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

Jennifer C Keene; Lindsey A Morgan; Nicholas S Abend; Sara V Bates; Sarah L Bauer Huang; Taeun Chang; Catherine J Chu; Hannah C Glass; Shavonne L Massey; Betsy Ostrander; Andrea C Pardo; Craig A Press; Janet S Soul; Renée A Shellhaas; Cameron Thomas; Niranjana Natarajan

doi:10.1016/j.pediatrneurol.2021.10.004

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

Pediatr Neurol. 2022 Mar:128:67-74. doi: 10.1016/j.pediatrneurol.2021.10.004. Epub 2021 Oct 11.

Authors

Jennifer C Keene¹, Lindsey A Morgan², Nicholas S Abend³, Sara V Bates⁴, Sarah L Bauer Huang⁵, Taeun Chang⁶, Catherine J Chu⁷, Hannah C Glass⁸, Shavonne L Massey³, Betsy Ostrander⁹, Andrea C Pardo¹⁰, Craig A Press¹¹, Janet S Soul¹², Renée A Shellhaas¹³, Cameron Thomas¹⁴, Niranjana Natarajan²

Affiliations

¹ Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington. Electronic address: Jennifer.c.keene@gmail.com.
² Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington.
³ Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
⁴ Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
⁵ Division of Pediatric & Developmental Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri.
⁶ Neurology, Children's National Hospital, George Washington University, Washington, District of Columbia.
⁷ Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
⁸ Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, San Francisco, California.
⁹ Division of Pediatric Neurology, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
¹⁰ Ann & Robert H. Lurie Children's Hospital, Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
¹¹ Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
¹² Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.
¹³ Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
¹⁴ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

PMID: 34750046
DOI: 10.1016/j.pediatrneurol.2021.10.004

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.

Keywords: Antiseizure medication; Fosphenytoin; Guideline; Levetiracetam; Neonatal critical care; Neonatal seizures; Phenobarbital; Protocol.

MeSH terms

Age Factors
Anticonvulsants / therapeutic use
Clinical Protocols
Critical Care*
Electroencephalography
Female
Humans
Infant, Newborn
Intensive Care Units, Neonatal
Male
Patient Selection
Seizures / diagnosis*
Seizures / therapy*
United States

Substances

Anticonvulsants