WEBVTT

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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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the

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newborn.

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Today's program,

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seizures with

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DR Richard Shrider,

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neonatologist at the James Whitcomb Riley

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Hospital for Children in Indianapolis

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indiana.

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Welcome to the newborn series

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on the Medical Educational Resource program.

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What 21.

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Uh today we're gonna talk a little bit about

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seizures in the newborn.

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Uh I realize seizures are not

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real common in the newborn period,

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but it's very important to understand a few

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basic things about seizures.

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There are a number of misconceptions.

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Many people have about seizures in the newborn because

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they kind of think of them like they think of seizures

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and older infants and Children and adults,

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and it's a little bit different in the newborn.

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So we're just gonna spend maybe a half hour or so today talking

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about uh neonatal seizures.

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One of the hardest and most difficult

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uh problems in neonatal seizures is

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diagnosing the fact that they are seizures.

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Usually we think uh in the

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older person of typical

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grand mall tonic clonic

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seizures or even petty mall seizures or

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temporal lobe seizures.

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Well,

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it's not like that at all in the newborn,

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in the newborn,

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seizures can be extremely

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subtle and it's very difficult and takes an

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experienced person many times to tell whether

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or not a newborn is having seizures.

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So the first of all,

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we're just gonna talk about how do you recognize seizures in the

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newborn?

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Now,

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these first couple slides.

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1st 3 slides,

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in fact,

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will list how seizures can

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present in the newborn.

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Now,

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some of them can be the typical tonic clonic

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seizures,

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but these are less common.

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You can have tonic seizures just where the arms

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or legs an extension or mile clonic

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seizures or just chronic movements of one

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extremity or likeness.

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Now there,

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let's get back to me for just a second.

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I just want to go through some of these,

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uh,

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what do we mean by clonic seizures?

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Well,

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we mean just where say one extremity is doing this.

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Okay,

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that's chronic extremity,

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clonic seizures.

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What about tonic seizures?

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Well,

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that's where one extremity say is just out like this.

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Or both extremities.

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Or maybe the leg.

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Uh and then mild chronic

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uh jerks can be the whole body

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going into a mile,

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chronic jerk or even just one extremity,

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uh having one mile chronic jerk.

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Okay,

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the next slide now list some more uh

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apnea or transient alterations of

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respiratory rate can be a manifestation of

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seizures.

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Tremors and we'll spend a little bit more time talking about

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tremors in a minute or just Veysel,

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motor changes,

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like the infant turning a little pale or modeled can

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be seizures very common in seizures are

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just eye blinking or eye opening.

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Next slide,

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uh Nystagmus or deviation of the eyes to one

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side or the other,

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facial twitching,

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chewing or sucking,

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drooling an abnormal cry.

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Now,

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these are all the different ways that seizures of the newborn

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can,

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can present.

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And most of the time,

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seizures are not the typical

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tonic clonic activity

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that you see in older people with seizures.

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Most of the time,

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seizures of the newborn are very subtle,

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like just a little bit of

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uh smacking of the lips or a little bit of deviation of

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the eyes or a little bit of facial

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twitching,

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uh maybe a little ticket

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nia or or slow respiratory

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rate.

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Uh so you really have to be a pro and you have

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to really keep your keep alert in order

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to pick up seizures in the newborn.

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Now,

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sometimes you have to differentiate seizures also

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from,

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from normal activity while an infant sleeping.

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Sometime while an Infinite sleeping,

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just like when you're sleeping,

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you will have a few mild chronic jerks and I'm sure all of

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you have experienced these and you have to,

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sometimes it's difficult when an infinite sleeping to tell whether or not a

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seizure activity or just normal activity that occurs

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during,

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during sleep.

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Now,

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the other problem uh in the newborn,

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that is totally different than in the

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adult or older child is jitteriness.

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How do we separate the jittery

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baby from the baby with seizures?

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And is it important to?

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Well,

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it probably is important.

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Jitteriness is fairly unique to the newborn.

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Uh It's probably normal in the newborn,

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although we still worry about all the different things

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that can cause seizures that might also cause jitteriness,

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but jitteriness probably is normal and

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probably does not carry with it.

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Uh uh the

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bad prognostic

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implications that some forms of seizures

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have in the newborn,

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uh and it's important to

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differentiate jitteriness from seizures and

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we get a number of babies every year referred in who

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referred in procedures,

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but really are jittery.

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Now,

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there are a number of ways you can differentiate that

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jitteriness from seizures and this next slide will show those.

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There are basically four ways.

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First of all with jitteriness,

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you do not have any abnormality of the

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eyes,

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Okay with jitteriness,

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you can stimulate it.

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That is a stimulus sensitive

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jitteriness is a tremor,

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not a chronic activity and

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jitteriness ceases with passive flexion.

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Now let's just go through those because I think they're very important.

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I'm sure all of you to take care of babies uh have done

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this for very long,

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have had the experience of not sure,

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not being sure whether babies having seizures or jitteriness and let's just

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go through those again,

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I activity okay.

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If a baby is having the stagnant jerking of his

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eyes or his eyes are deviated,

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way to one side,

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that's probably seizure activity.

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That's probably not jitteriness.

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Okay,

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if the baby is quiet and by

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clapping or making a little bit of noise or

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uh snapping

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your fingers or just stimulating the baby,

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you can have the baby start having jitteriness,

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that activity.

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That's probably jitteriness,

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not seizures.

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If the baby is having these movements and you hold his arm and

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it stops right away,

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that's probably jitteriness and probably not seizures.

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One of the most helpful things I found to differentiate the

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two.

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He's the type of movement.

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Now,

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when we talk about differentiating jitteriness from

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seizures,

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the type of seizure activity will worry about is chronic

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activity.

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Okay.

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And chronic activity always has a

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fast component and a slow component.

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Okay,

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fast and slow and I think you can

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appreciate that.

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Okay,

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Whereas jitteriness,

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the movement is just as fast in each

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direction.

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Okay,

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It's a tremor.

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Okay.

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You don't have a fast and a slow

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component.

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Okay.

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It's all fast.

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Okay.

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And that is one of the most helpful means I've found at least in

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differentiating jitteriness from seizures.

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Okay,

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now let's go on to the causes of seizures.

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Okay,

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and this is most important.

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The most important aspect of approaching the

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newborn with seizures is finding the cause

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of the seizures.

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Not treating the seizures with

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Fiona barbara Dilantin that comes second or third.

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The most important aspect about approaching the

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newborn with seizures is finding the cause and

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treating the cause of the seizure,

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not giving Dilantin or PHENobarbital.

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That comes second or third in the next slide shows

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some of the causes of seizures And

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I'm gonna go through all the different causes first and then we'll talk about the more

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common ones hypoglycemia.

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That is a blood sugar.

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That's less than 30,

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say in the full term.

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In less than 20 in the premature,

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in the first few days of life,

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or less than 40 after the first few days of life,

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low calcium.

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Both of these are fairly common causes of seizures,

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low magnesium,

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low sodium.

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Uh this is more common in premature babies.

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Low magnesium frequently occurs in babies

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who also have a low calcium.

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And that's and if you have a baby that has a low calcium

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not responding to calcium therapy,

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you ought to think of a low magnesium

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paradox in deficiency and dependency are

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very rare,

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but they do occur inborn errors of

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metabolism,

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like amino acid disorders,

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maple syrup,

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urine disease,

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your branch chain keto acid disorders like meth a

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moronic acid urea,

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all those very rare metabolic disorders,

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but also things like black toxemia,

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fennel,

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Keaton area,

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hypothyroidism.

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These can also cause seizures,

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hypothyroidism not very commonly.

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Uh jOHN does with connectors,

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brain damage from jOHN this

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hypothermia or hypothermia where the baby is

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too cold or too warm.

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All of these are causes of

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seizures,

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the most common on that slide being

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hypoglycemia and hippo calc me.

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Um but you also have to think of the other is also okay.

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The next slide shows,

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I think infectious causes sepsis and

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meningitis,

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fairly common causes of seizures.

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Encephalitis like viral infections in the brain,

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like herpes,

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simplex infection and congenital

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infections like talk so

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toxoplasmosis,

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rubella,

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uh syphilis and

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cytomegalovirus.

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Next slide shows some other causes of seizures,

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hemorrhage in the brain.

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Subarachnoid hemorrhage or peri

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ventricular and intra ventricular hemorrhage and we'll talk a

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little bit more about these in a few minutes.

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Next light and other causes,

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okay,

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developmental anomalies like cysts in the

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brain,

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uh encephalitis,

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seals,

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uh,

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anencephaly,

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etcetera,

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trauma due to birth,

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trauma as fix CIA,

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fetal hypoxia and hypoxia at

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delivery low APG ours drug,

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toxic drugs like toxicity of

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drugs,

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withdrawal of drugs and hyper

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viscosity or elevated hematocrit.

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Okay,

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now we're,

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I think we're gonna go and talk about a few more of these,

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uh,

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a little bit more in detail and

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uh,

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some of the things I just want to mention,

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uh,

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trauma,

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birth trauma used to be one of the most common causes of

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seizure.

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Okay,

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now it's not nearly as common,

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but it still does occur as fix.

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Eah,

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is one of the most common and most

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devastating causes of seizures.

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Babies who have seizures from asphyxia usually are

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born,

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uh,

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usually full term or post term frequently.

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Meconium stained with very low app

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guards usually and start having seizures.

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That may be all,

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uh,

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8,

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12,

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24 hours of age.

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The outlook of these babies is extremely

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poor.

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Uh even when treated appropriately.

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The only way to treat

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asphyxia is to prevent it.

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And uh once asphyxia occurs,

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the chances of brain damage occurring are very

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high.

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Uh The only way to treat it is by prevention

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really.

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I mean,

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there are some means.

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We can some ways we can treat us fix it,

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but the best way is to prevent it completely.

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Uh Some other things I just want to mention that we're not gonna go into

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detail further is is sepsis and meningitis is a

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cause of seizures.

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Any baby that has seizures

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has to be considered a candidate for

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septicemia and meningitis.

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Absolutely.

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Okay.

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Ah,

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metabolic causes.

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Again,

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as I mentioned,

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hypoglycemia,

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hippo calcium,

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you have to really be considered strongly.

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Okay,

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now,

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let's talk a little bit about drugs,

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drug toxicity and withdrawal.

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Uh and we'll go into that because that's

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a problem that not too many people think of

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very often we have that next slide.

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I think that's the next one.

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Yeah,

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signs of drug withdrawal in the newborn.

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What are signs of drug withdrawal?

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Well,

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they're very non specific.

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They include agitation,

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tremors,

11:54.940 --> 11:56.070
abrasions,

11:56.080 --> 11:57.240
yawning,

11:57.250 --> 11:58.350
sneezing,

11:58.360 --> 11:59.520
stuffy nose,

11:59.530 --> 12:00.460
fever,

12:00.470 --> 12:01.400
sweating,

12:01.410 --> 12:02.460
seizures,

12:02.470 --> 12:05.210
gastrointestinal problems like vomiting and

12:05.210 --> 12:07.960
diarrhea and respiratory distress.

12:08.440 --> 12:09.850
Now,

12:10.440 --> 12:12.210
these are pretty non specific symptoms.

12:12.210 --> 12:14.360
So you have to have a high index of suspicion.

12:14.740 --> 12:17.740
And don't just think drug withdrawal

12:17.740 --> 12:20.140
occurs in the county hospital.

12:20.280 --> 12:22.520
The first two cases of

12:22.520 --> 12:25.350
PHENobarbital withdrawal and infants were reported

12:25.550 --> 12:28.510
in the American Medical Association Journal

12:28.510 --> 12:29.820
about 78 years ago.

12:29.820 --> 12:30.650
And they were physicians,

12:30.650 --> 12:31.190
wives.

12:31.200 --> 12:33.790
Uh Drug withdrawal is

12:33.800 --> 12:36.460
very common in the middle class and upper class

12:36.460 --> 12:37.250
population.

12:37.250 --> 12:39.640
You just don't think of it in the in the lower

12:39.640 --> 12:40.870
socioeconomic groups.

12:40.980 --> 12:41.580
Okay,

12:41.580 --> 12:44.160
what about the treatment of drug withdrawal

12:44.840 --> 12:46.760
fluid balance is very important.

12:47.240 --> 12:48.540
Uh For obvious reasons,

12:48.540 --> 12:51.440
especially the vomiting and diarrhea parag or it

12:51.440 --> 12:52.360
can be used,

12:52.840 --> 12:54.460
Thora zine can be used.

12:55.240 --> 12:57.090
One should control the seizures.

12:57.400 --> 13:00.330
One should not give the narcotics which caused

13:00.330 --> 13:00.910
the withdrawal,

13:00.910 --> 13:02.460
like methadone and morphine.

13:02.840 --> 13:05.630
one may have to treat for 20 to 45

13:05.640 --> 13:07.310
days now,

13:07.320 --> 13:10.180
which drug is best to

13:10.180 --> 13:11.860
treat drug withdrawal with.

13:11.860 --> 13:13.740
That is whether one uses Parador IQ,

13:13.750 --> 13:16.750
or Valium or Thorazine or

13:16.750 --> 13:17.930
PHENobarbital.

13:17.940 --> 13:20.790
Uh there's no good proof that

13:20.790 --> 13:22.060
one is better than the other.

13:22.440 --> 13:25.270
Uh Drug withdrawal is not a benign disorder by the

13:25.270 --> 13:25.690
way.

13:25.700 --> 13:28.380
If not treated many babies uh

13:28.390 --> 13:31.190
will not do well and and may die from

13:31.190 --> 13:31.890
drug withdrawal.

13:31.890 --> 13:33.960
So it's important to diagnose it properly.

13:35.140 --> 13:37.950
Uh One of one of the of course

13:37.950 --> 13:40.810
the big problems with drug withdrawal is not just treating the

13:40.810 --> 13:43.660
symptoms of withdrawal but treating the

13:43.660 --> 13:45.120
baby long term wise,

13:45.120 --> 13:46.880
that is where is the baby gonna go?

13:46.880 --> 13:49.880
Does the baby have a home to go to treating the

13:49.880 --> 13:50.310
psycho?

13:50.310 --> 13:53.130
Social economic problems in the family are a

13:53.130 --> 13:54.430
lot more difficult of course,

13:54.430 --> 13:56.660
than treating the medical problems in the baby.

13:57.240 --> 13:59.710
Uh Now what drugs cause drug

13:59.710 --> 14:00.540
withdrawal?

14:00.550 --> 14:03.030
Most of the time we think of heroin

14:03.030 --> 14:04.660
morphine and things like that.

14:04.660 --> 14:07.590
And I think this next slide shows you some of the drugs

14:07.590 --> 14:09.270
that can cause drug withdrawal,

14:09.280 --> 14:10.380
morphine,

14:10.390 --> 14:11.260
Demerol,

14:11.270 --> 14:12.310
heroin,

14:12.320 --> 14:13.330
methadone,

14:13.340 --> 14:14.630
PHENobarbital,

14:14.640 --> 14:16.280
Darvon dora.

14:16.280 --> 14:18.510
Didn't I think that's good if I might if I remember

14:18.510 --> 14:21.500
Librium or dies dies of peroxide or whatever,

14:21.500 --> 14:22.390
something like that.

14:22.400 --> 14:25.190
Tall Win or pentastar seen amphetamines and

14:25.190 --> 14:25.450
finish.

14:25.450 --> 14:28.410
Diogenes notice things like Darvon

14:28.420 --> 14:31.380
and Librium things that are used,

14:31.390 --> 14:31.680
you know,

14:31.690 --> 14:34.230
millions of pills of which are

14:34.230 --> 14:35.360
consumed every year,

14:35.360 --> 14:37.920
many of them by pregnant women in

14:37.920 --> 14:38.490
general.

14:38.490 --> 14:41.100
I think you ought to take the philosophy that any

14:41.100 --> 14:43.810
psychotherapeutic drug can probably

14:43.810 --> 14:46.040
cause drug withdrawal in the newborn.

14:46.070 --> 14:48.710
And every year there are more and more

14:48.710 --> 14:51.490
cases reported of different drugs causing

14:51.490 --> 14:52.620
withdrawal in the newborn,

14:52.620 --> 14:54.360
like the Librium in the Darvon,

14:54.360 --> 14:56.560
that's only been reported in the past few years.

14:56.840 --> 14:59.820
Probably any analgesic or psychotherapeutic drug

14:59.820 --> 15:02.560
can probably cause drug withdrawal symptoms in the newborn.

15:03.240 --> 15:04.530
What about PHENobarbital?

15:04.830 --> 15:07.520
It used to be thought that PHENobarbital could

15:07.520 --> 15:09.260
cause drug withdrawal in the newborn

15:09.940 --> 15:12.660
only if the mother was

15:12.670 --> 15:15.010
on uh

15:15.020 --> 15:16.540
extremely high

15:16.550 --> 15:18.790
abusive doses of

15:18.790 --> 15:20.700
pentobarbital and that's not.

15:20.700 --> 15:22.770
So that's been shown not to be true.

15:22.780 --> 15:25.370
Even mothers who are on

15:25.380 --> 15:27.780
therapeutic doses of pentobarbital for

15:27.780 --> 15:28.660
seizures,

15:28.800 --> 15:31.790
their babies may have symptoms of drug withdrawal from

15:31.790 --> 15:32.850
the PHENobarbital.

15:33.040 --> 15:33.260
Now,

15:33.260 --> 15:36.190
I'm not advocating that the mother who's on PHENobarbital for

15:36.190 --> 15:38.730
seizures should have the PHENobarbital dC.

15:38.740 --> 15:39.900
Absolutely not.

15:39.910 --> 15:42.520
Uh seizures and the mother are darn good

15:42.520 --> 15:45.260
indication for giving PHENobarbital and or some other

15:45.260 --> 15:46.680
drugs to prevent the seizures.

15:46.690 --> 15:49.620
Hypoxia to the fetus that could occur if the

15:49.620 --> 15:52.390
mother became hypoxic from a seizure

15:52.540 --> 15:55.070
is a heck of a lot more dangerous to the fetus.

15:55.240 --> 15:57.930
Then the possibility of withdrawal

15:57.930 --> 16:00.660
symptoms from PHENobarbital I just like to mention

16:00.660 --> 16:03.400
besides the drug withdrawal symptoms,

16:03.400 --> 16:06.380
PHENobarbital can also cause PHENobarbital and

16:06.380 --> 16:08.940
or Dilantin can cause coagulation

16:08.940 --> 16:11.440
problems in the newborn with

16:11.450 --> 16:14.160
deficiency of vitamin K dependent clotting

16:14.160 --> 16:14.600
factors.

16:14.600 --> 16:14.730
So,

16:14.730 --> 16:17.350
if you have a mother who is on chronic

16:17.360 --> 16:19.120
PHENobarbital and or Dilantin,

16:19.120 --> 16:22.010
you have to think a couple of times uh about that

16:22.010 --> 16:24.370
newborn uh and double check them a couple times for

16:24.370 --> 16:26.940
withdrawal as well as uh

16:26.950 --> 16:28.660
possible waggle apathy.

16:29.540 --> 16:30.010
Okay,

16:30.010 --> 16:31.680
now that's drug withdrawal.

16:31.680 --> 16:34.350
Remember any psychotherapeutic or analgesic

16:34.350 --> 16:37.120
drug has the potential for causing withdrawal

16:37.120 --> 16:38.220
symptoms in the newborn.

16:38.350 --> 16:40.600
One thing I wanna mention about methadone to

16:40.610 --> 16:41.450
uh,

16:41.460 --> 16:44.460
methadone may uh,

16:44.470 --> 16:47.190
cause a few other problems.

16:47.200 --> 16:48.120
Uh,

16:48.130 --> 16:48.600
compared to,

16:48.600 --> 16:48.780
say,

16:48.780 --> 16:49.760
the heroin babies,

16:50.040 --> 16:52.010
babies who are born of methadone,

16:52.010 --> 16:54.940
addicted mothers are methadone treated mothers

16:55.130 --> 16:57.860
may have symptoms that

16:57.860 --> 17:00.810
occur later on rather

17:00.810 --> 17:02.280
than in the first few days of life.

17:02.290 --> 17:05.010
Most drug withdrawal symptoms occur in the first few days of

17:05.010 --> 17:05.480
life,

17:05.490 --> 17:08.070
but methadone babies may not have their

17:08.070 --> 17:09.490
symptoms until later on,

17:09.500 --> 17:12.450
and PHENobarbital babies may not have their symptoms till a

17:12.450 --> 17:13.120
week of age.

17:13.120 --> 17:14.360
And that's very important to remember,

17:14.360 --> 17:17.260
because once the baby goes home and comes back into the

17:17.260 --> 17:18.510
hospital or office,

17:18.520 --> 17:21.410
one doesn't think of maternal drugs as

17:21.410 --> 17:23.510
possibly causing symptoms in the baby.

17:23.540 --> 17:26.320
But some of these drugs may not cause withdrawal

17:26.320 --> 17:29.260
symptoms until the kids a week old or so,

17:29.270 --> 17:31.770
and many of them may need treatment for many,

17:31.770 --> 17:34.540
many weeks before the infant is

17:34.540 --> 17:35.170
doing well.

17:35.440 --> 17:35.650
Okay,

17:35.650 --> 17:36.850
now that's drug withdrawal.

17:36.860 --> 17:38.450
What about drug toxicity?

17:38.450 --> 17:41.310
I think the next slide as a few things about toxicity.

17:41.320 --> 17:42.120
One thing,

17:42.130 --> 17:45.020
para cervical and I'm just gonna just uh

17:45.030 --> 17:47.350
say a few words about drug toxicity

17:48.440 --> 17:51.430
when a baby has seizures in the first few minutes or

17:51.430 --> 17:52.360
hour of life.

17:53.040 --> 17:53.800
Generally.

17:53.800 --> 17:55.320
Besides the usual things,

17:55.320 --> 17:57.510
including hypoglycemia and hippo calcium,

17:57.510 --> 17:58.780
especially hypoglycemia.

17:58.780 --> 18:01.520
Though you ought to keep in mind the possibility of

18:01.520 --> 18:02.870
drug toxicity,

18:03.120 --> 18:04.850
especially toxicity,

18:04.850 --> 18:06.450
from the cane type drugs,

18:06.450 --> 18:08.860
map of a cane and beauty of a cane.

18:08.870 --> 18:09.890
Uh,

18:09.900 --> 18:12.690
these types of cane drugs can definitely

18:12.690 --> 18:15.640
cause neurologic symptoms in the

18:15.640 --> 18:16.230
newborn.

18:16.510 --> 18:16.720
Now,

18:16.720 --> 18:18.540
they may cause neurologic symptoms,

18:18.540 --> 18:18.690
say,

18:18.690 --> 18:21.680
from a para cervical in two different ways,

18:22.010 --> 18:24.560
even if given appropriately in the

18:24.560 --> 18:26.260
ejected properly into the mother.

18:26.480 --> 18:29.040
some of the drug may get into the

18:29.040 --> 18:31.670
bloodstream of the mother and then be given across the

18:31.670 --> 18:34.670
placenta to the fetus and because of the

18:34.670 --> 18:37.380
dissociation characteristics and the ionization

18:37.380 --> 18:38.260
characteristics of,

18:38.440 --> 18:39.900
of the cane drugs,

18:39.910 --> 18:42.690
and because the fetal ph is slightly

18:42.690 --> 18:44.560
lower than the mother's ph,

18:44.600 --> 18:47.260
the cane drugs may attend to

18:47.260 --> 18:48.750
accumulate in the fetus.

18:49.440 --> 18:49.680
Now.

18:49.680 --> 18:50.620
In addition,

18:50.630 --> 18:51.240
uh,

18:51.250 --> 18:53.370
there have been a number of cases reported

18:53.380 --> 18:55.540
where the paras cervical

18:55.550 --> 18:58.220
accidentally was injected into the baby's

18:58.220 --> 19:01.170
head rather than into the mother's muscle and

19:01.170 --> 19:01.780
tissue.

19:01.790 --> 19:04.760
And there's no doubt that

19:04.770 --> 19:07.670
that these cane drugs can cause toxicity in the

19:07.670 --> 19:10.500
newborn and when you have a baby that has seizures in the first

19:10.500 --> 19:11.450
hour or two of age,

19:11.460 --> 19:14.330
find out if he was given a a

19:14.340 --> 19:16.660
local anesthetic para cervical

19:17.340 --> 19:20.330
and uh consider the possibility of

19:20.330 --> 19:22.910
cane toxicity causing those symptoms.

19:22.910 --> 19:24.790
It's probably a lot more common than,

19:24.800 --> 19:25.860
than we realize.

19:26.340 --> 19:26.740
Okay,

19:26.740 --> 19:29.360
now I've gone through a lot of different causes of

19:29.360 --> 19:32.300
seizures and the stoop clinician says,

19:32.300 --> 19:32.520
oh,

19:32.520 --> 19:33.290
I can't think of,

19:33.380 --> 19:33.900
I can't,

19:33.910 --> 19:36.730
I can't work up a baby for every single

19:36.730 --> 19:38.000
one of those problems.

19:38.050 --> 19:40.430
You can think of everyone and I think you ought to think of

19:40.430 --> 19:41.090
everyone,

19:41.150 --> 19:44.000
but they're not all very common in the next slide

19:44.000 --> 19:46.170
gives you the common causes of seizures,

19:46.540 --> 19:48.100
perinatal complications,

19:48.100 --> 19:50.090
meaning trauma and asphyxia,

19:50.110 --> 19:51.280
extremely common,

19:51.280 --> 19:53.560
especially as fixing a very common

19:54.040 --> 19:55.020
hippo calc,

19:55.020 --> 19:55.400
mia,

19:55.410 --> 19:56.890
hypoglycemia,

19:56.900 --> 19:57.850
infection,

19:57.860 --> 20:00.820
developmental anomalies and hyper viscosity,

20:00.820 --> 20:01.960
high hematocrit.

20:02.060 --> 20:04.590
And I think every time you have a baby with

20:04.590 --> 20:05.070
seizures,

20:05.070 --> 20:07.470
you have to immediately consider these

20:07.470 --> 20:08.460
possibilities.

20:08.730 --> 20:11.150
These are the most common cause of seizures.

20:11.150 --> 20:12.090
Probably account for

20:12.090 --> 20:15.020
95-99 of

20:15.020 --> 20:16.400
all seizures in the newborn.

20:16.410 --> 20:18.260
You have to think of all those.

20:18.270 --> 20:19.930
And if you don't come up with a diagnosis,

20:19.940 --> 20:22.850
you have to start thinking of some of those other things we've gone through

20:22.850 --> 20:23.460
also.

20:24.140 --> 20:27.120
And I want to say a few words about hyper viscosity

20:27.120 --> 20:29.080
or policy theme to the next slide.

20:29.090 --> 20:32.080
Has that on there By hyper viscosity

20:32.080 --> 20:34.100
or policy themes in the newborn.

20:34.160 --> 20:37.160
We mean a hematocrit greater

20:37.160 --> 20:38.240
than 60-70.

20:38.250 --> 20:40.270
A central hematocrit greater than 60,

20:40.270 --> 20:40.870
70.

20:40.880 --> 20:43.510
And the treatment is partial exchange transfusion.

20:43.630 --> 20:44.280
Now,

20:44.290 --> 20:47.270
how common is hyper viscosity or policy theme in

20:47.270 --> 20:47.750
the newborn?

20:47.750 --> 20:47.860
Well,

20:47.860 --> 20:49.090
I don't know how common it is.

20:49.310 --> 20:50.090
Some centers,

20:50.090 --> 20:52.710
like in Denver where they did routine ng screening of every

20:52.710 --> 20:53.350
newborn,

20:53.440 --> 20:54.360
they found an incident.

20:54.360 --> 20:57.360
I think of around 8 to 12% of all their newborns.

20:57.370 --> 20:58.570
That's a high risk population.

20:58.570 --> 20:59.580
It was a referral center,

20:59.630 --> 21:00.070
but still,

21:00.070 --> 21:02.680
that's a pretty high percentage of babies who had a

21:02.680 --> 21:04.200
central venus.

21:04.200 --> 21:04.930
Him adequate,

21:04.930 --> 21:06.110
not a he'll stick to venus,

21:06.110 --> 21:06.880
him adequate,

21:06.980 --> 21:08.950
greater than 60 to 65.

21:09.340 --> 21:09.560
Now,

21:09.560 --> 21:12.240
the symptoms of hyper viscosity can be

21:12.240 --> 21:13.070
quite varied.

21:13.080 --> 21:13.850
Uh,

21:13.860 --> 21:14.740
seizures are one,

21:14.740 --> 21:17.710
but that's a late manifestation and you don't want to wait until the kid

21:17.710 --> 21:18.580
has seizures.

21:18.590 --> 21:20.460
Jitteriness is common.

21:21.140 --> 21:21.490
Uh,

21:21.500 --> 21:22.620
not feeding well,

21:22.620 --> 21:23.420
just kind of,

21:23.430 --> 21:23.770
you know,

21:23.770 --> 21:26.540
just kind of lethargic and irritable uh,

21:26.550 --> 21:29.540
neurologic symptoms are one of the most common group of symptoms with

21:29.540 --> 21:32.480
hyper viscosity and also pulmonary symptoms,

21:32.490 --> 21:34.010
respiratory distress,

21:34.020 --> 21:35.510
uh,

21:35.520 --> 21:37.330
so called transient to kidney.

21:37.330 --> 21:39.940
And they can have even a big heart and increased pulmonary

21:39.940 --> 21:40.850
vascular charity.

21:41.030 --> 21:42.860
They can also have hypoglycemia.

21:43.340 --> 21:43.490
Now,

21:43.490 --> 21:44.490
how do you diagnose it?

21:44.500 --> 21:45.010
Well,

21:45.020 --> 21:45.530
first of all,

21:45.530 --> 21:46.200
you can't go by,

21:46.200 --> 21:48.570
he'll stick completely because the heel stick

21:48.580 --> 21:51.530
maybe as much as 10% points

21:51.530 --> 21:53.650
higher than the venus hematocrit.

21:53.660 --> 21:55.380
So normally what we do,

21:55.380 --> 21:55.810
first of all,

21:55.810 --> 21:58.020
we screen every newborn for uh,

21:58.030 --> 22:01.010
with a hematocrit And if the venus him adequate

22:01.010 --> 22:01.780
is greater than,

22:01.780 --> 22:03.550
say 65 or 70,

22:03.640 --> 22:04.880
you ought to get.

22:04.890 --> 22:05.270
I mean,

22:05.290 --> 22:05.980
excuse me,

22:05.990 --> 22:08.920
if the heel stick hematocrit is greater than 65 or

22:08.920 --> 22:11.830
70 you ought to get a central of venus

22:11.840 --> 22:12.900
hematocrit.

22:12.910 --> 22:15.770
And if that's greater than 60 to 65

22:16.220 --> 22:17.560
the baby has symptoms,

22:17.570 --> 22:18.650
any of those symptoms,

22:18.650 --> 22:19.790
I just went through,

22:19.800 --> 22:21.540
especially seizures,

22:21.550 --> 22:24.090
then that baby needs treatment with a partial

22:24.090 --> 22:25.360
exchange transfusion,

22:25.440 --> 22:28.420
not just taking out 50 CCs of blood that will throw

22:28.420 --> 22:29.490
the kid into shock,

22:29.500 --> 22:32.010
but the same as doing an exchange

22:32.010 --> 22:32.920
transfusion safer.

22:32.920 --> 22:33.440
Hyperbole,

22:33.440 --> 22:34.050
rob anemia,

22:34.050 --> 22:36.910
putting an umbilical venous catheter in taking out

22:36.910 --> 22:38.160
10 CCs of blood,

22:38.160 --> 22:41.120
giving 10 CCs of either fresh frozen plasma or a

22:41.120 --> 22:43.630
5% protein solution or

22:43.640 --> 22:45.240
uh,

22:45.250 --> 22:47.060
normal sailing Taking out 10,

22:47.060 --> 22:49.940
giving 10 in order to get the hematocrit down

22:49.940 --> 22:52.550
to say around 55 or so

22:52.560 --> 22:55.180
hyper viscosity again is probably,

22:55.190 --> 22:57.990
is probably a lot more common than we realize.

22:58.000 --> 23:00.160
And babies who have symptoms,

23:00.640 --> 23:01.560
irritability,

23:01.570 --> 23:02.450
poor feeding,

23:02.460 --> 23:03.460
lethargy,

23:03.470 --> 23:04.420
seizures,

23:05.070 --> 23:07.100
respiratory distress,

23:08.060 --> 23:10.470
hyperglycemia and throughout the side of kenya,

23:10.480 --> 23:13.150
we have those symptoms from our signs from hyper

23:13.150 --> 23:15.900
viscosity should have a partial exchange transfusion.

23:16.000 --> 23:16.620
But remember,

23:16.620 --> 23:19.330
a partial exchange transfusion must be done by

23:19.340 --> 23:20.260
by pediatrician,

23:20.260 --> 23:20.540
who is,

23:20.540 --> 23:20.940
who is,

23:20.950 --> 23:23.630
who is really competent doing exchange transfusions,

23:23.640 --> 23:26.270
Exchange transfusions carry with them significant

23:26.270 --> 23:27.560
morbidity and mortality,

23:27.640 --> 23:29.770
especially if not done properly.

23:29.840 --> 23:32.360
A lot higher mortality than saying appendectomy would

23:33.040 --> 23:33.800
Okay,

23:33.810 --> 23:36.800
let's go on and talk a little bit more about other causes of seizures.

23:36.800 --> 23:38.690
Let's talk about intracranial hemorrhage.

23:38.700 --> 23:39.280
Okay,

23:39.360 --> 23:41.900
the next slide talks about sub Iraq noid

23:41.900 --> 23:42.670
hemorrhage.

23:42.760 --> 23:45.710
This is the most common form of intracranial hemorrhage

23:45.720 --> 23:47.960
usually occurs in premature babies,

23:48.130 --> 23:50.770
seizures usually occur after the first day or two

23:50.940 --> 23:53.790
and usually the baby otherwise appears well now.

23:53.790 --> 23:56.180
Subarachnoid hemorrhages are extremely

23:56.180 --> 23:56.800
common.

23:56.810 --> 23:57.330
Okay,

23:57.500 --> 24:00.350
they probably occur again a lot more than we

24:00.350 --> 24:03.240
realize because we don't routinely look for subarachnoid

24:03.240 --> 24:05.410
hemorrhages and the reason it's hard to,

24:05.420 --> 24:07.480
it's hard to diagnose the subarachnoid hemorrhages.

24:07.480 --> 24:09.730
Any of you all have done spinal taps and newborns,

24:09.820 --> 24:12.510
know the problems of traumatic spinal

24:12.510 --> 24:14.680
taps and if you get a little bit of blood,

24:14.680 --> 24:17.540
is it because the spinal fluid was bloody

24:17.550 --> 24:18.420
from a hemorrhage?

24:18.430 --> 24:20.930
Or is it because a little bit of a traumatic tap?

24:20.940 --> 24:23.470
And even though there are a lot of ways we can tell,

24:23.480 --> 24:25.760
we think we can tell a traumatic from

24:25.770 --> 24:28.530
uh from a traumatic tap from an actual

24:28.530 --> 24:29.620
bloody spinal fluid.

24:29.750 --> 24:31.860
Many times it's still extremely difficult,

24:32.440 --> 24:34.610
but subarachnoid hemorrhages are quite common.

24:34.620 --> 24:35.880
Now next slide,

24:35.880 --> 24:38.620
intra ventricular hemorrhages are less

24:38.620 --> 24:39.090
common,

24:39.090 --> 24:40.740
but a lot more devastating.

24:40.750 --> 24:43.160
Almost always in premature babies,

24:43.170 --> 24:45.900
usually in babies who are sick and have had a

24:45.900 --> 24:47.130
hypoxic events.

24:47.140 --> 24:50.130
The seizures may start Anywhere from a few hours

24:50.130 --> 24:53.060
to 48 or 72 hours after the hypoxic event,

24:53.440 --> 24:56.410
and usually there's catastrophic deterioration over

24:56.410 --> 24:58.780
a few days and the baby usually dies.

24:58.850 --> 25:01.580
If the baby does not die within a few days,

25:01.590 --> 25:02.210
the baby's,

25:02.220 --> 25:05.130
almost all of the babies will develop hydrocephalus and

25:05.130 --> 25:06.370
severe brain damage,

25:06.370 --> 25:08.620
although a few of them might be normal,

25:08.630 --> 25:11.550
intra ventricular or peri ventricular

25:11.550 --> 25:12.860
intra cerebral hemorrhages,

25:12.860 --> 25:15.680
as as dr Volpi in ST louis would like to call

25:15.680 --> 25:15.950
them.

25:16.140 --> 25:17.830
Uh those seizures are,

25:17.840 --> 25:20.380
are carried with them extremely high

25:20.380 --> 25:22.050
mortality and morbidity.

25:22.540 --> 25:23.000
Okay,

25:23.000 --> 25:25.600
now those are all the causes of seizures and

25:25.610 --> 25:28.210
uh we need to to set some

25:28.210 --> 25:31.200
priorities as far as evaluating the baby

25:31.200 --> 25:32.660
for seizures And in general,

25:32.660 --> 25:35.600
I think you ought to first think of correctable

25:35.600 --> 25:38.240
causes uh and

25:38.250 --> 25:40.550
always try to pick up the correctable causes.

25:40.550 --> 25:43.160
First cause is that you can are you can

25:43.160 --> 25:45.950
treat again the most important aspect of

25:45.950 --> 25:48.800
treating a newborn with seizures are finding the cause,

25:48.810 --> 25:51.780
not giving PHENobarbital and the next slide will

25:51.780 --> 25:54.530
go through some of the tests that we need to

25:54.530 --> 25:56.860
do to find the cause of seizures in a newborn.

25:57.540 --> 26:00.310
And I think every baby should have these first few

26:00.310 --> 26:02.680
tests as always history and physical are

26:02.690 --> 26:03.950
absolutely crucial.

26:03.960 --> 26:05.340
Absolutely crucial.

26:05.350 --> 26:08.120
Every baby should have trans illumination to look for

26:08.130 --> 26:11.010
either increased trans illumination or decreased

26:11.010 --> 26:11.960
trans illumination.

26:12.440 --> 26:13.960
Blood for calcium,

26:13.970 --> 26:14.780
glucose,

26:14.780 --> 26:17.600
magnesium sodium hematocrit and blood

26:17.600 --> 26:20.450
culture should be done on every single baby that has a seizure

26:20.840 --> 26:23.660
and a spinal tap should be done in every single baby that has a

26:23.670 --> 26:26.640
seizure spinal fluid for glucose protein and

26:26.640 --> 26:27.050
culture.

26:27.740 --> 26:29.450
One ought to also consider an E.

26:29.450 --> 26:29.540
E.

26:29.540 --> 26:29.950
G.

26:29.950 --> 26:32.130
Although not in an emergency situation.

26:32.140 --> 26:32.520
E.

26:32.520 --> 26:32.760
G.

26:32.760 --> 26:35.150
May be more helpful later on for

26:35.150 --> 26:36.630
prognostic purposes,

26:36.650 --> 26:39.160
especially if you don't find the cause of the

26:39.160 --> 26:39.840
seizure.

26:39.850 --> 26:42.640
And especially if there is a suggestion that it's an

26:42.640 --> 26:43.990
inborn error of metabolism.

26:44.000 --> 26:46.800
And personally I think in every baby with

26:46.800 --> 26:47.360
seizures,

26:47.540 --> 26:50.510
one Ought to do metabolic studies looking for inborn

26:50.510 --> 26:51.450
errors of metabolism,

26:51.450 --> 26:53.650
meaning blood for amino acids,

26:53.660 --> 26:55.060
for keto acids,

26:55.070 --> 26:56.260
ketones,

26:56.270 --> 26:59.170
uh looking for inborn errors of metabolism

26:59.940 --> 27:01.660
and if there's evidence of trauma,

27:01.660 --> 27:03.350
skull x rays ought to be considered.

27:03.360 --> 27:05.830
And then other studies now that other may

27:05.840 --> 27:08.040
uh may include

27:08.050 --> 27:10.240
sophisticated metabolic studies.

27:10.240 --> 27:12.590
If you think there's an inborn error of metabolism,

27:12.600 --> 27:15.030
other might might mean viral

27:15.030 --> 27:17.380
cultures and toxic rubella,

27:17.390 --> 27:17.980
rubella,

27:17.980 --> 27:19.440
cytomegalovirus tigers.

27:19.440 --> 27:21.670
If there's a suggestion of congenital infection,

27:21.940 --> 27:24.790
other might mean uh drug levels.

27:24.790 --> 27:25.790
If there's a suggestion of,

27:25.790 --> 27:26.250
say,

27:26.260 --> 27:29.130
beautiful cane toxicity to the newborn.

27:29.140 --> 27:31.790
Uh depending on the individual uh

27:31.800 --> 27:32.870
case involved.

27:32.880 --> 27:35.420
But I think the basic minimum of a

27:35.430 --> 27:38.170
history physical including trans illumination

27:38.640 --> 27:40.080
blood for calcium,

27:40.090 --> 27:40.860
glucose,

27:40.870 --> 27:42.020
magnesium,

27:42.030 --> 27:43.130
sodium,

27:43.140 --> 27:44.370
calcium,

27:44.370 --> 27:44.720
glucose,

27:44.720 --> 27:45.210
magnesium,

27:45.210 --> 27:46.270
sodium determination,

27:46.280 --> 27:47.460
blood culture,

27:47.470 --> 27:49.220
spinal tap for glucose,

27:49.220 --> 27:52.180
protein and culture ought to be done on every single

27:52.180 --> 27:53.350
baby with seizures.

27:53.360 --> 27:56.080
And I personally believe metabolic

27:56.080 --> 27:57.640
studies ought to be done also.

27:57.650 --> 28:00.510
Yearn for for metabolic screen for

28:00.520 --> 28:01.710
amino acid disorders,

28:01.710 --> 28:04.450
branch chain keto acid disorders and other inborn errors of

28:04.450 --> 28:05.170
metabolism.

28:05.640 --> 28:05.770
Okay,

28:05.770 --> 28:05.880
now,

28:05.880 --> 28:07.100
that's the most important thing.

28:07.110 --> 28:10.080
Quickly doing those tests and uh

28:10.090 --> 28:12.910
next we go on to therapy and I think the next slide will

28:12.910 --> 28:15.870
have specific therapy immediately after

28:15.870 --> 28:18.500
those blood tests are drawn and that should be within a couple

28:18.500 --> 28:18.900
minutes.

28:18.900 --> 28:19.150
Okay?

28:19.150 --> 28:20.210
Not an hour later.

28:20.260 --> 28:22.640
But immediately after the blood tests are drawn.

28:22.650 --> 28:25.310
Even before the results come back and I ve should be

28:25.310 --> 28:27.440
placed in 1 to 2.

28:27.450 --> 28:28.570
Actually 1 to 4.

28:28.570 --> 28:30.580
Even milliliters per kilogram of D.

28:30.580 --> 28:31.180
10 to D.

28:31.180 --> 28:32.760
25 should be given I.

28:32.760 --> 28:33.200
V.

28:33.430 --> 28:35.350
In case there's hypoglycemia.

28:35.540 --> 28:37.730
Now some people like to use d 25.

28:37.740 --> 28:39.080
I personally prefer d.

28:39.080 --> 28:42.080
10 but that's controversial as long as you get

28:42.080 --> 28:42.340
an I.

28:42.340 --> 28:42.570
V.

28:42.570 --> 28:45.470
going and giving given some glucose you'll get the blood

28:45.470 --> 28:48.240
sugar up and then of course it should be rechecked again.

28:48.240 --> 28:51.060
This should be done even before the blood glucose comes

28:51.060 --> 28:51.350
back.

28:52.040 --> 28:54.990
Okay calcium should also be

28:54.990 --> 28:56.610
given 10% calcium.

28:56.620 --> 28:59.270
One half to two CC's per kilogram

28:59.270 --> 29:01.320
very slowly with an E.

29:01.320 --> 29:01.540
K.

29:01.540 --> 29:01.750
G.

29:01.750 --> 29:03.280
Monitor in place next.

29:03.280 --> 29:06.250
Like now if if

29:06.250 --> 29:08.910
the seizures are the cause of the seizures are not found

29:08.910 --> 29:11.300
and you really can't figure out what's going on.

29:11.330 --> 29:13.700
One ought to consider giving paradox in or B.

29:13.700 --> 29:15.380
Six vitamin B.

29:15.380 --> 29:15.640
6,

29:15.640 --> 29:16.880
20 to 50 mg I.

29:16.880 --> 29:17.140
V.

29:17.140 --> 29:19.660
I've never seen a baby with paradox

29:19.660 --> 29:21.990
independent or deficient seizures but it does occur

29:21.990 --> 29:24.760
occasionally if there's a magnesium

29:24.760 --> 29:27.540
deficiency uh with a low magnesium

29:27.550 --> 29:30.290
mag sulfate 3% to 26

29:30.290 --> 29:31.970
millimeters ivy again with an E.

29:31.970 --> 29:32.160
K.

29:32.160 --> 29:32.380
G.

29:32.380 --> 29:34.170
Monitor going should be given.

29:34.540 --> 29:37.520
Now that's the specific therapy and I just want to reemphasize

29:37.520 --> 29:40.450
that you don't wait around for 24 hours until your tests

29:40.450 --> 29:41.090
are back.

29:41.100 --> 29:43.830
You immediately get the blood glucose,

29:43.840 --> 29:44.480
calcium,

29:44.480 --> 29:45.550
magnesium sodium,

29:45.550 --> 29:47.040
spinal tap blood culture.

29:47.050 --> 29:47.590
Get an I.

29:47.590 --> 29:47.820
V.

29:47.820 --> 29:50.260
And start the glucose going personally.

29:50.260 --> 29:51.950
We like to get a dexter stick first.

29:51.950 --> 29:54.690
And if the dexter stick is low we would put an I.

29:54.690 --> 29:54.900
V.

29:54.900 --> 29:57.550
And give glucose even before we do the LP.

29:57.640 --> 30:00.440
But even if the dexter stick is normal after we sent the blood

30:00.440 --> 30:03.350
studies down to the lab and we've done our tests over say may

30:03.350 --> 30:04.960
be taken 5 10 15 minutes.

30:04.970 --> 30:07.760
We would then also give glucose because sometimes the

30:07.760 --> 30:09.520
dexter stick won't be all that accurate.

30:09.530 --> 30:12.510
But we don't want to wait until all the tests come back from the lab because it maybe

30:12.510 --> 30:13.770
an hour or two or three

30:14.940 --> 30:17.930
now besides specific therapy and

30:17.930 --> 30:20.830
say for example if it's not hypoglycemia and it's not

30:20.830 --> 30:21.610
hipaa calcium me,

30:21.610 --> 30:23.110
it's not hippo magnesium mia.

30:23.120 --> 30:25.980
Uh You've done an

30:25.980 --> 30:26.140
L.

30:26.140 --> 30:26.350
P.

30:26.350 --> 30:28.030
And there's no evidence of meningitis.

30:28.040 --> 30:30.800
Uh And you started the baby on antibiotics for possible

30:30.800 --> 30:31.460
sepsis.

30:31.470 --> 30:33.270
But the kids still having seizures.

30:33.280 --> 30:36.160
Well then of course you have to go on to uh and a

30:36.160 --> 30:38.750
convulsive therapy specific anticonvulsant

30:38.750 --> 30:39.390
therapy.

30:39.440 --> 30:40.330
Now some people,

30:40.330 --> 30:43.280
especially in older infants and Children and adults like to use

30:43.280 --> 30:43.930
Valium,

30:43.970 --> 30:46.450
I personally do not prefer Valium in the

30:46.450 --> 30:47.010
newborn.

30:47.020 --> 30:49.850
Uh cinnabar probably works

30:49.860 --> 30:51.310
just as well as Valium.

30:51.320 --> 30:54.280
Ivi Finbar you have to Valium only works

30:54.280 --> 30:57.170
for a short period of time anyway and you have to give gina barbe anyway.

30:57.240 --> 30:59.810
So I prefer personally just to start with

30:59.820 --> 31:00.250
ivy,

31:00.250 --> 31:03.240
PHENobarbital in a baby with seizures and that's the next

31:03.240 --> 31:03.500
slide.

31:03.500 --> 31:05.910
I think Vienna Bar Battle,

31:05.910 --> 31:08.840
I consider the drug of choice and a convulsion drug of choice

31:08.840 --> 31:09.520
in the newborn.

31:09.790 --> 31:12.060
That's 10 mg per kilogram.

31:12.440 --> 31:12.820
I?

31:12.820 --> 31:15.460
Ve Okay slowly now you got to be prepared for

31:15.460 --> 31:17.500
possible apnea of course and

31:17.510 --> 31:20.360
uh you got to be prepared for that

31:20.370 --> 31:21.930
now if the seizures don't stop,

31:21.940 --> 31:23.200
stop within the hour.

31:23.200 --> 31:26.000
So uh with this we may repeat

31:26.000 --> 31:28.970
that uh that same dose 10 per kilo slowly

31:28.970 --> 31:29.450
ivy.

31:29.840 --> 31:31.060
Then usually orally,

31:31.060 --> 31:33.320
the baby will require 5 to 10 mg per

31:33.320 --> 31:35.010
kilogram orally.

31:35.100 --> 31:37.540
In uh To to say two divided doses

31:37.550 --> 31:40.470
after a maintenance or after

31:40.480 --> 31:40.880
the I.

31:40.880 --> 31:41.050
V.

31:41.050 --> 31:41.860
Dose is given.

31:42.240 --> 31:45.020
Now one of the major problems with the pentobarbital and

31:45.020 --> 31:45.500
Dilantin.

31:45.500 --> 31:48.340
Most problems people have is they don't give enough to start with.

31:48.340 --> 31:50.610
They give a too low of a dose.

31:50.620 --> 31:53.300
Uh So it's important that when the baby's first seven

31:53.300 --> 31:54.990
seizures to give a high enough dose.

31:55.210 --> 31:56.090
Now Dilantin,

31:56.090 --> 31:58.500
the next slide also

31:58.510 --> 32:01.480
is the dose is 10 mg per

32:01.480 --> 32:02.640
kilogram ivy.

32:02.650 --> 32:05.420
And that also may be repeated if it doesn't work.

32:05.430 --> 32:08.050
And the oil doses roughly 5 to 10 mg per

32:08.050 --> 32:09.030
kilogram per day.

32:09.040 --> 32:11.920
However in order to treat the patient properly

32:11.920 --> 32:13.450
and to know what dose to give,

32:13.460 --> 32:16.200
you have to be able to monitor with

32:16.210 --> 32:19.160
micro essays the blood Dilantin,

32:19.160 --> 32:19.990
PHENobarbital level.

32:20.000 --> 32:22.980
It's really the only way to properly

32:22.980 --> 32:25.770
determine how much to barb or

32:25.770 --> 32:27.210
Dilantin the baby needs.

32:27.220 --> 32:29.850
You can't just go by clinical symptoms.

32:29.850 --> 32:32.760
You can't go by an average dose of 5 to

32:32.760 --> 32:34.860
10 mg per kilogram per day

32:35.740 --> 32:37.790
because many babies require more than that.

32:37.790 --> 32:40.710
Many babies require less and the

32:40.720 --> 32:43.560
the metabolism of Dilantin and PHENobarbital

32:43.650 --> 32:46.110
is extremely variable in the

32:46.110 --> 32:46.720
newborn.

32:46.730 --> 32:48.960
And some newborns require a little bit.

32:48.960 --> 32:51.470
Some newborns require a lot and it changes

32:51.470 --> 32:54.470
quickly over over the first few uh weeks

32:54.470 --> 32:55.360
and months of life.

32:55.440 --> 32:58.180
So the only way to properly determine how

32:58.180 --> 33:01.090
much PHENobarbital and the baby needs for seizures is by

33:01.090 --> 33:02.490
measuring blood levels.

33:02.500 --> 33:05.100
I just want to reemphasize that many

33:05.100 --> 33:08.050
babies many times the people when they use pentobarbital

33:08.050 --> 33:09.750
and they don't give enough to start with.

33:09.760 --> 33:11.400
On the other side of the coin,

33:11.420 --> 33:12.510
you've gotta be prepared,

33:12.510 --> 33:14.350
especially with PHENobarbital for Anthony.

33:14.350 --> 33:16.950
And then you have to be prepared for possible innovation of the baby.

33:17.540 --> 33:19.710
Now Dilantin we don't use very often.

33:19.720 --> 33:21.980
Dilantin rarely is needed.

33:21.990 --> 33:24.340
And about the only time we need Dilantin in the

33:24.340 --> 33:27.070
newborn is in babies who have severe

33:27.070 --> 33:29.740
seizures from asphyxia or

33:29.740 --> 33:32.170
babies who have severe seizures from meningitis.

33:32.180 --> 33:34.300
And it's not very often we use that.

33:34.300 --> 33:35.090
We need Dilantin.

33:35.090 --> 33:36.560
Usually just find a barb.

33:36.570 --> 33:38.790
Usually just treating the cause like

33:38.790 --> 33:39.790
hypoglycemia,

33:39.790 --> 33:40.850
hypoglycemia.

33:41.240 --> 33:41.480
Again,

33:41.480 --> 33:44.230
I just want to reemphasize you gotta treat the cause

33:44.230 --> 33:47.080
first before jumping in and using the

33:47.180 --> 33:48.240
PHENobarbital,

33:48.240 --> 33:51.120
PHENobarbital comes after you treat the cause

33:51.130 --> 33:51.860
of the seizures.

33:52.540 --> 33:53.320
Okay,

33:53.340 --> 33:53.570
now,

33:53.570 --> 33:54.790
in addition to the drugs,

33:54.790 --> 33:56.850
of course you've got to support the baby.

33:56.850 --> 33:59.400
I think the next slide just kind of reminds us that

33:59.400 --> 34:00.430
supportive care,

34:00.430 --> 34:03.300
like intravenous fluids and a cardiac monitor are

34:03.300 --> 34:04.300
also necessary.

34:04.300 --> 34:04.720
Okay,

34:04.720 --> 34:07.450
you can't just give the final barbara,

34:07.450 --> 34:09.760
just give the glucose of its hypoglycemia.

34:09.840 --> 34:12.510
You have to continue to monitor the baby very

34:12.510 --> 34:13.350
closely.

34:13.440 --> 34:14.090
Uh,

34:14.100 --> 34:16.770
especially if he's got complicated disease,

34:16.770 --> 34:18.020
like say meningitis.

34:18.030 --> 34:18.780
Uh,

34:18.790 --> 34:21.360
it's extremely difficult and complicated procedure of

34:21.360 --> 34:22.350
monitoring that baby.

34:23.040 --> 34:23.470
Okay,

34:23.470 --> 34:24.470
now,

34:24.480 --> 34:27.430
one of the things to say about Dilantin to uh

34:27.440 --> 34:30.130
all Dilantin gives a lot of problems.

34:30.140 --> 34:30.580
Uh,

34:30.590 --> 34:33.530
the oral suspension of Dilantin that's used is

34:33.530 --> 34:36.340
notorious for settling out in the

34:36.340 --> 34:37.440
bottom of the bottle.

34:37.620 --> 34:40.410
And that's why we prefer not to use the oral

34:40.410 --> 34:41.720
suspension of Dilantin.

34:41.720 --> 34:44.470
We prefer to use the tablets and have the

34:44.470 --> 34:46.940
mother cut up the tablets and put them in,

34:46.940 --> 34:47.130
say,

34:47.130 --> 34:48.120
with the formula,

34:48.190 --> 34:49.320
the oral suspension,

34:49.320 --> 34:50.400
that's commercially available.

34:50.400 --> 34:53.380
Dilantin is not carries with it

34:53.380 --> 34:54.220
lots of problems.

34:54.220 --> 34:54.960
And a lot of times,

34:54.960 --> 34:57.940
babies will not get enough Dilantin because they'll get the top of the

34:57.940 --> 34:59.280
bottle where there is no doubt land,

34:59.280 --> 35:02.000
or then at the end they'll get all the Dilantin because it's settled out.

35:02.010 --> 35:03.860
So we prefer to have the,

35:03.940 --> 35:04.800
the tablets.

35:04.800 --> 35:05.820
I think they're triangular.

35:05.820 --> 35:06.470
If I recall,

35:06.470 --> 35:08.470
cut up by the mother and put into the,

35:08.640 --> 35:11.380
into the formula for the babies when they're on oral

35:11.380 --> 35:11.870
Dylan.

35:11.880 --> 35:12.310
Okay,

35:12.310 --> 35:12.890
now,

35:12.900 --> 35:15.600
all of this business about diagnosing and treating

35:15.600 --> 35:16.250
seizures,

35:16.260 --> 35:17.850
what's the prognosis of them?

35:18.740 --> 35:19.580
Well,

35:19.580 --> 35:20.960
in many cases it's not good,

35:21.340 --> 35:23.820
remember for the correctable causes

35:24.440 --> 35:25.550
hypoglycemia,

35:25.770 --> 35:28.010
calc mia infection,

35:28.020 --> 35:29.610
hyper viscosity.

35:29.620 --> 35:32.330
If you can prevent the seizures and

35:32.330 --> 35:35.230
treat the disorder before seizures occur.

35:35.240 --> 35:38.040
The prognosis for the baby as far as his brain is

35:38.040 --> 35:39.820
concerned is much,

35:39.820 --> 35:42.270
much better then if you wait and pick up the

35:42.270 --> 35:44.670
hypoglycemia after the seizures occur,

35:45.140 --> 35:46.080
uh,

35:46.090 --> 35:49.040
and the sooner you pick up the disease diagnosed the

35:49.050 --> 35:51.370
cause of the seizures and treat the cause.

35:51.380 --> 35:53.830
The better the outlook of the baby as far as the brains

35:53.830 --> 35:54.400
concert,

35:54.550 --> 35:56.640
and the next couple slides will summarize the

35:56.640 --> 35:57.560
prognosis.

35:58.040 --> 36:00.890
If the baby has severe seizures due to

36:00.890 --> 36:01.720
asphyxia,

36:01.720 --> 36:03.590
low apgar hypoxia.

36:03.660 --> 36:05.300
The prognosis is not good.

36:05.300 --> 36:08.210
Only roughly 10 or 20 of these babies will turn out

36:08.210 --> 36:10.470
normal and treating these babies is

36:10.470 --> 36:12.130
extremely difficult,

36:12.140 --> 36:13.550
extremely complex.

36:14.630 --> 36:17.480
If a baby has seizures from subarachnoid hemorrhage,

36:17.490 --> 36:19.500
almost all these babies turn out normal.

36:20.030 --> 36:21.510
If the baby has seizures,

36:21.510 --> 36:22.000
for example,

36:22.000 --> 36:24.950
a premature baby with bad respiratory distress on a ventilator

36:24.950 --> 36:27.380
and has an intra ventricular hemorrhage or peri

36:27.380 --> 36:29.640
ventricular intra cerebral hemorrhage.

36:29.680 --> 36:31.730
The prognosis extremely dismal.

36:31.740 --> 36:33.080
And most of these babies die,

36:33.080 --> 36:34.290
you know the few that survive.

36:34.300 --> 36:37.010
Almost all have severe neurologic

36:37.010 --> 36:37.550
impairment.

36:38.330 --> 36:41.050
If they have early hippo calcium e as the

36:41.050 --> 36:41.720
seizures,

36:41.730 --> 36:44.250
about half of the babies will do well laid hippo

36:44.250 --> 36:46.470
calcium AEA meeting at a week of age or so,

36:46.480 --> 36:49.400
uh most of the babies will do well again,

36:49.400 --> 36:52.100
these these problems should be prevented

36:52.430 --> 36:55.430
early hippo calcium e occurs usually in premature babies,

36:55.430 --> 36:56.130
sick babies,

36:56.140 --> 36:57.400
infants of diabetic mothers.

36:57.410 --> 36:59.070
And it can be prevented by picking it up,

36:59.080 --> 37:01.970
watching it uh and and treating it

37:01.980 --> 37:04.030
before the baby has seizures laid,

37:04.030 --> 37:06.170
hippo calc mia is very uncommon.

37:06.170 --> 37:07.550
Now we don't see it much anymore.

37:09.030 --> 37:10.570
Hypoglycemia.

37:10.580 --> 37:13.420
If the baby has seizures from hypoglycemia,

37:13.430 --> 37:15.160
half of the babies will be normal,

37:15.160 --> 37:17.900
and a half will be abnormal If you pick up the

37:17.900 --> 37:20.770
hypoglycemia before the baby has seizures

37:20.780 --> 37:23.250
and treat the hypoglycemia and prevent the

37:23.250 --> 37:23.810
seizures,

37:23.820 --> 37:26.340
all the babies almost will be normal

37:27.030 --> 37:28.010
meningitis.

37:28.290 --> 37:31.010
Somewhere between 15 and 35% of the

37:31.010 --> 37:32.740
babies are normal,

37:32.740 --> 37:34.040
but these are old figures.

37:34.040 --> 37:34.610
And actually,

37:34.610 --> 37:36.060
if you look at the newer figures,

37:36.060 --> 37:38.980
especially from Dallas uh and and

37:38.980 --> 37:41.280
also some of the figures of Group B strep,

37:41.290 --> 37:43.070
it's probably not nearly this bad.

37:43.070 --> 37:44.750
It's probably just the reverse.

37:44.750 --> 37:46.720
Probably Somewhere around

37:46.720 --> 37:49.350
60-75 or 80 of the babies who are

37:49.350 --> 37:51.490
normal if treated properly,

37:51.500 --> 37:52.980
even though they have meningitis,

37:53.530 --> 37:56.370
if they have developmental anomalies like big cyst in the

37:56.370 --> 37:57.540
brain or encephalitis,

37:57.540 --> 37:59.310
seals and they have seizures from that.

37:59.320 --> 38:00.090
The prognosis,

38:00.090 --> 38:00.430
again,

38:00.440 --> 38:01.650
is very poor.

38:02.420 --> 38:02.830
Okay,

38:02.830 --> 38:05.810
that pretty well summarizes uh the causes

38:05.810 --> 38:07.420
of diagnosis of seizures,

38:07.430 --> 38:10.230
the causes of the seizures and the treatment of them.

38:10.240 --> 38:11.380
Again,

38:11.380 --> 38:13.380
it's not a very common problem in the newborn,

38:13.390 --> 38:15.860
but it's a problem that demands

38:15.870 --> 38:18.520
immediate appropriate

38:18.530 --> 38:21.340
attention and it's different

38:21.620 --> 38:22.840
type of care.

38:22.920 --> 38:25.810
Then you would give the older child or adult with

38:25.810 --> 38:26.390
seizures.

38:26.400 --> 38:29.190
Uh I think that's all for now.

38:29.200 --> 38:31.900
And later on we'll pick some other

38:31.900 --> 38:33.560
topic and discuss that.

38:33.570 --> 38:35.150
Thank you very much for joining me today.

38:40.520 --> 38:43.230
The new board with Dr

38:43.230 --> 38:44.330
Richard Schreiner.

38:45.020 --> 38:45.340
Mhm.

38:45.820 --> 38:48.750
Was produced by the Medical Television facility,

38:49.640 --> 38:50.070
Medical,

38:50.070 --> 38:53.020
educational resources program of Indiana

38:53.020 --> 38:54.640
University School of Medicine.

38:56.120 --> 38:57.040
Mm hmm.

38:58.100 --> 38:59.560
Yeah,