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Treatment of seizures in newborns: the dilemma of starting the right drug, at the right time, in the right doses, and monitoring the right endpoints.

A 25-week gestational age newborn, birthweight 650 grams, has several complications in the first 3 days of life including respiratory distress syndrome treated with surfactant, clinical signs of patent ductus arteriosus which is being evaluated to confirm diagnosis and consideration for ligation, and intraventricular hemorrhage diagnosed on the morning of day 3 of life. On the afternoon of day 3, the patient develops seizure-like activities. Symptoms consist of jerking of the right shoulder followed by chewing motions, and are associated with oxygen desaturation and tachycardia. These symptoms occur about 5 times over a one-hour period. An electroencephalogram (EEG) is ordered and three events are noted during a 30 minute recording. A debate about initiating anticonvulsant therapy ensues; the neurologist wants to wait until the EEG is interpreted to initiate an anticonvulsant, while the pharmacotherapy specialist argues for initiating phenobarbital during the EEG, timed to be given during any observed clinical seizure activity or obvious electrographic seizure activity on the EEG. Based on the neurologist’s recommendaTreatment of seizures in Newborns: The Dilemma of starting the Right Drug, at the Right Time, in the Right Doses, and Monitoring the Right endpoints