Seizures noted in the delivery room often are caused by blinking, fluctuation of vital signs, and staring. Continudirect injection of local anesthetic agents into the fetal scalp ous bedside electroencephalographic monitoring can help (associated with transient bradycardia and fixed dilated identify subtle seizures. pupils), severe anoxia, or congenital brain malformation. The diagnostic evaluation of infants with seizures should Seizures after the first 5 days of life may be the result of involve an immediate determination of capillary blood gluinfection or drug withdrawal. Seizures associated with leth-cose levels with a Chemstrip. In addition, blood concenargy, acidosis, and a family history of infant deaths may trations of sodium, calcium, glucose, and bilirubin should be the result of an inborn error of metabolism. An infant be determined. When infection is suspected, cerebrospinal whose parent has a history of a neonatal seizure also is at fluid and blood specimens should be obtained for culture. risk for benign familial seizures. In an infant who appears After the seizure has stopped, a careful examination should well, a sudden onset on day 1 to 3 of life of seizures that are be done to identify signs of increased intracranial pressure, of short duration and that do not recur may be the result congenital malformations, and systemic illness. If signs of elevated intracranial pressure are absent, a lumbar puncture should be performed. If the diagnosis is not apparentat this point, further evaluation should involve magneticresonance imaging, computed tomography, or cerebralultrasound and tests to determine the presence of an inbornerror of metabolism. Determinations of inborn errors of metabolism are especially important in infants with unexplained lethargy, coma, acidosis, ketonuria, or respiratoryalkalosis.
The treatment of neonatal seizures may be specific, such as treatment of meningitis or the correction of hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia, or vitamin B6 deficiency or dependency. In the absence of an identifiable cause, therapy should involve an anticonvulsant agent, such as 20 to 40 mg/kg of phenobarbital, 10 to 20 mg/kg of phenytoin, or 0.1 to 0.3 mg/kg of diazepam. Treatment of status epilepticus requires repeated doses of phenobarbital and may require diazepam or midazolam, titrated to clinical signs. The long-term outcome for neonatal seizures usually is related to the underlying cause and to the primary pathology, such as hypoxic-ischemic encephalopathy, meningitis, drug withdrawal, stroke, or hemorrhage.