EBNEO commentary: Reducing the percentage of surviving infants with acute symptomatic seizures discharged on anti‐seizure medication

Nangle AM, He Z, Bhalla S, Bullock J, Carlson A, Dutt M, Hamrick S, Jones P, Piazza A, Vale A, Sewell EK. Reducing the percentage of surviving infants with acute symptomatic seizures discharged on anti-seizure medication. J Perinatol 2024. PMID 39043995. There is strong guidance to discontinue antiseizure medications (ASMs) prior to hospital discharge for neonates with acute symptomatic seizures. In the 2023 International League Against Epilepsy (ILAE) Task Force on Neonatal Seizures published guidelines,1 one of the six main recommendations is that ‘following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings’. Additionally, a comparative effectiveness study found no difference in neurodevelopmental impairment or epilepsy rates at 24 months among children whose ASM was discontinued vs. maintained at hospital discharge.2 While these recommendations have become stronger with time, they are not new: it has been more than a decade since the 2011 WHO Guidelines on Neonatal Seizures advised considering discontinuation of ASMs in neonates who had been seizure-free for 72 h.3 Despite these strong recommendations, there remains variation in clinical practice.4-7 The intuitive bias—particularly in centres without in-person neurology to evaluate the infant during the NICU hospitalisation—is that the ‘safer’ approach is to maintain the infant on ASMs until they see a neurologist in clinic. However, unnecessary ASM may contribute to long-term cognitive impairment8 and does not diminish the risk for future seizures.2, 4, 6 Inclusion of standardised treatment pathways for management of neonatal seizures has been shown to reduce the number of infants discharged home on ASMs. In the ILAE Task Force on Neonatal Seizures, 80% of experts surveyed ‘completely agreed’ and the remaining 20% of experts ‘mostly agreed’ that ‘a standardized treatment pathway for the management of neonatal seizures should be available in each neonatal unit’.1 Across hospitals with neonatal seizure treatment pathways, there is broad agreement on much of the treatment approach, including early discontinuation of ASMs.9 In Nangle et al., the authors describe the initiation of a neonatal seizure pathway in three hospitals where it did not previously exist and found ~50% reduction in infants discharged on ASMs in the subsequent epoch. Notably, the authors even reached 0% of infants with acute symptomatic seizures discharged on ASMs in 2023 at their Delivery Hospitals. We would like to particularly highlight that the authors of this study demonstrated feasibility and meaningful improvement in hospitals without in-person neurology consult availability. In fact, although possibly confounding by disease severity and seizure burden, fewer infants were discharged on ASM in the hospitals without neurology consult compared to the NICU with neurology consultation available. Additionally, their success highlights the benefits of working in multidisciplinary teams—both across various types of clinicians and partnerships between neonatology and neurology. URL LINK: https://ebneo.org/ebneo-commentary-reducing-anti-seizure-medication-at-discharge Danielle Barber: Writing – original draft; writing – review and editing. Jill Chang: Writing – original draft; writing – review and editing.