
fetal hypoxia and hypoxia at
delivery low APG ours drug,
toxic drugs like toxicity of
drugs,
withdrawal of drugs and hyper
viscosity or elevated hematocrit.
Okay,
now we're,
I think we're gonna go and talk about a few more of these,
uh,
a little bit more in detail and
uh,
some of the things I just want to mention,
uh,
trauma,
birth trauma used to be one of the most common causes of
seizure.
Okay,
now it's not nearly as common,
but it still does occur as fix.
Eah,
is one of the most common and most
devastating causes of seizures.
Babies who have seizures from asphyxia usually are
born,
uh,
usually full term or post term frequently.
Meconium stained with very low app
guards usually and start having seizures.
That may be all,
uh,
8,
12,
24 hours of age.
The outlook of these babies is extremely
poor.
Uh even when treated appropriately.
The only way to treat
asphyxia is to prevent it.
And uh once asphyxia occurs,
the chances of brain damage occurring are very
high.
Uh The only way to treat it is by prevention
really.
I mean,
there are some means.
We can some ways we can treat us fix it,
but the best way is to prevent it completely.
Uh Some other things I just want to mention that we're not gonna go into
detail further is is sepsis and meningitis is a
cause of seizures.
Any baby that has seizures
has to be considered a candidate for
septicemia and meningitis.
Absolutely.
Okay.
Ah,
metabolic causes.
Again,
as I mentioned,
hypoglycemia,
hippo calcium,
you have to really be considered strongly.
Okay,
now,
let's talk a little bit about drugs,
drug toxicity and withdrawal.
Uh and we'll go into that because that's
a problem that not too many people think of
very often we have that next slide.
I think that's the next one.
Yeah,
signs of drug withdrawal in the newborn.
What are signs of drug withdrawal?
Well,
they're very non specific.
They include agitation,
tremors,
abrasions,
yawning,
sneezing,
stuffy nose,
fever,
sweating,
seizures,
gastrointestinal problems like vomiting and
diarrhea and respiratory distress.
Now,
these are pretty non specific symptoms.
So you have to have a high index of suspicion.
And don't just think drug withdrawal
occurs in the county hospital.
The first two cases of
PHENobarbital withdrawal and infants were reported
in the American Medical Association Journal
about 78 years ago.
And they were physicians,
wives.
Uh Drug withdrawal is
very common in the middle class and upper class
population.
You just don't think of it in the in the lower
socioeconomic groups.
Okay,
what about the treatment of drug withdrawal
fluid balance is very important.
Uh For obvious reasons,
especially the vomiting and diarrhea parag or it
can be used,
Thora zine can be used.
One should control the seizures.
One should not give the narcotics which caused
the withdrawal,
like methadone and morphine.
one may have to treat for 20 to 45
days now,
which drug is best to
treat drug withdrawal with.
That is whether one uses Parador IQ,
or Valium or Thorazine or
PHENobarbital.
Uh there's no good proof that
one is better than the other.
Uh Drug withdrawal is not a benign disorder by the
way.
If not treated many babies uh
will not do well and and may die from
drug withdrawal.
So it's important to diagnose it properly.
Uh One of one of the of course
the big problems with drug withdrawal is not just treating the
symptoms of withdrawal but treating the
baby long term wise,
that is where is the baby gonna go?
Does the baby have a home to go to treating the
psycho?
Social economic problems in the family are a
lot more difficult of course,
than treating the medical problems in the baby.
Uh Now what drugs cause drug
withdrawal?
Most of the time we think of heroin
morphine and things like that.
And I think this next slide shows you some of the drugs
that can cause drug withdrawal,
morphine,
Demerol,
heroin,
methadone,
PHENobarbital,
Darvon dora.
Didn't I think that's good if I might if I remember
Librium or dies dies of peroxide or whatever,
something like that.
Tall Win or pentastar seen amphetamines and
finish.
Diogenes notice things like Darvon
and Librium things that are used,
you know,
millions of pills of which are
consumed every year,
many of them by pregnant women in
general.
I think you ought to take the philosophy that any
psychotherapeutic drug can probably
cause drug withdrawal in the newborn.
And every year there are more and more
cases reported of different drugs causing
withdrawal in the newborn,
like the Librium in the Darvon,
that's only been reported in the past few years.
Probably any analgesic or psychotherapeutic drug
can probably cause drug withdrawal symptoms in the newborn.
What about PHENobarbital?
It used to be thought that PHENobarbital could
cause drug withdrawal in the newborn
only if the mother was
on uh
extremely high
abusive doses of
pentobarbital and that's not.
So that's been shown not to be true.
Even mothers who are on
therapeutic doses of pentobarbital for
seizures,
their babies may have symptoms of drug withdrawal from
the PHENobarbital.
Now,
I'm not advocating that the mother who's on PHENobarbital for
seizures should have the PHENobarbital dC.
Absolutely not.
Uh seizures and the mother are darn good
indication for giving PHENobarbital and or some other
drugs to prevent the seizures.
Hypoxia to the fetus that could occur if the
mother became hypoxic from a seizure
is a heck of a lot more dangerous to the fetus.
Then the possibility of withdrawal
symptoms from PHENobarbital I just like to mention
besides the drug withdrawal symptoms,
PHENobarbital can also cause PHENobarbital and
or Dilantin can cause coagulation
problems in the newborn with
deficiency of vitamin K dependent clotting
factors.
So,
if you have a mother who is on chronic
PHENobarbital and or Dilantin,
you have to think a couple of times uh about that
newborn uh and double check them a couple times for
withdrawal as well as uh
possible waggle apathy.
Okay,
now that's drug withdrawal.
Remember any psychotherapeutic or analgesic
drug has the potential for causing withdrawal
symptoms in the newborn.
One thing I wanna mention about methadone to
uh,
methadone may uh,
cause a few other problems.
Uh,
compared to,
say,
the heroin babies,
babies who are born of methadone,
addicted mothers are methadone treated mothers
may have symptoms that
occur later on rather
than in the first few days of life.
Most drug withdrawal symptoms occur in the first few days of
life,
but methadone babies may not have their
symptoms until later on,
and PHENobarbital babies may not have their symptoms till a
week of age.
And that's very important to remember,
because once the baby goes home and comes back into the
hospital or office,
one doesn't think of maternal drugs as
possibly causing symptoms in the baby.
But some of these drugs may not cause withdrawal
symptoms until the kids a week old or so,
and many of them may need treatment for many,
many weeks before the infant is
doing well.
Okay,
now that's drug withdrawal.
What about drug toxicity?
I think the next slide as a few things about toxicity.
One thing,
para cervical and I'm just gonna just uh
say a few words about drug toxicity
when a baby has seizures in the first few minutes or
hour of life.
Generally.
Besides the usual things,
including hypoglycemia and hippo calcium,
especially hypoglycemia.
Though you ought to keep in mind the possibility of
drug toxicity,
especially toxicity,
from the cane type drugs,
map of a cane and beauty of a cane.
Uh,
these types of cane drugs can definitely
cause neurologic symptoms in the
newborn.
Now,
they may cause neurologic symptoms,
say,
from a para cervical in two different ways,
even if given appropriately in the
ejected properly into the mother.
some of the drug may get into the
bloodstream of the mother and then be given across the
placenta to the fetus and because of the
dissociation characteristics and the ionization
characteristics of,
of the cane drugs,
and because the fetal ph is slightly
lower than the mother's ph,
the cane drugs may attend to
accumulate in the fetus.
Now.
In addition,
uh,
there have been a number of cases reported
where the paras cervical
accidentally was injected into the baby's
head rather than into the mother's muscle and
tissue.
And there's no doubt that
that these cane drugs can cause toxicity in the
newborn and when you have a baby that has seizures in the first
hour or two of age,
find out if he was given a a
local anesthetic para cervical
and uh consider the possibility of
cane toxicity causing those symptoms.
It's probably a lot more common than,
than we realize.
Okay,
now I've gone through a lot of different causes of
seizures and the stoop clinician says,
oh,
I can't think of,
I can't,
I can't work up a baby for every single
one of those problems.
You can think of everyone and I think you ought to think of
everyone,
but they're not all very common in the next slide
gives you the common causes of seizures,
perinatal complications,
meaning trauma and asphyxia,
extremely common,
especially as fixing a very common
hippo calc,
mia,
hypoglycemia,
infection,
developmental anomalies and hyper viscosity,
high hematocrit.
And I think every time you have a baby with
seizures,
you have to immediately consider these
possibilities.
These are the most common cause of seizures.
Probably account for
95-99 of
all seizures in the newborn.
You have to think of all those.
And if you don't come up with a diagnosis,
you have to start thinking of some of those other things we've gone through
also.
And I want to say a few words about hyper viscosity
or policy theme to the next slide.
Has that on there By hyper viscosity
or policy themes in the newborn.
We mean a hematocrit greater
than 60-70.
A central hematocrit greater than 60,
70.
And the treatment is partial exchange transfusion.
Now,
how common is hyper viscosity or policy theme in
the newborn?
Well,
I don't know how common it is.
Some centers,
like in Denver where they did routine ng screening of every
newborn,
they found an incident.
I think of around 8 to 12% of all their newborns.
That's a high risk population.
It was a referral center,
but still,
that's a pretty high percentage of babies who had a
central venus.
Him adequate,
not a he'll stick to venus,
him adequate,
greater than 60 to 65.
Now,
the symptoms of hyper viscosity can be
quite varied.
Uh,
seizures are one,
but that's a late manifestation and you don't want to wait until the kid
has seizures.
Jitteriness is common.
Uh,
not feeding well,
just kind of,
you know,
just kind of lethargic and irritable uh,
neurologic symptoms are one of the most common group of symptoms with
hyper viscosity and also pulmonary symptoms,
respiratory distress,
uh,
so called transient to kidney.
And they can have even a big heart and increased pulmonary
vascular charity.
They can also have hypoglycemia.
Now,
how do you diagnose it?
Well,
first of all,
you can't go by,
he'll stick completely because the heel stick
maybe as much as 10% points
higher than the venus hematocrit.
So normally what we do,
first of all,
we screen every newborn for uh,
with a hematocrit And if the venus him adequate
is greater than,
say 65 or 70,
you ought to get.
I mean,
excuse me,
if the heel stick hematocrit is greater than 65 or
70 you ought to get a central of venus
hematocrit.
And if that's greater than 60 to 65
the baby has symptoms,
any of those symptoms,
I just went through,
especially seizures,
then that baby needs treatment with a partial
exchange transfusion,
not just taking out 50 CCs of blood that will throw
the kid into shock,
but the same as doing an exchange
transfusion safer.
Hyperbole,
rob anemia,
putting an umbilical venous catheter in taking out
10 CCs of blood,
giving 10 CCs of either fresh frozen plasma or a
5% protein solution or
uh,
normal sailing Taking out 10,
giving 10 in order to get the hematocrit down
to say around 55 or so
hyper viscosity again is probably,
is probably a lot more common than we realize.
And babies who have symptoms,
irritability,
poor feeding,
lethargy,
seizures,
respiratory distress,
hyperglycemia and throughout the side of kenya,
we have those symptoms from our signs from hyper
viscosity should have a partial exchange transfusion.
But remember,
a partial exchange transfusion must be done by
by pediatrician,
who is,
who is,
who is really competent doing exchange transfusions,
Exchange transfusions carry with them significant
morbidity and mortality,
especially if not done properly.
A lot higher mortality than saying appendectomy would
Okay,
let's go on and talk a little bit more about other causes of seizures.
Let's talk about intracranial hemorrhage.
Okay,
the next slide talks about sub Iraq noid
hemorrhage.
This is the most common form of intracranial hemorrhage
usually occurs in premature babies,
seizures usually occur after the first day or two
and usually the baby otherwise appears well now.
Subarachnoid hemorrhages are extremely
common.
Okay,
they probably occur again a lot more than we
realize because we don't routinely look for subarachnoid
hemorrhages and the reason it's hard to,
it's hard to diagnose the subarachnoid hemorrhages.
Any of you all have done spinal taps and newborns,
know the problems of traumatic spinal
taps and if you get a little bit of blood,
is it because the spinal fluid was bloody
from a hemorrhage?
Or is it because a little bit of a traumatic tap?
And even though there are a lot of ways we can tell,
we think we can tell a traumatic from
uh from a traumatic tap from an actual
bloody spinal fluid.
Many times it's still extremely difficult,
but subarachnoid hemorrhages are quite common.
Now next slide,
intra ventricular hemorrhages are less
common,
but a lot more devastating.
Almost always in premature babies,
usually in babies who are sick and have had a
hypoxic events.
The seizures may start Anywhere from a few hours
to 48 or 72 hours after the hypoxic event,
and usually there's catastrophic deterioration over
a few days and the baby usually dies.
If the baby does not die within a few days,
the baby's,
almost all of the babies will develop hydrocephalus and
severe brain damage,
although a few of them might be normal,
intra ventricular or peri ventricular
intra cerebral hemorrhages,
as as dr Volpi in ST louis would like to call
them.
Uh those seizures are,
are carried with them extremely high
mortality and morbidity.
Okay,
now those are all the causes of seizures and
uh we need to to set some
priorities as far as evaluating the baby
for seizures And in general,
I think you ought to first think of correctable
causes uh and
always try to pick up the correctable causes.
First cause is that you can are you can
treat again the most important aspect of
treating a newborn with seizures are finding the cause,
not giving PHENobarbital and the next slide will
go through some of the tests that we need to
do to find the cause of seizures in a newborn.
And I think every baby should have these first few
tests as always history and physical are
absolutely crucial.
Absolutely crucial.
Every baby should have trans illumination to look for
either increased trans illumination or decreased
trans illumination.
Blood for calcium,
glucose,
magnesium sodium hematocrit and blood
culture should be done on every single baby that has a seizure
and a spinal tap should be done in every single baby that has a
seizure spinal fluid for glucose protein and
culture.
One ought to also consider an E.
E.
G.
Although not in an emergency situation.
E.
G.
May be more helpful later on for
prognostic purposes,
especially if you don't find the cause of the
seizure.
And especially if there is a suggestion that it's an
inborn error of metabolism.
And personally I think in every baby with
seizures,
one Ought to do metabolic studies looking for inborn
errors of metabolism,
meaning blood for amino acids,
for keto acids,
ketones,
uh looking for inborn errors of metabolism
and if there's evidence of trauma,
skull x rays ought to be considered.
And then other studies now that other may
uh may include
sophisticated metabolic studies.
If you think there's an inborn error of metabolism,
other might might mean viral
cultures and toxic rubella,
rubella,
cytomegalovirus tigers.
If there's a suggestion of congenital infection,
other might mean uh drug levels.
If there's a suggestion of,
say,
beautiful cane toxicity to the newborn.
Uh depending on the individual uh
case involved.
But I think the basic minimum of a
history physical including trans illumination
blood for calcium,
glucose,
magnesium,
sodium,
calcium,
glucose,
magnesium,
sodium determination,
blood culture,
spinal tap for glucose,
protein and culture ought to be done on every single
baby with seizures.
And I personally believe metabolic
studies ought to be done also.
Yearn for for metabolic screen for
amino acid disorders,
branch chain keto acid disorders and other inborn errors of
metabolism.
Okay,
now,
that's the most important thing.
Quickly doing those tests and uh
next we go on to therapy and I think the next slide will
have specific therapy immediately after
those blood tests are drawn and that should be within a couple
minutes.
Okay?
Not an hour later.
But immediately after the blood tests are drawn.
Even before the results come back and I ve should be
placed in 1 to 2.
Actually 1 to 4.
Even milliliters per kilogram of D.
10 to D.
25 should be given I.
V.
In case there's hypoglycemia.
Now some people like to use d 25.
I personally prefer d.
10 but that's controversial as long as you get
an I.
V.
going and giving given some glucose you'll get the blood
sugar up and then of course it should be rechecked again.
This should be done even before the blood glucose comes
back.
Okay calcium should also be
given 10% calcium.
One half to two CC's per kilogram
very slowly with an E.
K.
G.
Monitor in place next.
Like now if if
the seizures are the cause of the seizures are not found
and you really can't figure out what's going on.
One ought to consider giving paradox in or B.
Six vitamin B.
6,
20 to 50 mg I.
V.
I've never seen a baby with paradox
independent or deficient seizures but it does occur
occasionally if there's a magnesium
deficiency uh with a low magnesium
mag sulfate 3% to 26
millimeters ivy again with an E.
K.
G.
Monitor going should be given.
Now that's the specific therapy and I just want to reemphasize
that you don't wait around for 24 hours until your tests
are back.
You immediately get the blood glucose,
calcium,
magnesium sodium,
spinal tap blood culture.
Get an I.
V.
And start the glucose going personally.
We like to get a dexter stick first.
And if the dexter stick is low we would put an I.
V.
And give glucose even before we do the LP.
But even if the dexter stick is normal after we sent the blood
studies down to the lab and we've done our tests over say may
be taken 5 10 15 minutes.
We would then also give glucose because sometimes the
dexter stick won't be all that accurate.
But we don't want to wait until all the tests come back from the lab because it maybe
an hour or two or three
now besides specific therapy and
say for example if it's not hypoglycemia and it's not
hipaa calcium me,
it's not hippo magnesium mia.
Uh You've done an
L.
P.
And there's no evidence of meningitis.
Uh And you started the baby on antibiotics for possible
sepsis.
But the kids still having seizures.
Well then of course you have to go on to uh and a
convulsive therapy specific anticonvulsant
therapy.
Now some people,
especially in older infants and Children and adults like to use
Valium,
I personally do not prefer Valium in the
newborn.
Uh cinnabar probably works
just as well as Valium.
Ivi Finbar you have to Valium only works
for a short period of time anyway and you have to give gina barbe anyway.
So I prefer personally just to start with
ivy,
PHENobarbital in a baby with seizures and that's the next
slide.
I think Vienna Bar Battle,
I consider the drug of choice and a convulsion drug of choice
in the newborn.
That's 10 mg per kilogram.
I?
Ve Okay slowly now you got to be prepared for
possible apnea of course and
uh you got to be prepared for that
now if the seizures don't stop,
stop within the hour.
So uh with this we may repeat
that uh that same dose 10 per kilo slowly
ivy.
Then usually orally,
the baby will require 5 to 10 mg per
kilogram orally.
In uh To to say two divided doses
after a maintenance or after
the I.
V.
Dose is given.
Now one of the major problems with the pentobarbital and
Dilantin.
Most problems people have is they don't give enough to start with.
They give a too low of a dose.
Uh So it's important that when the baby's first seven
seizures to give a high enough dose.
Now Dilantin,
the next slide also
is the dose is 10 mg per
kilogram ivy.
And that also may be repeated if it doesn't work.
And the oil doses roughly 5 to 10 mg per
kilogram per day.
However in order to treat the patient properly
and to know what dose to give,
you have to be able to monitor with
micro essays the blood Dilantin,
PHENobarbital level.
It's really the only way to properly
determine how much to barb or
Dilantin the baby needs.
You can't just go by clinical symptoms.
You can't go by an average dose of 5 to
10 mg per kilogram per day
because many babies require more than that.
Many babies require less and the
the metabolism of Dilantin and PHENobarbital
is extremely variable in the
newborn.
And some newborns require a little bit.
Some newborns require a lot and it changes
quickly over over the first few uh weeks
and months of life.
So the only way to properly determine how
much PHENobarbital and the baby needs for seizures is by
measuring blood levels.
I just want to reemphasize that many
babies many times the people when they use pentobarbital
and they don't give enough to start with.
On the other side of the coin,
you've gotta be prepared,
especially with PHENobarbital for Anthony.
And then you have to be prepared for possible innovation of the baby.
Now Dilantin we don't use very often.
Dilantin rarely is needed.
And about the only time we need Dilantin in the
newborn is in babies who have severe
seizures from asphyxia or
babies who have severe seizures from meningitis.
And it's not very often we use that.
We need Dilantin.
Usually just find a barb.
Usually just treating the cause like
hypoglycemia,
hypoglycemia.
Again,
I just want to reemphasize you gotta treat the cause
first before jumping in and using the
PHENobarbital,
PHENobarbital comes after you treat the cause
of the seizures.
Okay,
now,
in addition to the drugs,
of course you've got to support the baby.
I think the next slide just kind of reminds us that
supportive care,
like intravenous fluids and a cardiac monitor are
also necessary.
Okay,
you can't just give the final barbara,
just give the glucose of its hypoglycemia.
You have to continue to monitor the baby very
closely.
Uh,
especially if he's got complicated disease,
like say meningitis.
Uh,
it's extremely difficult and complicated procedure of
monitoring that baby.
Okay,
now,
one of the things to say about Dilantin to uh
all Dilantin gives a lot of problems.
Uh,
the oral suspension of Dilantin that's used is
notorious for settling out in the
bottom of the bottle.
And that's why we prefer not to use the oral
suspension of Dilantin.
We prefer to use the tablets and have the
mother cut up the tablets and put them in,
say,
with the formula,
the oral suspension,
that's commercially available.
Dilantin is not carries with it
lots of problems.
And a lot of times,
babies will not get enough Dilantin because they'll get the top of the
bottle where there is no doubt land,
or then at the end they'll get all the Dilantin because it's settled out.
So we prefer to have the,
the tablets.
I think they're triangular.
If I recall,
cut up by the mother and put into the,
into the formula for the babies when they're on oral
Dylan.
Okay,
now,
all of this business about diagnosing and treating
seizures,
what's the prognosis of them?
Well,
in many cases it's not good,
remember for the correctable causes
hypoglycemia,
calc mia infection,
hyper viscosity.
If you can prevent the seizures and
treat the disorder before seizures occur.
The prognosis for the baby as far as his brain is
concerned is much,
much better then if you wait and pick up the
hypoglycemia after the seizures occur,
uh,
and the sooner you pick up the disease diagnosed the
cause of the seizures and treat the cause.
The better the outlook of the baby as far as the brains
concert,
and the next couple slides will summarize the
prognosis.
If the baby has severe seizures due to
asphyxia,
low apgar hypoxia.
The prognosis is not good.
Only roughly 10 or 20 of these babies will turn out
normal and treating these babies is
extremely difficult,
extremely complex.
If a baby has seizures from subarachnoid hemorrhage,
almost all these babies turn out normal.
If the baby has seizures,
for example,
a premature baby with bad respiratory distress on a ventilator
and has an intra ventricular hemorrhage or peri
ventricular intra cerebral hemorrhage.
The prognosis extremely dismal.
And most of these babies die,
you know the few that survive.
Almost all have severe neurologic
impairment.
If they have early hippo calcium e as the
seizures,
about half of the babies will do well laid hippo
calcium AEA meeting at a week of age or so,
uh most of the babies will do well again,
these these problems should be prevented
early hippo calcium e occurs usually in premature babies,
sick babies,
infants of diabetic mothers.
And it can be prevented by picking it up,
watching it uh and and treating it
before the baby has seizures laid,
hippo calc mia is very uncommon.
Now we don't see it much anymore.
Hypoglycemia.
If the baby has seizures from hypoglycemia,
half of the babies will be normal,
and a half will be abnormal If you pick up the
hypoglycemia before the baby has seizures
and treat the hypoglycemia and prevent the
seizures,
all the babies almost will be normal
meningitis.
Somewhere between 15 and 35% of the
babies are normal,
but these are old figures.
And actually,
if you look at the newer figures,
especially from Dallas uh and and
also some of the figures of Group B strep,
it's probably not nearly this bad.
It's probably just the reverse.
Probably Somewhere around
60-75 or 80 of the babies who are
normal if treated properly,
even though they have meningitis,
if they have developmental anomalies like big cyst in the
brain or encephalitis,
seals and they have seizures from that.
The prognosis,
again,
is very poor.
Okay,
that pretty well summarizes uh the causes
of diagnosis of seizures,
the causes of the seizures and the treatment of them.
Again,
it's not a very common problem in the newborn,
but it's a problem that demands
immediate appropriate
attention and it's different
type of care.
Then you would give the older child or adult with
seizures.
Uh I think that's all for now.
And later on we'll pick some other
topic and discuss that.
Thank you very much for joining me today.
The new board with Dr
Richard Schreiner.
Mhm.
Was produced by the Medical Television facility,
Medical,
educational resources program of Indiana
University School of Medicine.
Mm hmm.
Yeah,