Neonatal Seizures: How to Spot and Treat Infant Seizures Quickly

Neonatal seizure is a sudden, abnormal electrical discharge in the brain of a baby younger than 28 days that may appear as a visible movement or be hidden on the surface, often signaling an underlying medical issue.

Why Early Detection Matters

Newborn brains are still wiring themselves, so a single electrical storm can disrupt critical pathways. Studies from leading pediatric centers show that infants whose seizures are treated within the first hour have a 30% lower risk of long‑term neurodevelopmental impairment. In practice, the biggest hurdle is that many seizures are subtle seizures-brief eye‑blinks, lip‑smacking, or a fleeting change in breathing-easily missed by busy NICU staff.

How to Spot the Different Types

Clinicians categorize newborn seizures into four main patterns:

• Clonic seizures: rhythmic jerking of a limb or the whole body, usually lasting 10‑30 seconds.
• Tonic seizures: sustained stiffening of the arms, legs, or trunk, often lasting less than 10 seconds.
• Benign neonatal sleep myoclonus: harmless jerks that occur only during sleep and disappear with awakening.
• Subtle seizures: brief autonomic changes (e.g., tachycardia, apnea), eye deviation, or facial twitching. These are the most common-accounting for up to 60% of all neonatal seizures.

Because subtle seizures can be invisible to the naked eye, you need a reliable monitoring tool.

EEG Monitoring: The Gold Standard

The electroencephalogram (EEG) records electrical activity from the scalp and can detect both clinical and electrographic-only seizures. A 2024 multicenter review found that continuous video‑EEG captured 45% more seizure events than bedside observation alone. When a newborn is admitted to the Neonatal Intensive Care Unit (NICU), the typical protocol is:

1. Place a minimum of 10 electrodes within the first hour of suspicion.
2. Startcontinuous video‑EEG for at least 24hours.
3. Have a pediatric neurologist review the trace every 6hours or sooner if clinical changes arise.

Quick EEG interpretation can differentiate true seizures from benign movements, preventing unnecessary medication.

Underlying Causes You Can’t Ignore

Neonatal seizures rarely occur in isolation. Common etiologies include:

• Hypoxic‑ischemic encephalopathy (HIE): oxygen deprivation during birth, accounting for 30-40% of cases.
• Metabolic disturbances such as hypoglycemia, hypocalcemia, or severe hypernatremia.
• Intraventricular hemorrhage or other structural brain injuries.
• Inherited channelopathies and rare genetic mutations.

Identifying the trigger directs therapy: for HIE, therapeutic hypothermia is standard; for metabolic issues, correcting the serum abnormality often stops the seizures.

First‑Line Anticonvulsant Therapy

When a seizure is confirmed, the goal is rapid seizure control with the fewest side effects. Over the past decade, three drugs dominate the neonatal formulary:

Historically, Phenobarbital was the default, but recent randomized trials show that Levetiracetam achieves higher seizure freedom with a cleaner side‑effect profile. Many NICUs now start with levetiracetam, reserving phenobarbital for refractory cases.

Step‑by‑Step Management Algorithm

1. Stabilize airway and breathing. Initiate CPAP or mechanical ventilation if apnea is present.
2. Obtain a blood gas and basic metabolic panel to rule out hypoxia, acidosis, or electrolyte shifts.
3. Start continuous video‑EEG within 60minutes of suspicion.
4. If EEG confirms a seizure, give the first loading dose of Levetiracetam (40mg/kg). Re‑assess EEG after 10minutes.
5. If seizures persist, add a second loading dose of Phenobarbital (20mg/kg).
6. For refractory seizures (>30minutes despite two agents), consider continuous infusion of midazolam or barbiturate coma under specialist guidance.
7. Address the underlying cause simultaneously: initiate therapeutic hypothermia for HIE, correct glucose, calcium, or sodium as needed.

This algorithm compresses the decision‑making timeline to under two hours, which aligns with the “golden window” identified in recent outcome studies.

Monitoring and Follow‑Up

After acute control, infants need ongoing assessment:

• Repeat EEG at 24‑hour intervals for the first three days to catch late‑onset seizures.
• Neuroimaging (cranial ultrasound or MRI) within the first week to document structural injury.
• Developmental screening at 3, 6, and 12months using standardized tools such as the Bayley Scales.

Families should be counseled about the potential for epilepsy later in childhood-about 10‑15% of babies with neonatal seizures develop recurrent seizures after age two.

Related Concepts and Next Steps

Understanding neonatal seizures opens the door to a broader knowledge network. Key linked topics include:

• Seizure threshold in the developing brain.
• The role of genetic testing for channelopathies when seizures are refractory.
• Long‑term neuroprotective strategies beyond hypothermia, such as erythropoietin administration.
• Family support resources for parents navigating NICU uncertainty.

Readers who want to go deeper can explore "Management of Hypoxic‑Ischemic Encephalopathy" or "Genetic Causes of Early‑Onset Epilepsy" as logical next topics.

Frequently Asked Questions

What are the safest signs that a newborn might be having a seizure?

Look for repetitive eye‑rolling, brief pauses in breathing, sudden jerks of a single limb, or a sudden change in skin color. When in doubt, request a video‑EEG-subtle seizures often hide behind these cues.

How quickly should treatment start after a seizure is confirmed?

Ideally within the first hour. Studies show that every 30‑minute delay raises the risk of permanent brain injury by roughly 10%.

Is phenobarbital still used, or has it been replaced?

Phenobarbital remains a backup drug for seizures that don’t respond to levetiracetam. Its long half‑life is useful for maintenance, but it can cause sedation, so many centers reserve it for refractory cases.

Can metabolic problems trigger seizures, and how are they fixed?

Yes. Low blood sugar, calcium, or extreme sodium levels can provoke seizures. Rapid correction-IV dextrose for hypoglycemia, calcium gluconate for hypocalcemia, or careful fluid management for hypernatremia-often stops the seizures without drugs.

What long‑term follow‑up is needed after a neonatal seizure?

Regular EEGs for the first week, brain imaging, and developmental assessments at 3, 6, and 12 months are standard. Pediatric neurologists usually continue monitoring until school age to catch any emerging epilepsy early.

Does therapeutic hypothermia reduce seizure burden?

In infants with moderate to severe HIE, cooling the body to 33.5°C for 72hours cuts the incidence of seizures by about 40% and improves neurodevelopmental outcomes.