Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units.

TitleTreatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units.
Publication TypeJournal Article
Year of Publication2022
AuthorsKeene JC, Morgan LA, Abend NS, Bates SV, Huang SLBauer, Chang T, Chu CJ, Glass HC, Massey SL, Ostrander B, Pardo AC, Press CA, Soul JS, Shellhaas RA, Thomas C, Natarajan N
JournalPediatr Neurol
Volume128
Pagination67-74
Date Published2022 03
ISSN1873-5150
KeywordsAge Factors, Anticonvulsants, Clinical Protocols, Critical Care, Electroencephalography, Female, Humans, Infant, Newborn, Intensive Care Units, Neonatal, Male, Patient Selection, Seizures, United States
Abstract

OBJECTIVE: Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability.

METHODS: We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose.

RESULTS: Study center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing.

CONCLUSIONS: Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.

DOI10.1016/j.pediatrneurol.2021.10.004
Alternate JournalPediatr Neurol
PubMed ID34750046