NEONATAL SEIZURES

Definition:
The Occurrence of sudden, paroxysmal,
abnormal alteration of electrographic activity
at any point from birth to the end of the
neonatal period
Classification

1. Clonic seizures
2.Tonic seizures
3.subtle seizures
4.myoclonic seizures
1.Clonic seizures
Slow rhythmic jerking movements approximately 1-3 per second. Focal- Involves
face, upper or lower extremities on one side of body. May involve neck or trunk
infant is conscious during events. Multi focal- may migrate randomly from one part
of the body to another movements may start at different times.

2.Tonic seizures:
Extension, stiffening moment Generalized -Extension of the all four limbs. Upper
limbs maintained in a stiffly flexed position. Focal- sustained posturing of a limb
Asymmetric posturing of trunk or neck
3.Subtle seizures:
May develop in either full term or preterm infants but is more common in preterm.
Often overlooked by inexperienced observers.

Signs:

• Horizontal eye deviation

• Repititive blinking or fluttering of the eyelids

• Sucking or other oral buccal lingual movements.

• Arm movements that resemble rowing or swimming

• Leg movements described as pedaling or bicycling

4.Myoclonic:
• Rapid jerks that involve flexor muscle groups

• Focal -Involves upper extremity flexor muscle group

• No electro encephalogram (EEG )discharge observed

• Multi focal-Asynchronous twitching of several parts of the body

• No associated EEG discharges observed

• Generalized -Bilateral jerks of upper and lower limbs

• Associated with EEG discharges.

Etiology

I.Developmental neurologic problems:

•  Congenital hydrocephalus

•  Microcephaly

•  Cerebral dysgenesis

•  Porencephaly

•  Polymicrogyria

•  Agenesis of corpus callosum

Etiology

II.Perinatal complication III.Perinatal infections:

 Birth asphyxia  Meningitis
 Birth injuries  Septicemia
 Intracranial hemorrhage  Intra uterine infections
Etiology

IV.Metabolic problems: V.Drugs:

 Hypocalcemia  Mother if consuming narcotics

 Hypoglycemia  Theophylline

 Hypo magnesemia  Propylene glycol

 Hypo or hypernetremia

 Hyperbilirubinemia with kernicterus

 Inborn errors of metabolism

Common causes of neonatal seizures:
First 24 hours:

•  Perinatal asphyxia •  Hypoglycemia

•  Structural abnormalities •  Hypocalcemia

•  Pyridoxine dependency
•  Intracranial bleeds
•  Drug withdrawal
•  Inadvertment IV injection of local anaesthetic
24hours to7days: Beyond 7days:
•  Hypoxic ischemic encephalopathy •  Meningitis

•  Metabolic disturbances hypoglycemia •  Metabolic disturbances

/hypocalcemia /hypomagnesemia/ •  Inborn errors of metabolism

•  Pyridoxine dependency seizures

•  Meningitis

•  Drug withdrawal

•  Inborn errors of metabolism

Diagnostic evaluation
1.History: Complete history of the baby including birth history, time of onset of
seizures, maternal history and family history needs to be collected

2.Serum glucose and electrolytes: Transient neonatal hypoglycemia and

hypocalcemia are the main cause of seizures during first three weeks of life

3.CSF analysis: Lumbar puncture is done to obtain CSF sample. CSF is analyzed for
presence of infection or blood due to Intracranial hemorrhage

4.Imaging studies: Cranial CT scan or MRI is done for detecting parenchymal

abnormalities and congenital anomalies of brain

5.Electroencephalography(EEG): EEG plays a vital role in properly identifying and

differentiating neonatal seizures from non- epileptic events.
Treatment

1.Position the infant ;ensure that the airway is clear, the tongue does not fall
back and that there is no aspirations

2.Clear secretions by suctioning the oro/ nasopharynx.

3.If the neonate is in shock, provide fluid resuscitation along with the
medications for seizures

4.Collect blood for glucose, electrolytes, calcium and magnesium; if glucostix

is available, hypoglycemia can be immediately identified.

5.Control the seizure to stop the seizures activity

Follow up:
Continuation of anticonvulsants:

• Once seizures are controlled in the acute phase,it is not necessary to

continue anticonvulsant. 

• Occasionally, for seizures that are difficult to control, a maintenance dose of

phenobarbitone(5mg/kg/day) is continued. 

• Discontinue all anticonvulsants before the neonate is discharged from the

hospital if the infant is neurologically normal on clinical examination.
Evaluation:
The infant must be evaluated for hydrocephalus by serial measurement of

the head circumference, neurosonography and MRI. This is especially relevant if

the seizures were due to meningitis, intracranial bleeds or structural anomalies of
the brain. Hearing and visual assessment should also be carried out to facilitate
appropriate therapy if required

Prognosis:
The combination of a 5 minutes apgar score of ˂3and fits and signs of
encephalopathy is associated with 33%mortality and 55% handicap.
Nurses responsibility
1. Monitor Seizures: Watch for signs of seizures and document details.

2. Administer Medications: Give seizure medications and monitor effects.

3. Check Vital Signs: Regularly monitor heart rate, breathing, and oxygen levels.

4. Assist with Tests: Help with EEGs and other diagnostic tests.

5. Work with the Team: Communicate with doctors and healthcare staff about the

baby’s condition.

6. Educate Families: Explain seizures and treatments to the baby’s family.

7. Ensure Safety: Take steps to protect the baby during and after seizures.
HYPOCALCEMIA
Definition:
Hypocalcemia is defined as total serum calcium
concentration of less than 8.5mg/ dl in children, less
than 8mg /dl in term neonates and less than7mg /dl
in preterm neonates.

Incidence:
Hypocalcemia is seen in approximately 1 of every
4000 newborns.
Etiology

I.Vitamin D deficiency.It occurs due to: II. Metabolic causes

•  Malabsorption •  Hypoparathyroidism

•  Malnutrition •  Pseudo hypoparathyroidism

•  Prolonged phenytoin therapy •  Hypomagnesemia

•  Abnormal phenytoin therapy •  Hyperphosphatemia

•  Abnormal metabolism of vitamin D

•  Congenital rickets
Etiology

III. Increased calcium loss from the body IV.Other causes:

•  Hypercalciuria •  Metabolic alkalosis

•  Prolong corticosteroid therapy •  Hypoproteinuria

•  Prolong frusemide therapy •  Infants of diabetic mother

•  Renal tubular necrosis •  Prematurity

•  Acute pancreatitis

•  IV lipid infusion
Types
1. Early onset:

Appears in first 48 hours; appears in preterm infants who experienced

perinatal hypoxia or sometimes in infant of diabetic mother.

2.Late onset:

Cow's milk- induced hypocalcemia (neonatal tetany); apparent after

first 3-4 days (high phosphorus/calcium ratio of cow’s milk depresses
parathyroid activity, reducing serum calcium levels); infants with
intestinal malabsorption, hypoparathyroidism or hypomagnesemia.
Clinical features
a) Early neonatal hypocalcemia oçcurs with in 48-72 hours of birth
and manifestation are
i) High pitch cry

ii) Intermittent cyanosis

iii)Oedema

iv) Vomiting

v) Abdominal distention

vi) Periods of apnea

Clinical features

b) Late neonatal hypocalcemia occurs 3-7days after birth

or even as 6 weeks of age .manifestations include:

i) Irritability and jitterness

ii) Muscular twitching

Diagnostic Evaluation

1. History of mother- Infants born to diabetic mothers have hypocalcemia

2. Estimation of gestational age of neonate: preterm infants develop

hypocalcemia easily

3. Blood investigations include estimation of Serum calcium, serum phosphate,

serum alkaline phosphatase

4. Hormone assay: Parathyroid hormone estimation is done

5. Skigram : Skigram of hands show signs of tetany.

Management

• Calcium therapy is the main stay of treatment for hypocalcemia.10% calcium

gluconate is administered in dose of 2ml/ kg, intravenously to control
seizures. Later on 5 ml/kg/day of 10% calcium gluconate is administered. oral
calcium therapy is continued as follow up.

• Magnesium administration is necessary to correct any hypomagnesemia

because hypocalcemia does not respond until low magnesium level is
corrected.
Prevention

• A diet high in calcium and low in phosphate is required. Infants

drinking regular cow's milk or evaporated milk must be given
humanized infant formula. 

• Infants who are susceptible to hypocalcemia should get calcium

gluconate in dose of 1ml/ kg intravenously, every 4 hours. Later on
a suitable calcium and phosphate oral preparation should be given
to the neonates.
Nurses responsibility

• Monitor Symptoms: Watch for signs of hypocalcaemia such as jitteriness,

muscle twitching, seizures, or poor feeding.

• Administer Medications: Ensure the newborn receives calcium supplements or

other medications as prescribed, and monitor for any side effects.

• Check Blood Calcium Levels: Regularly monitor the newborn’s blood calcium
levels as directed by the healthcare team.

• Assess Vital Signs: Keep track of heart rate, respiratory rate, and overall stability,
as hypocalcaemia can affect heart and breathing functions.
Nurses responsibility

• Support Feeding: Encourage proper feeding, as hypocalcaemia can

sometimes be related to feeding issues in newborns.

• Educate Families: Explain the condition, its treatment, and how parents can
help with feeding and monitoring at home.

• Collaborate with the Care Team: Communicate regularly with the doctors
and healthcare team about the baby’s condition and any changes in
symptoms or test results
HYPOGLYCEMIA
Definition:
Hypoglycemia refers to blood glucose less
than 40 mg/ dl for the first four weeks of
life irrespective of birth weight and
gestational age.
Types

1.Increased or impaired glucose utilization:

Large or normal- size infants who appear to suffer from hyperinsulinism
infants born to women with diabetes; Infants with increased metabolic
demands such as those with cold stress, sepsis or after resuscitation;
infants with enzymatic or metabolic endocrine defects

2.Decreased glucose stores:

Small or growth restricted infants, preterm infants.
Causes
1.Increased utilisation of 2.Decreased production 3.Increased Utilisation
glucose- hyperinsulinism: stress: and/ or decreased

• Infants of diabetic mother • Prematurity production:

(IDM) • Intrauterine growth Perinatal stress:

• Large for gestational age restriction • Shock

infants • Inadequate calorie intake • Sepsis
• Erythroblastosis
• Delayed onset of feeding • Asphyxia
• Islet cell hyperplasia
• Hypothermia
• Insulin producing tumors
Risk factors
• Blood infection

•  Endocrine disorders such as low thyroid hormone production

•  Inborn errors of metabolism

•  Intra uterine growth retardation

•  Birth asphyxia

•  Babies of mothers with diabetes

•  Premature babies
Symptoms of hypoglycaemia

• Abnormal cry • Hypotonia, limpness

• Apnea, cyanotic spells • Grunting, tachypnea

• Feeding difficulty • Seizures

• Sweating • Hypothermia

• Irritability • Tachycardia

• Jitterness, tremors • Lethargy or stupor

Laboratory Diagnosis
Glucometer random blood sugar if hypoglycemia is persistent or needs prolonged
treatment, one should consider the rarer causes and the following tests must be
carried out to determine the cause:

• Insulin to check for hyperinsulinemic states 

• Cortisol to diagnose decreased adrenal functions

• 17- OH progesterone to diagnose congenital adrenal hyper aplasia 

• Growth hormone to diagnose hypopituitarism

• Glucagon

• Urine and serum amino acid, Urine reducing substance, galactose

Management
• Hypoglycemia should be prevented by early initiation of breastfeeding with in first
hour of birth

• The baby should be nursed in warm or thermo neutral environment with careful
observation of ‘at –risk’situations and prevention of hypoxia and hypothermia

• In symptomatic infant with convulsions, 10% dextrose 2ml/kg intravenously is given

as a bolus.

• Blood glucose level to be checked every 1/2hourly

• Oral feeds are introduced gradually and glucose infusion is tapered off
Nursing management:
•  Identify infants at risk or with hypoglycemia

•  Administer IV glucose as prescribed

•  Initiate early breastfeeding or formula feedings in healthy infant

•  Ensure adequate intake of carbohydrates (breast milk or formula)

Complications: 

• Developmental delay

• Seizures

• Heart failure
Nurses responsibility

• Monitor Blood Glucose Levels: Regularly check the newborn’s blood sugar levels
using a glucometer, as directed by the healthcare team.

• Observe for Symptoms: Watch for signs of hypoglycemia such as jitteriness,

lethargy, poor feeding, rapid breathing, or seizures.

• Administer Treatment: Provide glucose supplementation, either orally or

intravenously, as prescribed to raise blood sugar levels.

• Ensure Proper Feeding: Encourage frequent feedings, whether breastfeeding or

formula feeding, to help stabilize blood sugar levels.
Nurses responsibility

• Monitor Vital Signs: Keep track of the baby’s heart rate, breathing, and
temperature, which can be affected by low blood sugar.

• Prevent Recurrences: Work with the care team to ensure regular feeding
schedules and monitor glucose levels to prevent further hypoglycemic
episodes.

• Educate Families: Teach parents about the importance of feeding and

monitoring the baby for signs of hypoglycemia at home.
HYPOMAGNESEMIA
Definition:
Hypomagnesemia occurs when serum
concentrations fall below 0.66

mmol./ L (1.6mg dl)

Risk factors

1. Hypocalcemia
7. Inherited renal wasting eg.Gitelman
2. Preterm and late preterm infants syndrome
3. Inadequate intake of magnesium 8. Associated hypocalciuria and
nephrocalcinosis
4. Infant of diabetic mother
9. Magnesuria secondary to frusemide or
5. IUGR especially if mother had
gentamicin
preeclampsia.
10.Citrated blood exchange transfusion
6. Hypoparathyroidism
Clinical manifestations
• Increased neuromuscular excitability (tetany)

• Hyperactive reflexes

• Skeletal muscle cramps

• Twitching

• Tremors

• Cardiac arrhythmias

• Seizures with severe hypomagnesemia

Diagnostic Evaluation:
1.serum magnesium level

2.Total and ionized calcium levels

Management:
• Acute hypomagnesemia should be treated with intravenous magnesium
sulphate

• Infusion must be monitored closely for cardiac arrhythmias and

hypotension
Nurses responsibility

• Monitor Symptoms: Watch for signs like tremors, muscle twitching, seizures, or
irritability, which can indicate low magnesium. Administer Magnesium

• Supplements: Give magnesium supplements or intravenous magnesium as

prescribed, and monitor for side effects.

• Check Blood Magnesium Levels: Regularly monitor blood magnesium levels as

directed to ensure they are returning to normal.

• Assess Vital Signs: Monitor heart rate and breathing, as hypomagnesemia can
affect cardiovascular and respiratory systems.
Nurses responsibility

• Monitor for Related Conditions: Keep an eye out for other electrolyte imbalances
like hypocalcemia or hypokalemia, which may occur alongside hypomagnesemia.

• Support Feeding: Ensure the newborn is feeding well, as nutrition can impact
electrolyte levels.

• Educate Families: Explain the condition, treatment, and how parents can support
recovery at home.

• Collaborate with the Care Team: Work closely with doctors and healthcare
professionals to adjust treatment based on the newborn's response.
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