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,