pediatrics
Neonatal Seizure Disorders
Treatment of Neonatal Seizure Disorders
Treatment of cause Antiseizure medications Treatment of neonatal seizures is focused primarily on the underlying disorder and secondarily on seizures. Forlow serum glucose,10%dextrose2 mL/kg IV is given, and the serum glucose level is monitored; additional infusions are given as needed but cautiously, to avoid hyperglycemia. Forhypocalcemia,10%calcium gluconate1 mL/kg IV (9 mg/kg of elemental calcium) is given; this dosage can be repeated for persistent hypocalcemic seizures. Rate ofcalcium gluconateinfusion should not exceed 0.5 mL/minute (50 mg/minute); continuous cardiac monitoring is necessary during the infusion. Extravasation should be avoided because skin may slough. Forhypomagnesemia,0.2 mL/kg (100 mg/kg) of a 50% magnesium sulfate solution is given IM. Bacterial infectionsare treated with antibiotics. Herpes encephalitisis treated withacyclovir. Antiseizure medications are used unless seizures stop quickly after correction of reversible disorders such as hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia, or hypernatremia. Phenobarbitalis still the most commonly used drug; a loading dose of 15 to 20 mg/kg IV is given. If seizures continue, 5 to 10 mg/kg IV can be given every 15 to 30 minutes until seizures cease or until a maximum of 40 mg/kg is given. If seizures are persistent, maintenance therapy may be started about 24 hours later at 1.5 to 2 mg/kg every 12 hours and increased to 2.5 mg/kg every 12 hours based on clinical or EEG response or serum drug levels.Phenobarbitalis continued IV, especially if seizures are frequent or prolonged. When the infant is stable,phenobarbitalcan be given orally at 3 to 4 mg/kg once/day. Therapeutic serum levels ofphenobarbitalare 20 to 40 mcg/mL (85 to 170 micromol/L), but higher levels are sometimes needed at least temporarily. Levetiracetamis used to treat neonatal seizures because it is less sedating thanphenobarbital. It is given IV as a 20- to 60-mg/kg IV loading dose given at 2 to 5 mg/kg/minute, and therapy may be continued as 10 to 30 mg/kg IV every 12 hours. Therapeutic levels are not well-established in the neonate. Fosphenytoincan be used if seizures continue despitephenobarbitalandlevetiracetam. The loading dose is 20 mg PE (phenytoinequivalents)/kg IV. It is given over 30 minutes to avoid hypotension or arrhythmias. A maintenance dose may be started at 2 to 3 mg PE/kg every 12 hours and adjusted based on clinical response or serum levels. Therapeutic serum levels forphenytoinin neonates are 8 to 15 mcg/mL (32 to 60 micromol/L). Lorazepam0.1 mg/kg IV may be used initially for a prolonged seizure or for resistant seizures and repeated at 5- to 10-minute intervals, up to 3 doses in any 8-hour period. Neonates given IV antiseizure medications are closely observed; large doses and combinations of medications, particularlylorazepamplusphenobarbital, may result in respiratory depression. The optimal duration of maintenance therapy is not known for any of the antiseizure medications and depends on the underlying etiology of seizures and on the presence of risk factors for seizure recurrence. 