Colin Snow
Newborns can have seizures in their sleep, and seizures are one of the most common signs of neurological difficulties in a baby. They can be difficult to diagnose because the signs of seizures may mimic normal movements and behaviours seen in healthy newborns. Seizures in newborns may have visible signs, such as rhythmic twitching, posturing, or subtle movements like bicycling or eye deviation, but some seizures may not show any obvious symptoms at all. Tonic seizures, for example, usually occur while the baby is sleeping and can last about 20 seconds. The symptoms of neonatal seizures depend on the type of seizure, and they can be generalized, affecting the entire body, focal, affecting one area or limb, or multifocal, affecting more than one limb.
| Characteristics | Values |
|---|---|
| Incidence | 12 per 1,000 term infants |
| Cause | Lack of oxygen before or during birth, brain injury, infection |
| Symptoms | Rhythmic twitching, posturing, subtle movements like bicycling or eye deviation, repetitive, rhythmic contractions of the face, arms, legs, neck, or torso, continuous but brief stiffening of the neck or body, unusual facial expressions, eye movements, or mouth movements |
| Diagnosis | Electroencephalogram (EEG), blood and spinal fluid evaluations, magnetic resonance imaging (MRI), computed tomography (CT) scan, genetic tests |
| Treatment | Anticonvulsant therapy, antiepileptic medication, long-term care |
| Prognosis | 17% of infants in one study died or were transferred to hospice care, more than half of all babies who have neonatal seizures have conditions that affect them throughout their life |
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What You'll Learn
Neonatal seizures are difficult to diagnose
Secondly, neonatal seizures can be short and subtle, making them difficult to detect and diagnose. The brief nature of these seizures increases the likelihood of missing them, especially if they occur during sleep or when the baby is not being actively monitored.
Thirdly, the pathophysiology and electroclinical manifestations of neonatal seizures differ from those of older patients. Many seizures in newborns present as electrographic-only events without any clinical signs, making them challenging to identify and diagnose. Additionally, previous studies have shown that most neonatal seizures are electrographic-only, meaning they do not exhibit the typical clinical symptoms associated with seizures.
Furthermore, diagnosing neonatal seizures requires specialized testing, such as an electroencephalogram (EEG). An EEG is a non-invasive test that records electrical activity in the baby's brain. While it is essential for diagnosing and managing neonatal seizures, it may not always detect seizures, especially in cases of benign familial neonatal seizures, which often yield normal EEG readings. Therefore, even with advanced technology, confirming a diagnosis of neonatal seizures can be challenging.
Lastly, the underlying causes of neonatal seizures can vary, and determining the specific cause requires further imaging tests, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans. These additional tests add complexity to the diagnostic process and may prolong the time required to reach a definitive diagnosis.
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Symptoms of neonatal seizures
Neonatal seizures are common and occur during a newborn's first month, with most seizures taking place within the first week of a baby's life. They are caused by sudden, abnormal and excessive electrical activity in the brain. Premature or low birth weight babies are more likely to suffer neonatal seizures than full-term infants.
Neonatal seizures can be difficult to diagnose because they may be short and subtle, and the signs may mimic normal movements and behaviours seen in healthy newborns. An electroencephalogram (EEG) is essential for diagnosing and managing neonatal seizures. This is a non-invasive test where electrodes are applied to the baby's head to record electrical activity in their brain.
The symptoms of neonatal seizures depend on the type of seizure the baby is experiencing: subtle, clonic, tonic, or myoclonic. Subtle seizures are more common among full-term babies and include random or roving eye movements, eyelid blinking or fluttering, eyes rolling up, eye opening, and staring. Clonic seizures are very brief and don't happen often. They include rhythmic jerking movements that may involve the muscles of the face, tongue, arms, legs, or other body regions. Tonic seizures usually occur while the baby is sleeping and typically last about 20 seconds or less. Symptoms include sustained stiffening or tightening of the muscles in one area or the whole body. Myoclonic seizures are more frequent in pre-term babies than full-term ones and include quick, single repetitive jerking motions, involving one arm or leg or the whole body.
Other signs of neonatal seizures include unusual repetitive or stereotypic movements, alterations in autonomic functions such as blood pressure or heart rate, and chewing motions and "bicycling" movements.
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Types of neonatal seizures
Neonatal seizures are a commonly encountered neurological condition in newborns. They are defined as sudden, paroxysmal, abnormal alterations of electrographic activity from birth until the end of the neonatal period, which is considered to be the first 28 days of life for a full-term infant.
The symptoms of neonatal seizures depend on the type of seizure the baby is experiencing. These can be categorised into subtle, clonic, tonic, myoclonic, focal clonic, focal tonic, generalised tonic, and motor automatisms. Subtle seizures are more common among full-term babies and their symptoms include random or roving eye movements, eyelid blinking or fluttering, eyes rolling up, eye-opening, and staring. Clonic seizures are very brief and do not happen often. They may go away on their own but if they don't, they require long-term treatment. Tonic seizures usually occur while the baby is sleeping and typically last about 20 seconds. Myoclonic seizures are rapid, single, or arrhythmic repetitive jerks that may affect a finger, a limb, or the whole body. Focal clonic seizures involve one or both sides of the body or one arm or leg, and they usually produce electrical evidence that shows up on an EEG exam. Focal tonic seizures may be focal, multifocal, or generalized, symmetrical, or asymmetrical. Finally, motor automatisms include ocular signs, oral-buccal-lingual movements, progression movements, and complex purposeless movements.
It is important to note that neonatal seizures are often a sign of a serious underlying neurological condition and can be life-threatening. They are usually clinically subtle, inconspicuous, and difficult to recognize from normal behaviors, so it is important to seek medical attention if you suspect your baby is having seizures.
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Causes of neonatal seizures
Seizures in newborns, or neonatal seizures, occur during the neonatal or newborn period, which is within the first 28 days of a full-term infant's life. Premature or low-birth-weight babies are more likely to suffer from neonatal seizures than full-term infants.
Neonatal seizures are challenging to diagnose because they often manifest with subtle signs and symptoms, and the signs may mimic normal movements and behaviours seen in healthy newborns. An electroencephalogram (EEG) is a crucial test for diagnosing and managing neonatal seizures. This non-invasive test involves placing electrodes on the baby's head to record electrical activity in their brain. However, babies with benign familial neonatal seizures typically have normal EEG readings. If a seizure is indicated by the EEG, imaging tests such as magnetic resonance imaging (MRI) or computed tomography (CT) scans may be used to determine the underlying cause.
The leading causes of neonatal seizures include hypoxic ischemic encephalopathy (HIE), vascular disorders, infections, and acquired metabolic derangements. HIE is the most common cause, often related to a complicated birth process, and it accounts for up to 20% of neonatal seizures. Infectious causes can range from generalised sepsis to primary neurological infections like meningitis, encephalitis, or meningoencephalitis.
Benign familial neonatal epilepsy, which typically appears by day 2 or 3 of life, is caused by autosomal dominant mutations in the genes encoding potassium channels KCNQ2 and KCNQ3. It is associated with a family history of neonatal seizures and usually has a positive outcome.
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Treatment for neonatal seizures
Neonatal seizures occur during a newborn's first month, with most seizures taking place within the first week of a baby's life. They are caused by sudden, abnormal and excessive electrical activity in the brain.
Diagnosis
An electroencephalogram (EEG) is essential for diagnosing and managing neonatal seizures. This non-invasive test involves placing electrodes on the baby's head to record electrical activity in their brain. If the EEG indicates that a baby is having seizures, imaging tests of the brain, including magnetic resonance imaging (MRI) and computed tomography (CT) scans, may be used to determine the cause.
Treatment
There is currently no consensus on the most appropriate treatment for neonatal seizures, with controversy surrounding whether all seizures should be treated. However, 70% of seizures will abate with phenobarbitone. Other commonly used anti-seizure medications (ASMs) include midazolam, lorazepam, clonazepam, phenytoin, and lidocaine.
Therapeutic hypothermia may also reduce seizure activity in neonates with hypoxic-ischemic encephalopathy. In addition, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM.
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Frequently asked questions
Newborn seizures, or neonatal seizures, are paroxysmal alterations in neurological function. They are caused by sudden, abnormal and excessive electrical activity in the brain. They occur during the neonatal, or newborn, period, which is the first 28 days after birth for a full-term infant.
Symptoms of newborn seizures depend on the type of seizure the baby is experiencing. Subtle seizures, which are more common among full-term babies, include random or roving eye movements, eyelid blinking or fluttering, eyes rolling up, eye opening, and staring. Clonic seizures are very brief and don't happen often, and include rhythmic jerking movements that may involve the muscles of the face, tongue, arms, legs or other body regions. Tonic seizures usually occur while the baby is sleeping and include forward tonic flexion lasting 1-10 seconds, either singularly or in long clusters.
Newborn seizures can be difficult to diagnose because the seizure may be short and subtle, and the signs may mimic normal movements and behaviours of healthy newborns. The gold standard test for diagnosis is an electroencephalogram (EEG), which records the brain's electrical activity and helps detect seizure activity. For high-risk newborns, at least 24 hours of EEG monitoring is recommended. Other tests to determine the cause of seizures include blood and spinal fluid evaluations, magnetic resonance imaging (MRI), and computed tomography (CT) scans.
Treatment for newborn seizures depends on the cause of the seizures. Some neonatal seizures may stop without treatment, but others may need medication such as antiepileptics or anticonvulsants like phenobarbitone. Less than 15% of infants with neonatal seizures will have recurrent seizures after the newborn period.
