Neonatal Seizure/Status Epilepticus — ILAE Neonatal Seizure Treatment Guideline — Clinical Pathway: N/IICU

Neonatal Seizure/Status Epilepticus Clinical Pathway — N/IICU

ILAE Neonatal Seizure Treatment Guideline: Recommendations Summary

The Neonatal Task Force of the International League Against Epilepsy developed evidence-based recommendations using a systematic literature review, meta-analysis, and expert opinion using Delphi consensus methodology.

1st Line ASM
  • Phenobarbital
    1st line anti-seizure medication (ASM) for neonates with seizures requiring ASM
  • Evidence-based recommendation: moderate
  • Recommended as 1st line ASM regardless of etiology, including HIE, stroke,
    and hemorrhage
  • Consensus recommendation: high agreement
  • Phenytoin or Carbamazepine
    • For suspected channelopathy due to clinical or EEG features, sodium channel blocker may be used as a 1st line ASM
    • Consensus recommendation: high agreement
2nd Line ASM
  • Phenytoin or Leviracetam
    • 2nd line ASM for most etiologies, including HIE, stroke
      or hemorrhage
    • Consensus recommendation: moderate agreement
  • Phenytoin or Carbamazepine
    • For suspected channelopathy due to clinical or EEG features, sodium channel blocker may be used as a 2nd line ASM
    • Consensus recommendation: high agreement
  • Levetiracetam
    • May be preferred as a 2nd line ASM if cardiac disorder
    • Consensus recommendation: moderate agreement
ASM Duration
  • Following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge, regardless of MRI or EEG findings
  • Consensus recommendation: high-agreement
Impact of Hypothermia
  • Therapeutic hypothermia may reduce seizure burden in neonates with HIE
  • Evidence recommendation: weak
  • Consensus recommendation: high agreement
Seizure Burden
and Outcome
  • Treating neonatal seizures to achieve a lower seizure burden may be associated with improved outcomes, including neurodevelopment and epilepsy
  • Consensus recommendation: moderate agreement
Pyridoxine and Pyridoxal-5-Phosphate
  • A trial of pyridoxine (add-on to ASM) may be attempted in neonates with clinical features or EEG characteristics suggestive of vitamin B6-dependent epilepsy and neonates with seizures unresponsive to 2nd line ASM without an identified etiology
  • Consensus recommendation: high agreement
Pathways
  • A standardized pathway for the management of neonatal seizures should be available in each neonatal unit
  • Consensus recommendation: high agreement
Communication
  • Parents/guardians of a neonate with seizures should be informed the neonate is having seizures, possible etiologies, and initial treatment options with subsequent discussions based on the neonate’s condition
  • Consensus recommendation: high agreement

Reference

The ILAE Classification of Seizures and the Epilepsies: Modification for Seizures in the Neonate