Neonatal Seizures: Clinical Spectrum, Etiology, and Current Approaches

Neonatal seizure is a neurological emergency that requires rapid intervention due to the probability of significant underlying central nervous system damage. It is more common in preterm than in term neonates. An important feature of neonatal seizures is that there may be only electrographic seizures without clinical findings, making it impossible to diagnose without monitoring with electroencephalography. According to the new seizure classification, neonatal seizures are classified as motor seizures, including automatisms, clonic, epileptic spasm, myoclonic, and tonic seizures, and non-motor seizures, including autonomic, behavioral arrest, sequential seizure, and unclassifiable seizures. Prenatal, natal, and postnatal history, a good physical examination, comprehensive neurological examination, and brain neuroimaging are important to understand the underlying etiology. Hypoglycemia or electrolyte disturbances should be considered first. Phenobarbital, an anti-seizure medication (ASM), is currently still the first-line treatment. Levetiracetam and phenytoin are recommended as second-line treatments. Phenytoin is not recommended for patients with cardiac disease. Midazolam and lidocaine should be considered in the following steps. Inborn errors of metabolism diseases and neonatal epilepsy should be considered in neonatal seizures that do not respond to ASM. The prognosis of neonatal seizures is related to the underlying etiology. Increased seizure burden is associated with adverse neurodevelopmental and neuroimaging outcomes and increased risk of epilepsy and death.