Seizures and Epilepsy

38 ■ Section 2: Common Pediatric Neurologic Problems
Syndromes
Benign familial neonatal seizures
Benign familial neonatal seizures occur as a genetic
disorder with an autosomal dominant inheritance pattern
associated with chromosome 20q. The seizures
typically start on day of life 2 or 3. The neonate may
have as many as 10 to 20 seizures per day. The syndrome
is usually self-limited and benign, but approximately
10% of cases progress to an antiepileptic
drug-requiring seizure disorder. Neurological development
is normal. 58–61
Fifth-day fits
Fifth-day fits usually begin on day of life 4 to 6. The
seizures are typically multifocal clonic seizures and are
frequently associated with apnea. The seizures usually
last for less than 24 hours. Fifth-day fits progress to status
epilepticus in 80% of cases. 58–61
Benign neonatal sleep myoclonus
Benign neonatal sleep myoclonus begins during the first
week of life. The seizures are usually bilateral myoclonic
jerks that last for several minutes and occur only during
NREM sleep. The EEG is normal or slow. The seizures
worsen with the administration of benzodiazepines. The
seizures usually resolve within 2 months and neurological
outcome is normal. 58–61
Benign myoclonus of early infancy
Benign myoclonus of early infancy has an onset at age 3
to 9 months but it can be much earlier. The seizures
resemble infantile spasms but the EEG is normal. The
seizures usually occur while the patient is awake. The
seizures disorder may continue for 1 to 2 years but neurological
outcome is normal. 58–61
Treatment
The clinician should first search for underlying etiologies
producing the seizures and treat (hypoglycemia,
hypocalcemia, sepsis). If the clinician cannot find a
readily identifiable and treatable etiology, the frontline
agent of choice for treating seizures is phenobarbital
(see Table 3-14 for dosing suggestions). 62 Phenobarbital
as a single agent will stop seizure activity in 42% of
patients. When the seizure does not respond to a single
agent, phenytoin is added with an increase in efficacy to
65%. Currently, fosphenytoin, the salt ester of phenytoin,
is preferred in the neonate because it is an aqueous
solution that is soluble in glucose-containing solutions,
can be administered more quickly than phenytoin, and
will not cause “purple glove syndrome.” 62 Purple glove
syndrome is necrosis or injury of the soft tissue that can
occur with intravenous infusion of the highly alkaline
phenytoin. The drug of choice for neonates in status is
lorazepam. This agent has several properties that make
it ideal—a long half-life and a small volume of distribution,
which prolongs its retention at high levels in the
brain.
REFERENCES
Table 3-14.
Neonatal AED Dosing Suggestions
Phenobarbital—20 mg/kg load over 10 to 15 min.
If necessary add more phenobarbital in 5-mg/kg boluses
Fosphenytoin—20 mg/kg at 1 mg/kg/min
Ativan—0.1 mg/kg
From Rennie J, Boylan G. Treatment of neonatal seizures. Arch Dis Child Fetal
Neonatal 2007;92:F148–F150.
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