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Field NK, Franck LS, Shellhaas RA, Glass HC, Young KA, Dhar S, Hamlett A, Pilon B, Means K, Soul JS, Massey SL, Wusthoff CJ, Chu CJ, Thomas C, Rogers E, Berl MM, Benedetti GM, Anwar T, Lemmon ME. Life After Neonatal Seizures: Characterizing the Longitudinal Parent Experience. Pediatr Neurol 2024; 161:76-83. [PMID: 39317023 DOI: 10.1016/j.pediatrneurol.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/06/2024] [Accepted: 08/19/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Parents of neonates with seizures report persistent symptoms of depression, anxiety, and posttraumatic stress. We aimed to characterize the parent experience of caring for children impacted by neonatal seizures, including longitudinal assessment across childhood. METHODS This prospective, observational, multicenter study was conducted at Neonatal Seizure Registry (NSR) sites in partnership with the NSR Parent Advisory Panel. Parents completed surveys at discharge; 12, 18, and 24 months; and 3, 4, 5, 7, and 8 years. Surveys included demographic information and open-ended questions targeting parent experience. A conventional content analysis approach was used. RESULTS A total of 320 caregivers completed at least one open-ended question, with the majority of respondents at discharge (n = 142), 12 months (n = 169), 18 months (n = 208), and 24 months (n = 245). We identified the following three primary themes. (1) Personal Burden of Care: Parents experienced emotional distress, financial strain, physical demands, and fears for their child's unknown outcome; (2) Managing Day-to-Day Life: Parents described difficulties navigating their parenting role, including managing their child's challenging behaviors and understanding their child's needs amid neurodevelopmental impairment; (3) My Joys as a Parent: Parents valued bonding with their child, being a caregiver, and watching their child's personality grow. CONCLUSIONS Parents of children impacted by neonatal seizures face persistent challenges, which are interwoven with the joys of being a parent. Our findings suggest that future interventions should promote resiliency, address caregivers' psychosocial needs longitudinally, and provide enhanced support for parents caring for children with medical complexity.
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Affiliation(s)
| | - Linda S Franck
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, California
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Hannah C Glass
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California
| | | | - Saisha Dhar
- Trinity College, Duke University, Durham, North Carolina
| | - Ashley Hamlett
- NSR Parent Partner, Duke University Medical Center, Durham, North Carolina
| | - Betsy Pilon
- NSR Parent Partner, Executive Director - Hope for HIE, West Bloomfield, Michigan
| | - Katie Means
- NSR Parent Partner, Cincinnati Children's Hospital Medical Center, Fort Thomas, Kentucky
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney J Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Palo Alto, California
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati and Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Elizabeth Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Madison M Berl
- Departments of Psychiatry and Behavioral Sciences, Children's Research Institute, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Giulia M Benedetti
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, Ann Arbor, Michigan
| | - Tayyba Anwar
- Departments of Neurology and Pediatrics, Children's National Hospital and The George Washington University School of Medicine, Washington, District of Columbia
| | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, NC, USA, Duke-Margolis Center for Health Policy, Washington, District of Columbia.
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Nangle AM, He Z, Bhalla S, Bullock J, Carlson A, Dutt M, Hamrick S, Jones P, Piazza A, Vale A, Sewell EK. Reducing the percentage of surviving infants with acute symptomatic seizures discharged on anti-seizure medication. J Perinatol 2024:10.1038/s41372-024-02044-9. [PMID: 39043995 DOI: 10.1038/s41372-024-02044-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To evaluate the impact of inclusion of an anti-seizure medication (ASM) weaning protocol in a neonatal seizure pathway on the percent of infants discharged on ASMs. STUDY DESIGN This cohort study included surviving infants with acute symptomatic seizures treated with ASMs across three institutions. We evaluated infants in 2 epochs, pre- and post-implementation of the ASM weaning protocol. The primary outcome was discharge on ASM. RESULTS Of 116 included infants, the percent of infants discharged on ASMs was 69% in epoch 1 versus 34% in epoch 2 (p < 0.001). There was no significant difference between epochs in recurrence of seizures after discharge by 1 year of age (p = 0.125). There was an annual decrease in the percent of infants discharged on ASM across all institutions. CONCLUSION Inclusion of a formal ASM weaning protocol as part of an institutional seizure pathway reduced percent of infants with acute symptomatic seizures discharged on ASM.
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Affiliation(s)
- Anne Marie Nangle
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Zhulin He
- Pediatric Biostatistics Core, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sonam Bhalla
- Division of Pediatric Neurology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Alyssa Carlson
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University School of Nursing, Atlanta, GA, USA
| | - Monideep Dutt
- Division of Pediatric Neurology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shannon Hamrick
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Anthony Piazza
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Allison Vale
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Elizabeth K Sewell
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Sandoval Karamian AG, DiGiovine MP, Massey SL. Neonatal Seizures. Pediatr Rev 2024; 45:381-393. [PMID: 38945992 DOI: 10.1542/pir.2023-006016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 07/02/2024]
Affiliation(s)
- Amanda G Sandoval Karamian
- Division of Neurology, Department of Pediatrics, University of Utah School of Medicine and Primary Children's Hospital, Salt Lake City, UT
| | - Marissa P DiGiovine
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Shavonne L Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Toptan HH, Karadag NN, Topcuoglu S, Ozalkaya E, Dincer E, Cakir H, Gunes AO, Karatekin G. Comparative Outcomes of Levetiracetam and Phenobarbital Usage in the Treatment of Neonatal Seizures: A Retrospective Analysis. Healthcare (Basel) 2024; 12:800. [PMID: 38610222 PMCID: PMC11011900 DOI: 10.3390/healthcare12070800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVES AND AIM The primary aim of this study was to conduct a comparative analysis of the safety and efficacy of levetiracetam (LEV) and phenobarbital (PB) as first-line treatments for neonatal seizure management. This study was designed to measure and compare the incidence of adverse effects and to determine the discharge and mortality rates associated with the use of these antiseizure medications (ASMs). Through this comparison, this research sought to provide insights to optimise care for neonates experiencing seizures. MATERIALS AND METHODS This retrospective cohort study evaluated 104 neonates treated for seizures at Zeynep Kamil Hospital from 2015 to 2020 after excluding those on non-PB/LEV antiseizure medications. Seizures were characterised using electroencephalogram (EEG) and categorised according to aetiology and frequency. Treatment efficacy was gauged by seizure cessation, as confirmed using EEG. Adverse effects and demographic data were recorded. Statistical analyses were conducted using SPSS, employing the Shapiro-Wilk, independent t-test, Mann-Whitney U test, and chi-square test, with a significance threshold of p < 0.05. RESULTS Overall, 104 neonates treated with first-line ASM were evaluated for efficacy; PB was administered in 68.26% of the cases, while LEV was utilised in 31.74%. The total complete response rate was 40.38%, with no significant difference between the PB and LEV groups (p = 0.309). The incidence rate ratios (IRRs) demonstrated that seizure frequency profoundly influenced treatment effectiveness, with IRRs of 2.09 for rare seizures, 3.25 for frequent seizures, and 4.01 for status epilepticus, indicating a higher treatment response rate with increasing seizure frequency. For second-line treatment, among a subset of 62 patients, PB had a slight, non-significant advantage over LEV, with an odds ratio of 1.09, suggesting a marginally better response to LEV. Adverse events were significantly more frequent in the PB group, affecting 19 of 67 neonates (28.36%), compared to only 2 of 71 neonates (2.82%) in the LEV group (p < 0.001). No significant difference was observed in the discharge rates between the two groups (PB, 67.61%; LEV, 75.76%; p = 0.674). Interestingly, the mortality rate was significantly higher in the LEV group (45.45%) than that in the PB group (22.54%; p = 0.045). CONCLUSION This study underscores LEV's superior safety profile over PB in neonatal seizure management, evidenced by a significantly lower rate of adverse events. PB seems to be more effective in the second-line treatment of neonatal seizures. Despite the lack of significant differences in the discharge rates, the higher mortality rate associated with LEV warrants further investigation. These findings advocate the cautious selection of antiepileptic drugs in neonatal care, with a preference for LEV based on its safety profile.
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Affiliation(s)
- Handan Hakyemez Toptan
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children’s Disease Health Training and Research Center-Istanbul, 34668 Istanbul, Turkey; (N.N.K.); (S.T.); (E.O.); (A.O.G.)
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Jagadish S, Czech TM, Zimmerman MB, Glykys J. Epilepsy Incidence and Developmental Outcomes After Early Discontinuation of Antiseizure Medication in Neonatal Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2024; 153:48-55. [PMID: 38320458 DOI: 10.1016/j.pediatrneurol.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Neonatal seizures caused by hypoxic-ischemic encephalopathy (HIE) have significant morbidity and mortality. There is variability in clinical practice regarding treatment duration with antiseizure medication (ASM) after resolution of provoked neonatal seizures. We examined epilepsy incidence and developmental outcomes in post-HIE neonates discharged or not on ASM. METHODS We conducted a retrospective chart review of all HIE-admitted neonates to the University of Iowa Hospitals & Clinics neonatal intensive care unit between January 2008 and February 2021 who presented with encephalopathy, underwent therapeutic hypothermia, and developed seizures. Neonates were divided into two groups depending on whether ASM was continued or discontinued on discharge. We evaluated the incidence of epilepsy and developmental outcomes on follow-up in these two cohorts up to 12 months. RESULTS Sixty-nine neonates met the study criteria. ASM was continued on discharge in 41 neonates (59%) and discontinued before discharge in 28 (41%). At the 12-month follow-up, nine neonates (13%) had a diagnosis of epilepsy, out of which seven neonates had ASM continued on discharge (odds ratio [OR]: 2.84; 95% confidence interval [CI]: 0.48, 29.9)]. There was no statistical difference between the development of postneonatal epilepsy between the two groups (P value 0.29). There was no significant difference in developmental outcome between the two groups after adjusting for covariates like magnetic resonance imaging (MRI) brain abnormality and number of seizure days (OR: 0.68; 95% CI: 0.21, 2.22; P = 0.52). CONCLUSION We found no significant risk of seizure recurrence by age 12 months in infants who had discontinued ASM before discharge compared with those who had continued ASM. There was no difference in developmental outcomes at the 12-month follow-up between groups after adjusting for brain MRI abnormality and the number of seizure days during admission. Our results support early discontinuation of ASM after resolution of acute provoked seizures in neonates with HIE.
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Affiliation(s)
- Spoorthi Jagadish
- Child Neurology Residency Program, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
| | - Theresa Marie Czech
- Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Department of Neurology, The University of Iowa, Iowa City, Iowa
| | | | - Joseph Glykys
- Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Department of Neurology, The University of Iowa, Iowa City, Iowa; Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa.
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Tekgul H, Koroğlu OA, Tanrıverdi M, Yalaz M, Terek D, Aktan G, Akisu M, Kültürsay N. The net impact of clinical seizures on outcome characteristics in infants with neonatal encephalopathies at 12 months of age. Seizure 2024; 116:133-139. [PMID: 36588060 DOI: 10.1016/j.seizure.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To assess the impact of clinical neonatal seizures on outcome characteristics of preterm and term newborns with neonatal encephalopathy (NE). METHODS We designed a prospective comparative study with 53 babies (preterm neonates: 26 and term neonates: 27) with NE: group 1 (preterm neonates with seizures, n = 13), group 2 (preterm neonates without seizures, n = 13), group 3 (term neonates with seizures, n = 13) and group 4 (term neonates without seizures, n = 14). The functional outcome characteristics of the survivors were assessed by the Ankara Developmental Screening Inventory (ADSI) and the Guide for Monitoring Child Development (GMCD) at 12 months of age. RESULTS Clinically defined acute symptomatic seizures were diagnosed with prompt conventional EEG / amplitude-integrated EEG in preterm (92.3%) and term neonates (81.4%) with etiology-specific diagnoses of NE. There were no differences between the study groups regarding seizure semiology and EEG characteristics. A primary adverse outcome was defined in 22 (41.5%) of the cohort. However, only 15.3% of infants had an unfavorable functional outcome with ADSI at 12 months. Among the survivors, there was no significant difference between the study groups regarding ADSI scores. The GMDC test revealed normal development in 50% of survivors with seizures in the preterm group and 83% in the term group. CONCLUSION There was no significant difference between the characteristics of functional outcomes at 12 months in preterm and term neonates with NE for clinical seizures.
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Affiliation(s)
- Hasan Tekgul
- Department of Pediatrics, Division of Child Neurology, Ege University Medical Faculty, Turkey.
| | - Ozge A Koroğlu
- Department of Pediatrics, Division of Neonatology, Ege University Medical Faculty, Turkey
| | - Mahir Tanrıverdi
- Department of Pediatrics, Ege University Medical Faculty, Turkey
| | - Mehmet Yalaz
- Department of Pediatrics, Division of Neonatology, Ege University Medical Faculty, Turkey
| | - Demet Terek
- Department of Pediatrics, Division of Neonatology, Ege University Medical Faculty, Turkey
| | - Gül Aktan
- Department of Pediatrics, Division of Child Neurology, Ege University Medical Faculty, Turkey
| | - Mete Akisu
- Department of Pediatrics, Division of Neonatology, Ege University Medical Faculty, Turkey
| | - Nilgün Kültürsay
- Department of Pediatrics, Division of Neonatology, Ege University Medical Faculty, Turkey
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Pacchiano F, Tortora M, Criscuolo S, Jaber K, Acierno P, De Simone M, Tortora F, Briganti F, Caranci F. Artificial intelligence applied in acute ischemic stroke: from child to elderly. LA RADIOLOGIA MEDICA 2024; 129:83-92. [PMID: 37878222 PMCID: PMC10808481 DOI: 10.1007/s11547-023-01735-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023]
Abstract
This review will summarize artificial intelligence developments in acute ischemic stroke in recent years and forecasts for the future. Stroke is a major healthcare concern due to its effects on the patient's quality of life and its dependence on the timing of the identification as well as the treatment. In recent years, attention increased on the use of artificial intelligence (AI) systems to help categorize, prognosis, and to channel these patients toward the right therapeutic procedure. Machine learning (ML) and in particular deep learning (DL) systems using convoluted neural networks (CNN) are becoming increasingly popular. Various studies over the years evaluated the use of these methods of analysis and prediction in the assessment of stroke patients, and at the same time, several applications and software have been developed to support the neuroradiologists and the stroke team to improve patient outcomes.
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Affiliation(s)
- Francesco Pacchiano
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Caserta, Italy
| | - Mario Tortora
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy.
| | - Sabrina Criscuolo
- Pediatric University Department, Bambino Gesù Children Hospital, Rome, Italy
| | - Katya Jaber
- Department of Elektrotechnik und Informatik, Hochschule Bremen, Bremen, Germany
| | | | - Marta De Simone
- UOC Neuroradiology, AORN San Giuseppe Moscati, Avellino, Italy
| | - Fabio Tortora
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Francesco Briganti
- Department of Advanced Biomedical Sciences, University "Federico II", Via Pansini, 5, 80131, Naples, Italy
| | - Ferdinando Caranci
- Department of Precision Medicine, University of Campania "L. Vanvitelli", Caserta, Italy
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Cappellari AM, Palumbo S, Margiotta S. Questions and Controversies in Neonatal Seizures. CHILDREN (BASEL, SWITZERLAND) 2023; 11:40. [PMID: 38255354 PMCID: PMC10814600 DOI: 10.3390/children11010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Neonatal seizures are relatively common, but their diagnosis and management remain challenging. We reviewed the scientific literature on neonatal seizures from July 1973 to November 2023. Several parameters were considered, including pathophysiology, diagnostic criteria, electroencephalographic findings and treatment. Recent classification system of seizures and epilepsies in the newborn, as well as treatment recommendations of neonatal seizures, have been proposed. Nonetheless, the approach to neonatal seizures varies among clinicians and centres, including detection, investigation, treatment and follow-up of patients. There are still many issues on the diagnosis and treatment of neonatal seizures, including the meaning or relevance of some electroencephalographic findings, the precise estimation of the seizure burden, the limited efficacy and side effects risk of antiseizure medications, and the best measures to establish the outcome.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milano, Italy
| | - Sarah Palumbo
- Postgraduate School of Paediatrics, Department of Pediatrics, University of Milan, 20122 Milano, Italy; (S.P.); (S.M.)
| | - Stefania Margiotta
- Postgraduate School of Paediatrics, Department of Pediatrics, University of Milan, 20122 Milano, Italy; (S.P.); (S.M.)
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Arias-Llorente RP, Lareu-Vidal S, González-Sánchez S, Blanco-Lago R. [A series of 22 cases of perinatal arterial ischaemic stroke: risk factors, clinical management and neurological sequelae]. Rev Neurol 2023; 77:151-158. [PMID: 37750545 PMCID: PMC10831710 DOI: 10.33588/rn.7707.2023158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Perinatal arterial ischaemic stroke (PAIS) is almost as common as in adulthood and causes significant neurological sequelae. AIM The aim is to describe the risk situations surrounding these neonates, the clinical manifestations, the management, the cost-effectiveness of diagnostic tests and the neurological sequelae. PATIENTS AND METHODS We conducted an observational study of a cohort of patients consisting of neonates with a gestational age = 35 weeks diagnosed with PAIS in our hospital between 2010 and 2021. RESULTS Twenty-two cases of PAIS were included, and the incidence in our centre was 1/1,869 live newborns. The data showed that 81.8% had some intrapartum risk factor and 40.9% had a combination of several risk factors. It started with seizures (mean age 27.3 hours) in 77.3% of cases. Patients with a stroke in the left hemisphere had more sequelae (77.8%) than those with a stroke on the right-hand side (16.6%) (p = 0.041), with the exception of infantile cerebral palsy (p = 0.04), while we found no difference between hemispheres in the frequency of language impairment (p = 0.06). The mean follow-up time was 6.13 ± 3.06 years. A total of 63.6% of infants had neurological sequelae: infantile cerebral palsy (40.9%), language disorders (22.7%) and intellectual disability (9%). Moreover, 18.2% developed epilepsy (between 0.25 and 1.8 years) and antiseizure treatment was maintained after discharge in 37.5% of cases in the last years of the study. CONCLUSIONS If a newborn infant presents seizures, it is necessary to rule out the possibility of a stroke. PAIS causes neurological sequelae in over 60% of cases. Early identification is essential to improve the neurological prognosis and avoid the prolonged use of antiseizure drugs where possible.
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Affiliation(s)
| | - S Lareu-Vidal
- Hospital Universitario Central de Asturias, 33006 Oviedo, España
| | | | - R Blanco-Lago
- Hospital Universitario Central de Asturias, Oviedo, España
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Barsch Bergqvist A, Simatou E, Skiöld B, Mitha A, Bolk J. Term-born infants with a perinatal stroke frequently had seizures and were prescribed anti-seizure medication at discharge. Acta Paediatr 2023; 112:1907-1915. [PMID: 37365777 DOI: 10.1111/apa.16890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/07/2023] [Accepted: 06/26/2023] [Indexed: 06/28/2023]
Abstract
AIM We investigated the prevalence of seizures in term-born infants with a perinatal stroke in Swedish neonatal wards, assessed the anti-seizure medication prescribed and determined the accuracy of diagnostic codes. METHODS This cross-sectional study used data from the Swedish Neonatal Quality Register. The cases were infants born at ≥37 weeks in 2009-2018 and admitted to a neonatal ward in Stockholm County with a stroke diagnosis, confirmed by their medical chart. The controls were all Swedish infants born during those years. RESULTS There were 76 infants with a confirmed perinatal stroke: 51 ischaemic and 25 haemorrhagic. Seizures were documented in 66/76 (87%) of infants with a stroke and 0.2% of the controls. Anti-seizure medication was administered to 64/66 (97%) infants with a stroke and seizures. In 60 cases, the drugs administered were specified, with phenobarbital used in 59/60 cases (98%). More than one drug was administered to 25/60 (42%) infants and 31/60 (52%) were discharged with anti-seizure medication. The positive predictive value for the stroke diagnostic codes was 80.5% (95% CI 76.5-84.5). CONCLUSION Seizures were common in infants with a perinatal stroke. More than one anti-seizure drug was often required and many infants were on anti-seizure medication at discharge, against Swedish recommendations.
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Affiliation(s)
| | - Eleni Simatou
- Department of Child Neurology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Beatrice Skiöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ayoub Mitha
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- CHU Lille, Paediatric and Neonatal Intensive Care Transport Unit, Department of Emergency Medicine, SAMU 59, Lille University Hospital, Lille, France
| | - Jenny Bolk
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Sewell EK, Shankaran S, McDonald SA, Hamrick S, Wusthoff CJ, Adams-Chapman I, Chalak LF, Davis AS, Van Meurs K, Das A, Maitre N, Laptook A, Patel RM. Antiseizure medication at discharge in infants with hypoxic-ischaemic encephalopathy: an observational study. Arch Dis Child Fetal Neonatal Ed 2023; 108:421-428. [PMID: 36732048 PMCID: PMC10293046 DOI: 10.1136/archdischild-2022-324612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/06/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess variability in continuation of antiseizure medication (ASM) at discharge and to evaluate if continuation of ASM at discharge is associated with death or disability among infants with hypoxic-ischaemic encephalopathy (HIE) and seizures. DESIGN Retrospective study of infants enrolled in three National Institute of Child Health and Human Development Neonatal Research Network Trials of therapeutic hypothermia. SETTING 22 US centres. PATIENTS Infants with HIE who survived to discharge and had clinical or electrographic seizures treated with ASM. EXPOSURES ASM continued or discontinued at discharge. OUTCOMES Death or moderate-to-severe disability at 18-22 months, using trial definitions. Multivariable logistic regression evaluated the association between continuation of ASM at discharge and the primary outcome, adjusting for severity of HIE, hypothermia trial treatment arm, use of electroencephalogram, discharge on gavage feeds, Apgar Score at 5 min, birth year and centre. RESULTS Of 302 infants included, 61% were continued on ASMs at discharge (range 13%-100% among 22 centres). Electroencephalogram use occurred in 92% of the cohort. Infants with severe HIE comprised 24% and 22% of those discharged with and without ASM, respectively. The risk of death or moderate-to-severe disability was greater for infants continued on ASM at discharge, compared with those infants discharged without ASM (44% vs 28%, adjusted OR 2.14; 95% CI 1.13 to 4.05). CONCLUSIONS In infants with HIE and seizures, continuation of ASM at discharge varies substantially among centres and may be associated with a higher risk of death or disability at 18-22 months of age.
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Affiliation(s)
- Elizabeth K Sewell
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Seetha Shankaran
- Pediatrics Neonatology, Wayne State University Childrens Hospital of MI, Detroit, Michigan, USA
| | | | - Shannon Hamrick
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | | | - Ira Adams-Chapman
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Lina F Chalak
- Pediatrics, UT Southwestern Dallas, dallas, Texas, USA
| | - Alexis S Davis
- Pediatrics, Stanford University, Palo Alto, California, USA
| | - Krisa Van Meurs
- Division of Neonatology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Abhik Das
- RTI International, Rockville, Maryland, USA
| | - Nathalie Maitre
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Abbott Laptook
- Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Ravi Mangal Patel
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
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12
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Levetiracetam versus Phenobarbital for Neonatal Seizures: A Retrospective Cohort Study. Pediatr Neurol 2023; 138:62-70. [PMID: 36401982 DOI: 10.1016/j.pediatrneurol.2022.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/22/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although phenobarbital (PB) is commonly used as a first-line antiseizure medication (ASM) for neonatal seizures, in 2015 we chose to replace it with levetiracetam (LEV), a third-generation ASM. Here, we compared the safety and efficacy of LEV and PB as first-line ASM, considering the years before and after modifying our treatment protocol. METHODS We conducted a retrospective cohort study of 108 neonates with electroencephalography (EEG)-confirmed seizures treated with first-line LEV or PB in 2012 to 2020. RESULTS First-line ASM was LEV in 33 (31%) and PB in 75 (69%) neonates. The etiology included acute symptomatic seizures in 69% of cases (30% hypoxic-ischemic encephalopathy, 32% structural vascular, 6% infectious, otherwise metabolic) and neonatal epilepsy in 22% (5% structural due to brain malformation, 17% genetic). Forty-two of 108 (39%) neonates reached seizure freedom following first-line therapy. Treatment response did not vary by first-line ASM among all neonates, those with acute symptomatic seizures, or those with neonatal-onset epilepsy. Treatment response was lowest for neonates with a higher seizure frequency, particularly for those with status epilepticus versus rare seizures (P < 0.001), irrespective of gestational age, etiology, or EEG findings. Adverse events were noted in 22 neonates treated with PB and in only one treated with LEV (P < 0.001). CONCLUSIONS Our study suggests a potential noninferiority and a more acceptable safety profile for LEV, which may thus be a reasonable option as first-line ASM for neonatal seizures in place of PB. Treatment should be initiated as early as possible since higher seizure frequencies predispose to less favorable responses.
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13
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de Corrêa NC, Bom JMDS, Scherer MR, Nunes ML. Clinical profile of a cohort of neonates with seizures: Association between semiology, etiology, and electroencephalographic findings. Pediatr Neonatol 2022; 63:582-589. [PMID: 35922262 DOI: 10.1016/j.pedneo.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/23/2022] [Accepted: 04/28/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Seizures are the most common sign of neurologic dysfunction, reflecting a wide variety of central nervous system disorders. METHODS A retrospective cross-sectional study of neonates with a clinical diagnosis of seizures was conducted in order to verify relationships between clinical aspects and EEG findings. Patients were divided into 3 groups according to the EEG recording available as: 1) with confirmatory ictal EEG; 2) with altered but non-ictal EEG; and 3) without any EEG recording. Variables related to pregnancy and birth history, neonatal complications, and seizure semiology (by video or clinical description) were compared to EEG findings. RESULTS 97 neonates were included (39.1% preterm, 54.6% male), 71 with available EEG data (56.3% with ictal EEG). The group without EEG presented clinical characteristics significantly different from the others such as extreme prematurity, low birth weight, and higher neonatal mortality (P = 0.002, 0.001, and 0.003, respectively). The most common etiology was hypoxic-ischemic encephalopathy (HIE) (46.4%) followed by vascular disorders, which predominated in extremely preterm neonates (P = 0.006). Sequential seizure was the most common type (44.6%) and was more frequently identified in term neonates (46%). In 51.2% of the ictal recordings the main finding was electrographic seizure without clinical manifestation. Discharge using antiseizure medication was higher among those with ictal or altered non-ictal EEG (P < 0.001). CONCLUSIONS HIE is still a frequently etiology for neonatal seizures. Even if the patients in the sample were not under continuous EEG, the substantial proportion of electrographic seizures without clinical manifestations detected suggests the importance of continuous EEG monitoring in neonates at increased risk of seizures.
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Affiliation(s)
- Natália Corrêa de Corrêa
- Board Certified on Pediatrics, Neonatal Intensive Care Unit, Hospital Sao Lucas, PUCRS, Porto Alegre, RS, Brazil
| | | | | | - Magda Lahorgue Nunes
- Brain Institute, Porto Alegre, RS, Brazil; School of Medicine, PUCRS, Porto Alegre, RS, Brazil.
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14
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Hashish M, Bassiouny MR. Neonatal seizures: stepping outside the comfort zone. Clin Exp Pediatr 2022; 65:521-528. [PMID: 35381172 PMCID: PMC9650361 DOI: 10.3345/cep.2022.00115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/22/2022] [Indexed: 11/27/2022] Open
Abstract
Seizures are the most common neurological disorders in newborns. Managing neonatal seizures is challenging, especially for neurologists who are not neonatal specialists. Acute brain injury during ischemic insult is a key component of seizure occurrence, while genetic and metabolic disorders play less prevalent but more severe roles. The diagnosis of neonatal seizure is ambiguous, as the subjective differentiation between seizure and nonepileptic events is difficult; therefore, electrographic recording is the gold standard for diagnosis. The detection of electrographic seizures by neonatologists is currently facilitated by amplitude-integrated electroencephalography availability in many neonatal intensive care units. Although it is less sensitive than conventional electroencephalography, it is better to record all risky neonates to filter the abnormal events as early as possible to enable the initiation of dedicated therapy at proper dose and time and facilitate the initial response to antiepileptic drugs. This, in turn, helps maintain the balance between unnecessary drug use and their neurotoxic effects. Moreover, the early treatment of electrographic seizures plays a vital role in the suppression of subsequent abnormal brain electricity (status epilepticus) and shortening the hospital stay. An explicit understanding of seizure etiology and pathophysiology should direct attention to the proper prescription of short- and long-term antiepileptic medications to solve the challenging issue of whether neonatal seizures progress to postneonatal epilepsy and long-term cognitive deficits. This review addresses recent updates in different aspects of neonatal seizures, particularly electrographic discharge, including their definition, etiology, classification, diagnosis, management, and neurodevelopmental outcomes.
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Affiliation(s)
- Menna Hashish
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt
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15
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Srivastava R, Mailo J, Dunbar M. Perinatal Stroke in Fetuses, Preterm and Term Infants. Semin Pediatr Neurol 2022; 43:100988. [PMID: 36344024 DOI: 10.1016/j.spen.2022.100988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022]
Abstract
Perinatal stroke is a well-defined heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of postnatal life. The most focused lifetime risk for stroke occurs during the first week after birth. The morbidity of perinatal stroke is high, as it is the most common cause of hemiparetic cerebral palsy which results in lifelong disability that becomes more apparent throughout childhood. Perinatal strokes can be classified by the timing of diagnosis (acute or retrospective), vessel involved (arterial or venous), and underlying cause (hemorrhagic or ischemic). Perinatal stroke has primarily been reported as a disorder of term infants; however, the preterm brain possesses different vulnerabilities that predispose an infant to stroke injury both in utero and after birth. Accurate diagnosis of perinatal stroke syndromes has important implications for investigations, management, and prognosis. The classification of perinatal stroke by age at presentation (fetal, preterm neonatal, term neonatal, and infancy/childhood) is summarized in this review, and includes detailed descriptions of risk factors, diagnosis, treatment, outcomes, controversies, and resources for family support.
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Affiliation(s)
- R Srivastava
- Division of Pediatric Neurology, Department of Pediatrics, University of Albertam, AB, Canada
| | - J Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Albertam, AB, Canada
| | - M Dunbar
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Alberta Children's Hospital Research Institute (ACHRI), Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada.
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16
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Guidotti I, Lugli L, Ori L, Roversi MF, Casa Muttini ED, Bedetti L, Pugliese M, Cavalleri F, Stefanelli F, Ferrari F, Berardi A. Neonatal seizures treatment based on conventional multichannel EEG monitoring: an overview of therapeutic options. Expert Rev Neurother 2022; 22:623-638. [PMID: 35876114 DOI: 10.1080/14737175.2022.2105698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Seizures are the main neurological emergency during the neonatal period and are mostly acute and focal. The prognosis mainly depends on the underlying etiology. Conventional multichannel video-electroencephalographic (cEEG) monitoring is the gold standard for diagnosis, but treatment remains a challenge. AREAS COVERED : This review, based on PubMed search over the last 4 decades, focuses on the current treatment options for neonatal seizures based on cEEG monitoring. There is still no consensus on seizure therapy, owing to poor scientific evidence. Traditionally, the first-line treatments are phenobarbital and phenytoin, followed by midazolam and lidocaine, but their efficacy is limited. Therefore, current evidence strongly suggests the use of alternative antiseizure medications. Randomized controlled trials of new drugs are ongoing. EXPERT OPINION : Therapy for neonatal seizures should be prompt and tailored, based on semeiology, mirror of the underlying cause, and cEEG features. Further research should focus on antiseizure medications that directly act on the etiopathogenetic mechanism responsible for seizures and are therefore more effective in seizure control.
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Affiliation(s)
- Isotta Guidotti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Licia Lugli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Ori
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Maria Federica Roversi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Elisa Della Casa Muttini
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Bedetti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Marisa Pugliese
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, Modena, Italy
| | - Francesca Stefanelli
- Department of Medical and Surgical Sciences of the Mothers, Children and Adults, Post Graduate School of Pediatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Alberto Berardi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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17
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Numis AL, Shellhaas RA. Neonatal Seizure Management: What Is Timely Treatment and Does It Influence Neurodevelopment? J Pediatr 2022; 243:7-8. [PMID: 34896429 DOI: 10.1016/j.jpeds.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience and Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Renée A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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18
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Massey SL, Glass HC, Shellhaas RA, Bonifacio S, Chang T, Chu C, Cilio MR, Lemmon ME, McCulloch CE, Soul JS, Thomas C, Wusthoff CJ, Xiao R, Abend NS. Characteristics of Neonates with Cardiopulmonary Disease Who Experience Seizures: A Multicenter Study. J Pediatr 2022; 242:63-73. [PMID: 34728234 PMCID: PMC8882137 DOI: 10.1016/j.jpeds.2021.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare key seizure and outcome characteristics between neonates with and without cardiopulmonary disease. STUDY DESIGN The Neonatal Seizure Registry is a multicenter, prospectively acquired cohort of neonates with clinical or electroencephalographic (EEG)-confirmed seizures. Cardiopulmonary disease was defined as congenital heart disease, congenital diaphragmatic hernia, and exposure to extracorporeal membrane oxygenation. We assessed continuous EEG monitoring strategy, seizure characteristics, seizure management, and outcomes for neonates with and without cardiopulmonary disease. RESULTS We evaluated 83 neonates with cardiopulmonary disease and 271 neonates without cardiopulmonary disease. Neonates with cardiopulmonary disease were more likely to have EEG-only seizures (40% vs 21%, P < .001) and experience their first seizure later than those without cardiopulmonary disease (174 vs 21 hours of age, P < .001), but they had similar seizure exposure (many-recurrent electrographic seizures 39% vs 43%, P = .27). Phenobarbital was the primary initial antiseizure medication for both groups (90%), and both groups had similarly high rates of incomplete response to initial antiseizure medication administration (66% vs 68%, P = .75). Neonates with cardiopulmonary disease were discharged from the hospital later (hazard ratio 0.34, 95% CI 0.25-0.45, P < .001), although rates of in-hospital mortality were similar between the groups (hazard ratio 1.13, 95% CI 0.66-1.94, P = .64). CONCLUSION Neonates with and without cardiopulmonary disease had a similarly high seizure exposure, but neonates with cardiopulmonary disease were more likely to experience EEG-only seizures and had seizure onset later in the clinical course. Phenobarbital was the most common seizure treatment, but seizures were often refractory to initial antiseizure medication. These data support guidelines recommending continuous EEG in neonates with cardiopulmonary disease and indicate a need for optimized therapeutic strategies.
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Affiliation(s)
- Shavonne L. Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Hannah C. Glass
- Departments of Neurology and UCSF Weill Institute for Neuroscience, University of California, San Francisco,Department of Epidemiology & Biostatistics, University of California San Francisco
| | | | | | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine & Health Sciences
| | - Catherine Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Maria Roberta Cilio
- Departments of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Monica E. Lemmon
- Department of Pediatrics and Population Health Sciences, Duke University School of Medicine
| | - Charles E. McCulloch
- Department of Epidemiology & Biostatistics, University of California San Francisco
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School
| | - Cameron Thomas
- Department of Pediatrics, Division of Neurology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati
| | | | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S. Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA,Department of Anesthesia & Critical Care Medicine, University of Pennsylvania
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19
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Keene JC, Morgan LA, Abend NS, Bates SV, Bauer Huang SL, Chang T, Chu CJ, Glass HC, Massey SL, Ostrander B, Pardo AC, Press CA, Soul JS, Shellhaas RA, Thomas C, Natarajan N. Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units. Pediatr Neurol 2022; 128:67-74. [PMID: 34750046 DOI: 10.1016/j.pediatrneurol.2021.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/12/2021] [Accepted: 10/04/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability. METHODS We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalography (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose. RESULTS Study center NICUs had a median of 70 beds (interquartile range: 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20 mg/kg IV was the first-line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second-line ASM with variable dosing. Third-line ASMs were most commonly fosphenytoin or levetiracetam, with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation after resolution of acute symptomatic seizures with variable timing. CONCLUSIONS Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity that require further research include optimal second-line ASM, dosage, and timing of ASM discontinuation.
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Affiliation(s)
- Jennifer C Keene
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington.
| | - Lindsey A Morgan
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Nicholas S Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Sara V Bates
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah L Bauer Huang
- Division of Pediatric & Developmental Neurology, Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Taeun Chang
- Neurology, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, San Francisco, California
| | - Shavonne L Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Betsy Ostrander
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Andrea C Pardo
- Ann & Robert H. Lurie Children's Hospital, Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Craig A Press
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Janet S Soul
- Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Niranjana Natarajan
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
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20
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Whole-exome sequencing with targeted analysis and epilepsy after acute symptomatic neonatal seizures. Pediatr Res 2022; 91:896-902. [PMID: 33846556 PMCID: PMC9064802 DOI: 10.1038/s41390-021-01509-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The contribution of pathogenic gene variants with development of epilepsy after acute symptomatic neonatal seizures is not known. METHODS Case-control study of 20 trios in children with a history of acute symptomatic neonatal seizures: 10 with and 10 without post-neonatal epilepsy. We performed whole-exome sequencing (WES) and identified pathogenic de novo, transmitted, and non-transmitted variants from established and candidate epilepsy association genes and correlated prevalence of these variants with epilepsy outcomes. We performed a sensitivity analysis with genes associated with coronary artery disease (CAD). We analyzed variants throughout the exome to evaluate for differential enrichment of functional properties using exploratory KEGG searches. RESULTS Querying 200 established and candidate epilepsy genes, pathogenic variants were identified in 5 children with post-neonatal epilepsy yet in only 1 child without subsequent epilepsy. There was no difference in the number of trios with non-transmitted pathogenic variants in epilepsy or CAD genes. An exploratory KEGG analysis demonstrated a relative enrichment in cell death pathways in children without subsequent epilepsy. CONCLUSIONS In this pilot study, children with epilepsy after acute symptomatic neonatal seizures had a higher prevalence of coding variants with a targeted epilepsy gene sequencing analysis compared to those patients without subsequent epilepsy. IMPACT We performed whole-exome sequencing (WES) in 20 trios, including 10 children with epilepsy and 10 without epilepsy, both after acute symptomatic neonatal seizures. Children with post-neonatal epilepsy had a higher burden of pathogenic variants in epilepsy-associated genes compared to those without post-neonatal epilepsy. Future studies evaluating this association may lead to a better understanding of the risk of epilepsy after acute symptomatic neonatal seizures and elucidate molecular pathways that are dysregulated after brain injury and implicated in epileptogenesis.
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21
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Nickels K. Neonatal Seizures: Providing Care With Evidence, Not Just Experience. Epilepsy Curr 2021; 21:427-429. [PMID: 34924849 PMCID: PMC8652323 DOI: 10.1177/15357597211040937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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22
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Lemmon ME, Glass HC, Shellhaas RA, Barks MC, Bansal S, Annis D, Guerriero JL, Pilon B, Wusthoff CJ, Chang T, Soul JS, Chu CJ, Thomas C, Massey SL, Abend NS, Rau S, Rogers EE, Franck LS. Family-Centered Care for Children and Families Impacted by Neonatal Seizures: Advice From Parents. Pediatr Neurol 2021; 124:26-32. [PMID: 34509000 PMCID: PMC8523194 DOI: 10.1016/j.pediatrneurol.2021.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Parents of neonates with seizures are at risk of mental health symptoms due to the impact of illness on family life, prognostic uncertainty, and the emotional toll of hospitalization. A family-centered approach is the preferred model to mitigate these challenges. We aimed to identify strategies to promote family-centered care through an analysis of parent-offered advice to clinicians caring for neonates with seizures. METHODS This prospective, observational, and multicenter (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. Parents completed surveys about family well-being at 12, 18, and 24 months corrected gestational age. Parents were asked open-ended questions eliciting their advice to clinicians caring for neonates with seizures. Responses were analyzed using a conventional content analysis approach. RESULTS Among the 310 parents who completed surveys, 118 (38%) shared advice for clinicians. These parents were predominantly mothers (n = 103, 87%). Three overarching themes were identified. (1) Communicate information effectively: parents appreciate when clinicians offer transparent and balanced information in an accessible way. (2) Understand and validate parent experience: parents value clinicians who display empathy, compassion, and a commitment to parent-partnered clinical care. (3) Providesupportand resources: parents benefit from emotional support, education, connection with peers, and help navigating the health care system. CONCLUSIONS Parents caring for neonates with seizures appreciate a family-centered approach in health care encounters, including skilled communication, understanding and validation of the parent experience, and provision of support and resources. Future interventions should focus on building structures to reinforce these priorities.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA,Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Hannah C. Glass
- Departments of Neurology and Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California, USA,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Renée A. Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Carol Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Simran Bansal
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dana Annis
- NSR Parent Partner, Children’s National Hospital, Washington, DC, USA
| | - Jennifer L. Guerriero
- NSR Parent Partner, Children’s Hospital Boston, Boston, MA, USA,Dana Farber Cancer Institute
| | | | | | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine J. Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA,Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shavonne L. Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Rau
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth E. Rogers
- Departments of Neurology and Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Linda S. Franck
- Department of Family Health Care Nursing, University of California, San Francisco, San Francisco, California, USA
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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Wusthoff CJ, Sundaram V, Abend NS, Massey SL, Lemmon ME, Thomas C, McCulloch CE, Chang T, Soul JS, Chu CJ, Rogers EE, Bonifacio SL, Cilio MR, Glass HC, Shellhaas RA. Seizure Control in Neonates Undergoing Screening vs Confirmatory EEG Monitoring. Neurology 2021; 97:e587-e596. [PMID: 34078719 PMCID: PMC8424499 DOI: 10.1212/wnl.0000000000012293] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/03/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine whether screening continuous EEG monitoring (cEEG) is associated with greater odds of treatment success for neonatal seizures. METHODS We included term neonates with acute symptomatic seizures enrolled in the Neonatal Seizure Registry (NSR), a prospective, multicenter cohort of neonates with seizures. We compared 2 cEEG approaches: (1) screening cEEG, initiated for indications of encephalopathy or paralysis without suspected clinical seizures; and (2) confirmatory cEEG, initiated for the indication of clinical events suspicious for seizures, either alone or in addition to other indications. The primary outcome was successful response to initial seizure treatment, defined as seizures resolved without recurrence within 30 minutes after initial loading dose of antiseizure medicine. Multivariable logistic regression analyses assessed the association between cEEG approach and successful seizure treatment. RESULTS Among 514 neonates included, 161 (31%) had screening cEEG and 353 (69%) had confirmatory cEEG. Neonates with screening cEEG had a higher proportion of successful initial seizure treatment than neonates with confirmatory cEEG (39% vs 18%; p < 0.0001). After adjusting for covariates, there remained a greater odds ratio (OR) for successful initial seizure treatment in the screening vs confirmatory cEEG groups (adjusted OR 2.44, 95% confidence interval 1.45-4.11, p = 0.0008). CONCLUSIONS These findings provide evidence from a large, contemporary cohort of neonates that a screening cEEG approach may improve odds of successful treatment of acute seizures. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for neonates a screening cEEG approach, compared to a confirmatory EEG approach, increases the probability of successful treatment of acute seizures.
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Affiliation(s)
- Courtney J Wusthoff
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor.
| | - Vandana Sundaram
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Nicholas S Abend
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Shavonne L Massey
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Monica E Lemmon
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cameron Thomas
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Charles E McCulloch
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Taeun Chang
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Janet S Soul
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Catherine J Chu
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Elizabeth E Rogers
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Sonia Lomeli Bonifacio
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Maria Roberta Cilio
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Hannah C Glass
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Renée A Shellhaas
- From the Divisions of Child Neurology and Pediatrics (Neonatology) (C.J.W.) and Division of Neonatal & Developmental Medicine, Department of Pediatrics (S.L.B.), Stanford University; Quantitative Sciences Unit (V.S.), Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Departments of Neurology (N.S.A., S.L.M.), Pediatrics (N.S.A., S.L.M.), and Anesthesia & Critical Care Medicine (N.S.A.), University of Pennsylvania Perelman School of Medicine; Department of Pediatrics (Division of Neurology) (N.S.A., S.L.M.), Children's Hospital of Philadelphia, PA; Departments of Pediatrics and Population Health Sciences (M.E.L.), Duke University School of Medicine, Durham, NC; Department of Pediatrics (C.T.), College of Medicine, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH; Departments of Epidemiology and Biostatistics (C.E.M., H.C.G.) and Pediatrics (E.E.R.) and Department of Neurology and Weill Institute for Neuroscience and Department of Pediatrics, UCSF Benioff Children's Hospital (H.C.G.), University of California San Francisco; Neurology (T.C.), George Washington University School of Medicine, Children's National Hospital, Washington, DC; Department of Neurology (J.S.S.), Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (C.J.C.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Pediatric Neurology (M.R.C.), Department of Pediatrics, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium; and Division of Pediatric Neurology (R.A.S.), Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
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DeLaGarza-Pineda O, Mailo JA, Boylan G, Chau V, Glass HC, Mathur AM, Shellhaas RA, Soul JS, Wusthoff CJ, Chang T. Management of seizures in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101279. [PMID: 34563467 DOI: 10.1016/j.siny.2021.101279] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Neonatal encephalopathy (NE) is the most common etiology of acute neonatal seizures - about half of neonates treated with therapeutic hypothermia for NE have EEG-confirmed seizures. These seizures are best identified with continuous EEG monitoring, as clinical diagnosis leads to under-diagnosis of subclinical seizures and over-treatment of events that are not seizures. High seizure burden, especially status epilepticus, is thought to augment brain injury. Treatment, therefore, is aimed at minimizing seizure burden. Phenobarbital remains the mainstay of treatment, as it is more effective than levetiracetam and easier to administer than fosphenytoin. Emerging evidence suggests that, for many neonates, it is safe to discontinue the phenobarbital after acute seizures resolve and prior to hospital discharge.
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Affiliation(s)
- Oscar DeLaGarza-Pineda
- Department of Neurology, University Hospital "Dr. Jose E. Gonzalez", Monterrey, Nuevo León, Mexico.
| | - Janette A Mailo
- Neurology & Pediatrics, Stollery Children's Hospital and Glenrose Rehabilitation Hospital University of Alberta, Alberta, Canada.
| | - Geraldine Boylan
- Department of Pediatrics & Child Health University College Cork, Cork, Ireland.
| | - Vann Chau
- Division of Neurology, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Saint Louis University School of Medicine, SSM-Health Cardinal Glennon Children's Hospital, Saint Louis, MO, USA.
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Janet S Soul
- Neurology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics-Neonatal and Developmental Medicine Stanford Children's Health, Palo Alto, CA, USA.
| | - Taeun Chang
- Neurology & Pediatrics, George Washington University School of Medicine & Health Sciences, Children's National Hospital, Washington, DC, USA.
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Shellhaas RA, Wusthoff CJ, Numis AL, Chu CJ, Massey SL, Abend NS, Soul JS, Chang T, Lemmon ME, Thomas C, McNamara NA, Guillet R, Franck LS, Sturza J, McCulloch CE, Glass HC. Early-life epilepsy after acute symptomatic neonatal seizures: A prospective multicenter study. Epilepsia 2021; 62:1871-1882. [PMID: 34212365 DOI: 10.1111/epi.16978] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We aimed to evaluate early-life epilepsy incidence, seizure types, severity, risk factors, and treatments among survivors of acute neonatal seizures. METHODS Neonates with acute symptomatic seizures born 7/2015-3/2018 were prospectively enrolled at nine Neonatal Seizure Registry sites. One-hour EEG was recorded at age three months. Post-neonatal epilepsy and functional development (Warner Initial Developmental Evaluation of Adaptive and Functional Skills - WIDEA-FS) were assessed. Cox regression was used to assess epilepsy-free survival. RESULTS Among 282 infants, 37 (13%) had post-neonatal epilepsy by 24-months [median age of onset 7-months (IQR 3-14)]. Among those with post-neonatal epilepsy, 13/37 (35%) had infantile spasms and 12/37 (32%) had drug-resistant epilepsy. Most children with post-neonatal epilepsy had abnormal neurodevelopment at 24-months (WIDEA-FS >2SD below normal population mean for 81% of children with epilepsy vs 27% without epilepsy, RR 7.9, 95% CI 3.6-17.3). Infants with severely abnormal neonatal EEG background patterns were more likely to develop epilepsy than those with mild/moderate abnormalities (HR 3.7, 95% CI 1.9-5.9). Neonatal EEG with ≥3 days of seizures also predicted hazard of epilepsy (HR 2.9, 95% CI 1.4-5.9). In an adjusted model, days of neonatal EEG-confirmed seizures (HR 1.4 per day, 95% CI 1.2-1.6) and abnormal discharge examination (HR 3.9, 95% CI 1.9-7.8) were independently associated with time to epilepsy onset. Abnormal (vs. normal) three-month EEG was not associated with epilepsy. SIGNIFICANCE In this multicenter study, only 13% of infants with acute symptomatic neonatal seizures developed post-neonatal epilepsy by age 24-months. However, there was a high risk of severe neurodevelopmental impairment and drug-resistant seizures among children with post-neonatal epilepsy. Days of EEG-confirmed neonatal seizures was a potentially modifiable epilepsy risk factor. An EEG at three months was not clinically useful for predicting epilepsy. These practice changing findings have implications for family counseling, clinical follow-up planning, and future research to prevent post-neonatal epilepsy.
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Affiliation(s)
- Renée A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Courtney J Wusthoff
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA.,Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Departments of Anesthesia & Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy A McNamara
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Linda S Franck
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Glass HC, Soul JS, Chang T, Wusthoff CJ, Chu CJ, Massey SL, Abend NS, Lemmon M, Thomas C, Numis AL, Guillet R, Sturza J, McNamara NA, Rogers EE, Franck LS, McCulloch CE, Shellhaas RA. Safety of Early Discontinuation of Antiseizure Medication After Acute Symptomatic Neonatal Seizures. JAMA Neurol 2021; 78:817-825. [PMID: 34028496 PMCID: PMC8145161 DOI: 10.1001/jamaneurol.2021.1437] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is discontinuation of antiseizure medication (ASM) after resolution of acute symptomatic neonatal seizures and prior to discharge from the hospital associated with functional neurodevelopment or epilepsy at 24 months? Findings In this comparative effectiveness study of 303 children with neonatal seizures from 9 centers, 64% had ASM maintained at hospital discharge. No difference was found between ASM maintenance and discontinuation groups in functional neurodevelopment or epilepsy; 13% of children developed epilepsy, including more than one-third with infantile spasms. Meaning These results support discontinuing ASMs for most neonates with acute symptomatic seizures prior to discharge from the hospital, an approach that may represent an evidence-based change in practice for many clinicians. Importance Antiseizure medication (ASM) treatment duration for acute symptomatic neonatal seizures is variable. A randomized clinical trial of phenobarbital compared with placebo after resolution of acute symptomatic seizures closed early owing to low enrollment. Objective To assess whether ASM discontinuation after resolution of acute symptomatic neonatal seizures and before hospital discharge is associated with functional neurodevelopment or risk of epilepsy at age 24 months. Design, Setting, and Participants This comparative effectiveness study included 303 neonates with acute symptomatic seizures (282 with follow-up data and 270 with the primary outcome measure) from 9 US Neonatal Seizure Registry centers, born from July 2015 to March 2018. The centers all had level IV neonatal intensive care units and comprehensive pediatric epilepsy programs. Data were analyzed from June 2020 to February 2021. Exposures The primary exposure was duration of ASM treatment dichotomized as ASM discontinued vs ASM maintained at the time of discharge from the neonatal seizure admission. To enhance causal association, each outcome risk was adjusted for propensity to receive ASM at discharge. Propensity for ASM maintenance was defined by a logistic regression model including seizure cause, gestational age, therapeutic hypothermia, worst electroencephalogram background, days of electroencephalogram seizures, and discharge examination (all P ≤ .10 in a joint model except cause, which was included for face validity). Main Outcomes and Measures Functional neurodevelopment was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS) at 24 months powered for propensity-adjusted noninferiority of early ASM discontinuation. Postneonatal epilepsy, a prespecified secondary outcome, was defined per International League Against Epilepsy criteria, determined by parent interview, and corroborated by medical records. Results Most neonates (194 of 303 [64%]) had ASM maintained at the time of hospital discharge. Among 270 children evaluated at 24 months (mean [SD], 23.8 [0.7] months; 147 [54%] were male), the WIDEA-FS score was similar for the infants whose ASMs were discontinued (101 of 270 [37%]) compared with the infants with ASMs maintained (169 of 270 [63%]) at discharge (median score, 165 [interquartile range, 150-175] vs 161 [interquartile range, 129-174]; P = .09). The propensity-adjusted average difference was 4 points (90% CI, −3 to 11 points), which met the a priori noninferiority limit of −12 points. The epilepsy risk was similar (11% vs 14%; P = .49), with a propensity-adjusted odds ratio of 1.5 (95% CI, 0.7-3.4; P = .32). Conclusions and Relevance In this comparative effectiveness study, no difference was found in functional neurodevelopment or epilepsy at age 24 months among children whose ASM was discontinued vs maintained at hospital discharge after resolution of acute symptomatic neonatal seizures. These results support discontinuation of ASM prior to hospital discharge for most infants with acute symptomatic neonatal seizures.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Epidemiology & Biostatistics; University of California, San Francisco
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Courtney J Wusthoff
- Department of Neurology, Stanford University, Palo Alto, California.,Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shavonne L Massey
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Monica Lemmon
- Departments of Pediatrics, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Linda S Franck
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Family Health Care Nursing, University of California, San Francisco
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics; University of California, San Francisco
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Vojcek E, Jermendy A, Laszlo AM, Graf R, Rudas G, Berenyi M, Seri I. The role of brain territorial involvement and infection/inflammation in the long-term outcome of neonates with arterial ischemic stroke: A population-based cohort study. Early Hum Dev 2021; 158:105393. [PMID: 34034089 DOI: 10.1016/j.earlhumdev.2021.105393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Neonatal arterial ischemic stroke (NAIS) carries the risk of significant long-term neurodevelopmental burden on survivors. AIMS To assess the long-term neurodevelopmental outcome of term neonates diagnosed with NAIS and investigate the associations among brain territorial involvement on MRI, clinical risk factors and neurodevelopmental outcomes. STUDY DESIGN Population-based cohort study. SUBJECTS Seventy-nine term neonates with NAIS confirmed by MRI born between 2007 and 2017. OUTCOME MEASURES Long-term neurodevelopmental outcome assessed using the Bayley Scales of Infant Development-II, the Brunet-Lézine test and the Binet Intelligence scales-V. RESULTS Follow-up was available in 70 (89%) of the subjects enrolled, at a median age of 60 months [IQR: 35-84]. Normal neurodevelopmental outcome was found in 43% of the patients. In a multivariable model, infants with main MCA stroke had an increased risk for overall adverse outcome (OR: 9.1, 95% CI: 1.7-48.0) and a particularly high risk for cerebral palsy (OR: 55.9, 95% CI: 7.8-399.2). The involvement of the corticospinal tract without extensive stroke also increased the risk for cerebral palsy/fine motor impairment (OR: 13.5, 95% CI: 2.4-76.3). Multiple strokes were associated with epilepsy (OR: 9.5, 95% CI: 1.0-88.9) and behavioral problems (OR: 4.4, 95% CI: 1.1-17.5) and inflammation/infection was associated with cerebral palsy (OR: 9.8, 95% CI: 1.4-66.9), cognitive impairment (OR: 9.2, 95% CI: 1.8-47.8) and epilepsy (OR: 10.3, 95% CI: 1.6-67.9). CONCLUSIONS Main MCA stroke, involvement of the corticospinal tract, multiple strokes and inflammation/infection were independent predictors of adverse outcome, suggesting that the interplay of stroke territorial involvement and clinical risk factors influence the outcome of NAIS.
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Affiliation(s)
- Eszter Vojcek
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Saint John Hospital and North-Buda Unified Hospitals, Budapest, Hungary.
| | - Agnes Jermendy
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna M Laszlo
- Institute of Mathematics and Base Sciences, Szent István University, Budapest, Hungary
| | - Rozsa Graf
- Department of Rehabilitation, Szent János Hospital and North Buda United Hospitals, Budapest, Hungary
| | - Gabor Rudas
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Marianne Berenyi
- Department of Developmental Neurology, Saint Margaret Hospital, Budapest, Hungary
| | - Istvan Seri
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, United States
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Ziobro JM, Eschbach K, Shellhaas RA. Novel Therapeutics for Neonatal Seizures. Neurotherapeutics 2021; 18:1564-1581. [PMID: 34386906 PMCID: PMC8608938 DOI: 10.1007/s13311-021-01085-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 02/04/2023] Open
Abstract
Neonatal seizures are a common neurologic emergency for which therapies have not significantly changed in decades. Improvements in diagnosis and pathophysiologic understanding of the distinct features of acute symptomatic seizures and neonatal-onset epilepsies present exceptional opportunities for development of precision therapies with potential to improve outcomes. Herein, we discuss the pathophysiology of neonatal seizures and review the evidence for currently available treatment. We present emerging therapies in clinical and preclinical development for the treatment of acute symptomatic neonatal seizures. Lastly, we discuss the role of precision therapies for genetic neonatal-onset epilepsies and address barriers and goals for developing new therapies for clinical care.
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Affiliation(s)
- Julie M Ziobro
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA.
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, Denver Anschutz School of Medicine, Children's Hospital Colorado, University of Colorado, Aurora, CO, 80045, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA
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Abstract
OBJECTIVE This study aims to describe the frequency and characteristics of anticonvulsant medication treatments initiated in the neonatal period. STUDY DESIGN We analyzed a cohort of neonates with a seizure diagnosis who were discharged from institutions in the Pediatric Health Information System between 2007 and 2016. Adjusted risk ratios and 95% confidence intervals for characteristics associated with neonatal (≤ 28 days postnatal) anticonvulsant initiation were calculated via modified Poisson regression. RESULTS A total of 6,245 infants from 47 institutions were included. There was a decrease in both phenobarbital initiation within the neonatal period (96.9 to 91.3%, p = 0.015) and continuation at discharge (90.6 to 68.6%, p <0.001). Levetiracetam (7.9 to 39.6%, p < 0.001) initiation within the neonatal period and continuation at discharge (9.4 to 49.8%, p < 0.001) increased. Neonates born at ≥ 37 weeks' gestation and those diagnosed with intraventricular hemorrhage, ischemic/thrombotic stroke, other hemorrhagic stroke, and hypoxic ischemic encephalopathy (HIE) had a higher probability of anticonvulsant administration. The most prevalent diagnosis was HIE (n = 2,223, 44.4%). CONCLUSION Phenobarbital remains the most widely used neonatal seizure treatment. Levetiracetam is increasingly used as a second line therapy. Increasing levetiracetam use indicates a need for additional study to determine its effectiveness in reducing seizure burden and improving long-term outcomes.
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Abstract
Seizures are the most common neurological emergency in the neonates, and this age group has the highest incidence of seizures compared with any other period of life. The author provides a narrative review of recent advances in the genetics of neonatal epilepsies, new neonatal seizure classification system, diagnostics, and treatment of neonatal seizures based on a comprehensive literature review (MEDLINE using PubMED and OvidSP vendors with appropriate keywords to incorporate recent evidence), personal practice, and experience. Knowledge regarding various systemic and postzygotic genetic mutations responsible for neonatal epilepsy has been exploded in recent times, as well as better delineation of clinical phenotypes associated with rare neonatal epilepsies. An International League Against Epilepsy task force on neonatal seizure has proposed a new neonatal seizure classification system and also evaluated the specificity of semiological features related to particular etiology. Although continuous video electroencephalogram (EEG) is the gold standard for monitoring neonatal seizures, amplitude-integrated EEGs have gained significant popularity in resource-limited settings. There is tremendous progress in the automated seizure detection algorithm, including the availability of a fully convolutional neural network using artificial machine learning (deep learning). There is a substantial need for ongoing research and clinical trials to understand optimal medication selection (first line, second line, and third line) for neonatal seizures, treatment duration of antiepileptic drugs after cessation of seizures, and strategies to improve neuromorbidities such as cerebral palsy, epilepsy, and developmental impairments. Although in recent times, levetiracetam use has been significantly increased for neonatal seizures, a multicenter, randomized, blinded, controlled phase IIb trial confirmed the superiority of phenobarbital over levetiracetam in the acute suppression of neonatal seizures. While there is no single best choice available for the management of neonatal seizures, institutional guidelines should be formed based on a consensus of local experts to mitigate wide variability in the treatment and to facilitate early diagnosis and treatment.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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Srivastava R, Kirton A. Perinatal Stroke: A Practical Approach to Diagnosis and Management. Neoreviews 2021; 22:e163-e176. [PMID: 33649089 DOI: 10.1542/neo.22-3-e163] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Perinatal stroke is a focal vascular brain injury that occurs from the fetal period to 28 days of postnatal age. With an overall incidence of up to 1 in 1,000 live births, the most focused lifetime risk for stroke occurs near birth. Perinatal stroke can be classified by the timing of diagnosis, vessel involvement, and type of injury. Timing of diagnosis may be in the acute neonatal period or retrospectively after a period of normal development, followed by abnormal neurologic findings, with the injury presumed to have occurred around the time of birth. Strokes may be arterial or venous, ischemic, and/or hemorrhagic. Within these classifications, 6 perinatal stroke diseases are recognizable, based on clinical and radiographic features. Morbidity is high in perinatal stroke, because it accounts for most cases of hemiparetic cerebral palsy, with disability lasting a lifetime. Additional complications include disorders of sensation and vision, language delays, cognitive and learning deficits, epilepsy, and mental health consequences that affect the entire family. Advances in neonatal neurocritical care may afford opportunity to minimize brain injury and improve outcomes. In the chronic timeframe, progress made in neuroimaging and brain mapping is revealing the developmental plasticity that occurs, informing new avenues for neurorehabilitation. This review will summarize the diagnosis and management of each perinatal stroke disease, highlighting their similarities and distinctions and emphasizing a patient- and family-centered approach to management.
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Affiliation(s)
- Ratika Srivastava
- Department of Community Health Sciences.,Department of Pediatrics, Section of Neurology; and.,Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Adam Kirton
- Department of Pediatrics, Section of Neurology; and.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
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Kaminiów K, Kozak S, Paprocka J. Neonatal Seizures Revisited. CHILDREN-BASEL 2021; 8:children8020155. [PMID: 33670692 PMCID: PMC7922511 DOI: 10.3390/children8020155] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/02/2021] [Accepted: 02/12/2021] [Indexed: 12/29/2022]
Abstract
Seizures are the most common neurological disorder in newborns and are most prevalent in the neonatal period. They are mostly caused by severe disorders of the central nervous system (CNS). However, they can also be a sign of the immaturity of the infant’s brain, which is characterized by the presence of specific factors that increase excitation and reduce inhibition. The most common disorders which result in acute brain damage and can manifest as seizures in neonates include hypoxic-ischemic encephalopathy (HIE), ischemic stroke, intracranial hemorrhage, infections of the CNS as well as electrolyte and biochemical disturbances. The therapeutic management of neonates and the prognosis are different depending on the etiology of the disorders that cause seizures which can lead to death or disability. Therefore, establishing a prompt diagnosis and implementing appropriate treatment are significant, as they can limit adverse long-term effects and improve outcomes. In this review paper, we present the latest reports on the etiology, pathomechanism, clinical symptoms and guidelines for the management of neonates with acute symptomatic seizures.
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Affiliation(s)
- Konrad Kaminiów
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (K.K.); (S.K.)
| | - Sylwia Kozak
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (K.K.); (S.K.)
| | - Justyna Paprocka
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence:
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Kim HJ, Jang HN, Ahn H, Yum MS, Ko TS. Over 10-Year Outcomes of Infantile-Onset Epilepsies. J Clin Med 2021; 10:jcm10030430. [PMID: 33499362 PMCID: PMC7865548 DOI: 10.3390/jcm10030430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
Seizures in infancy have highly variable courses and underlying etiologies. However, there are only a few long-term follow-up studies regarding infantile-onset epilepsy. Therefore, we aimed to describe the clinical courses, seizure outcomes, and risk factors of infantile-onset epilepsy followed up for more than 10 years in a tertiary center. Methods: Data of the patients with epilepsy, diagnosed under the age of 12 months and followed up for more than 10 years, were retrieved from the electronic medical records of Asan Medical Center Children’s Hospital. The patients’ medical records were retrospectively reviewed, and clinical outcomes were assessed based on the duration of seizure freedom at the last follow-up. Results: Of the 146 patients, 103 (70.5%) entered at least one remission, of whom epilepsy was resolved in 46 (31.5%). Forty-nine (33.6%) were found to be intractable at last contact. Delayed development, neurological deficits, and later onset (>3 months) were significantly associated with intractable epilepsies (p < 0.01). Conclusions: This study demonstrated that many patients with infantile-onset epilepsy can experience seizure remission. However, in some cases, early onset epilepsy was highly associated with various comorbidities and intractable seizures. Therefore, appropriate diagnosis and treatment are necessary to prevent further neuropsychiatric complications.
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Affiliation(s)
- Hyun-Jin Kim
- Department of Pediatrics, Myongji Hospital, Goyang 10475, Korea;
| | - Han Na Jang
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Hyunji Ahn
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (H.N.J.); (H.A.)
- Correspondence: (M.-S.Y.); (T.-S.K.); Tel.: +82-2-3010-3386 (M.-S.Y. & T.-S.K.); Fax: +82-2-473-3725 (M.-S.Y. & T.-S.K.)
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Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
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Lemmon ME, Bonifacio SL, Shellhaas RA, Wusthoff CJ, Greenberg RG, Soul JS, Chang T, Chu CJ, Bates S, Massey SL, Abend NS, Cilio MR, Glass HC. Characterization of Death in Infants With Neonatal Seizures. Pediatr Neurol 2020; 113:21-25. [PMID: 32980743 PMCID: PMC7669564 DOI: 10.1016/j.pediatrneurol.2020.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/15/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neonatal seizures are associated with death and neurological morbidity; however, little is known about how neonates with seizures die. METHODS This was a prospective, observational cohort study of neonates with seizures treated at seven sites of the Neonatal Seizure Registry. We characterized the mode of death, evaluated the association between infant characteristics and mode of death, and evaluated predictors of death or transfer to hospice. RESULTS We enrolled 611 consecutive neonates with seizures, and 90 neonates (15%) died before hospital discharge at a median age of 11 days (range: 1 to 163 days); 32 (36%) died in the first postnatal week. An additional 19 neonates (3%) were transferred to hospice. The most common mode of in-hospital death was death after extubation amidst concerns for poor neurological prognosis, in the absence of life-threatening physiologic instability (n = 43, 48%). Only one infant died while actively receiving cardiopulmonary resuscitation. In an adjusted analysis, premature birth (odds ratio: 3.06, 95% confidence interval 1.59 to 5.90) and high seizure burden (odds ratio: 4.33, 95% confidence interval 1.88 to 9.95) were associated with increased odds of death or transfer to hospice. CONCLUSION In a cohort of neonates with seizures, death occurred predominantly after decisions to withdraw or withhold life-sustaining intervention(s). Future work should characterize how these decisions occur and develop optimized approaches to support families and clinicians caring for newborns with seizures.
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Affiliation(s)
- Monica E. Lemmon
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Dr, Durham, NC 27710, United States
| | - Sonia L. Bonifacio
- Departments of Pediatrics, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States
| | - Renée A. Shellhaas
- Department of Pediatrics, University of Michigan, 1540 E Hospital Dr, Ann Arbor, MI 48109, United States
| | - Courtney J. Wusthoff
- Departments of Pediatrics, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States;,Departments of Neurology, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Dr, Durham, NC 27710, United States;,Duke Clinical Research Institute, 301 W Morgan St, Durham, NC 27701, United States
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, United States
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine, 111 Michigan Ave NW, Washington, DC 20010, United States
| | - Catherine J. Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02115, United States
| | - Sara Bates
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02115, United States
| | - Shavonne L. Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104 United States
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104 United States;,Department of Anesthesia & Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 United States
| | - M. Roberta Cilio
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Hannah C. Glass
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, 1975 4th St, San Francisco, CA 94158, United States;,Department of Epidemiology & Biostatistics; University of California San Francisco, 1701 Divisadero St, San Francisco, CA 94115, United States;,Department of Neurology; UCSF Benioff Children’s Hospital, University of California San Francisco, 1975 4th St, San Francisco, CA 94158, United States
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Lemmon M, Glass H, Shellhaas RA, Barks MC, Bailey B, Grant K, Grossbauer L, Pawlowski K, Wusthoff CJ, Chang T, Soul J, Chu CJ, Thomas C, Massey SL, Abend NS, Rogers EE, Franck LS. Parent experience of caring for neonates with seizures. Arch Dis Child Fetal Neonatal Ed 2020; 105:634-639. [PMID: 32503792 PMCID: PMC7581607 DOI: 10.1136/archdischild-2019-318612] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Neonates with seizures have a high risk of mortality and neurological morbidity. We aimed to describe the experience of parents caring for neonates with seizures. DESIGN This prospective, observational and multicentre (Neonatal Seizure Registry) study enrolled parents of neonates with acute symptomatic seizures. At the time of hospital discharge, parents answered six open-ended response questions that targeted their experience. Responses were analysed using a conventional content analysis approach. RESULTS 144 parents completed the open-ended questions (732 total comments). Four themes were identified. Sources of strength: families valued medical team consensus, opportunities to contribute to their child's care and bonding with their infant. Uncertainty: parents reported three primary types of uncertainty, all of which caused distress: (1) the daily uncertainty of the intensive care experience; (2) concerns about their child's uncertain future and (3) lack of consensus between members of the medical team. Adapting family life: parents described the many ways in which they anticipated their infant's condition would lead to adaptations in their family life, including adjusting their family's lifestyle, parenting approach and routine. Many parents described financial and work challenges due to caring for a child with medical needs. Emotional and physical toll: parents reported experiencing anxiety, fear, stress, helplessness and loss of sleep. CONCLUSIONS Parents of neonates with seizures face challenges as they adapt to and find meaning in their role as a parent of a child with medical needs. Future interventions should target facilitating parent involvement in clinical and developmental care, improving team consensus and reducing the burden associated with prognostic uncertainty.
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Affiliation(s)
- Monica Lemmon
- Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hannah Glass
- Neurology and Pediatrics, University of California San Francisco, San Francisco, California, USA,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Renee A Shellhaas
- Pediatrics (Neurology Division), University of Michigan, Ann Arbor, Michigan, USA
| | - Mary Carol Barks
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Bria Bailey
- Neurology and Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Katie Grant
- Parent Partner, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Grossbauer
- Parent Partner, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kamil Pawlowski
- Parent Partner, UCSF Benioff Children’s Hospital Oakland, Oakland, California, USA
| | | | - Taeun Chang
- Neurology, Children’s National Medical Center, Washington, District of Columbia, USA
| | - Janet Soul
- Neurology, Children’s Hospital, Boston, Massachusetts, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cameron Thomas
- Pediatrics, Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicholas S Abend
- Neurology, Pediatrics, Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Linda S Franck
- Family Health Care Nursing, University of California San Francisco School of Nursing, San Francisco, California, USA
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Abstract
Perinatal strokes are a diverse but specific group of focal cerebrovascular injuries that occur early in brain development and affect an estimated 5 million people worldwide. The objective of this review is to describe the epidemiology, clinical presentations, pathophysiology, outcomes, and management for the 6 subtypes of perinatal stroke. Some perinatal strokes are symptomatic in the first days of life, typically with seizures, including neonatal arterial ischemic stroke, neonatal hemorrhagic stroke, and cerebral sinovenous thrombosis. The remaining subtypes present in the first year of life or later, usually with motor asymmetry and include arterial presumed perinatal ischemic stroke, presumed perinatal hemorrhagic stroke, and in utero periventricular venous infarction. The consequences of these injuries include cerebral palsy, epilepsy, and cognitive and behavioral challenges, in addition to the psychosocial impact on families. While there have been significant advances in understanding mechanisms of both injury and recovery, there is still a great deal to learn regarding causation and the optimization of outcomes.
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Affiliation(s)
- Mary Dunbar
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada.
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Abstract
Seizures are an important sign of neurologic dysfunction in neonates, and they most often represent acute brain injury such as hypoxic-ischemic encephalopathy, stroke, or intracranial hemorrhage (acute symptomatic seizures). Clinical identification of seizures is not reliable since seizures in neonates often do not have an apparent clinical correlate; therefore, electroencephalography should be used to accurately diagnose and manage neonatal seizures. Seizures are refractory to initial loading doses of standard medications in >50% of cases. Since seizures are commonly associated with adverse acute and long-term outcomes, and the seizures themselves may result in additional brain injury, it is important to quickly recognize, diagnose, and treat seizures in neonates. Local practice pathways may optimize efficiency in assessment and treatment for affected newborns. Herein, we review the etiology, methods of diagnosis, treatment, and current knowledge gaps for neonatal seizures.
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Dizon MLV, Rao R, Hamrick SE, Zaniletti I, DiGeronimo R, Natarajan G, Kaiser JR, Flibotte J, Lee KS, Smith D, Yanowitz T, Mathur AM, Massaro AN. Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. BMC Pediatr 2019; 19:67. [PMID: 30813933 PMCID: PMC6391819 DOI: 10.1186/s12887-019-1441-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/20/2019] [Indexed: 12/20/2022] Open
Abstract
Background While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods Children’s Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks’ gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results Ninety-five percent (range: 83–100%) of patients with electrographic seizures, and 26% (0–81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was $89.90 (IQR $24.52,$258.58). Conclusions Amongst Children’s Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.
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Affiliation(s)
- Maria L V Dizon
- Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, 225 East Chicago Ave, Box 45, Chicago, IL, 60611, USA.
| | - Rakesh Rao
- Washington University, St. Louis, MO, USA
| | | | | | - Robert DiGeronimo
- Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | | | | | - John Flibotte
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Toby Yanowitz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - An N Massaro
- Children's National Health Systems, Washington, DC, USA
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Glass HC, Soul JS, Chu CJ, Massey SL, Wusthoff CJ, Chang T, Cilio MR, Bonifacio SL, Abend NS, Thomas C, Lemmon M, McCulloch CE, Shellhaas RA. Response to antiseizure medications in neonates with acute symptomatic seizures. Epilepsia 2019; 60:e20-e24. [PMID: 30790268 DOI: 10.1111/epi.14671] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/22/2019] [Accepted: 01/23/2019] [Indexed: 11/30/2022]
Abstract
In a prospective cohort of 534 neonates with acute symptomatic seizures, 66% had incomplete response to the initial loading dose of antiseizure medication (ASM). Treatment response did not differ by gestational age, sex, medication, or dose. The risk of incomplete response was highest for seizures due to intracranial hemorrhage and lowest for hypoxic-ischemic encephalopathy, although the difference was not significant after adjusting for high seizure burden and therapeutic hypothermia treatment. Future trial design may test ASMs in neonates with all acute symptomatic seizure etiologies and could target neonates with seizures refractory to an initial ASM.
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Affiliation(s)
- Hannah C Glass
- Departments of Neurology and Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, California.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney J Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Palo Alto, California
| | - Taeun Chang
- Department of Neurology, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia
| | - Maria Roberta Cilio
- Departments of Neurology and Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Departments of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cameron Thomas
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Monica Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California
| | - Renée A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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Abstract
Perinatal arterial ischemic stroke is a relatively common and serious neurologic disorder that can affect the fetus, the preterm, and the term-born infant. It carries significant long-term disabilities. Herein we describe the current understanding of its etiology, pathophysiology and classification, different presentations, and optimal early management. We discuss the role of different brain imaging modalities in defining the extent of lesions and the impact this has on the prediction of outcomes. In recent years there has been progress in treatments, making early diagnosis and the understanding of likely morbidities imperative. An overview is given of the range of possible outcomes and optimal approaches to follow-up and support for the child and their family in the light of present knowledge.
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Abstract
The first weeks of life are a time of heightened risk for seizures due to age-dependent physiologic features of the developing brain that lead to increased neuronal excitation and decreased inhibition. Usually, seizures in neonates are a symptom of an acute brain injury; seizures are only rarely due to neonatal-onset epilepsy syndromes. Neonatal seizures are harmful to the developing brain; early and accurate diagnosis is critical. For suspected seizures, EEG monitoring should be initiated as soon as is feasible, in order to evaluate for events of concern, screen for subclinical seizures, and assess the EEG background. Amplitude-integrated EEG can provide excellent complementary data, particularly with regard to evolution of background patterns, but has limited sensitivity to detect individual neonatal seizures. An urgent and systematic approach to precise etiologic diagnosis is key for optimal management and estimates of prognosis. Evaluation of the seizure etiology must occur in parallel with initiation of appropriate treatment. It is critical that neonatologists and neurologists develop hospital-specific, consensus-based practice pathways for neonatal seizure evaluation and treatment. Such practice pathways can streamline medical decision making, facilitate rapid medication administration, and potentially decrease seizure burden and optimize outcomes. Herein, the pathophysiology, epidemiology, treatment, and long-term management considerations for neonatal seizures are presented.
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Affiliation(s)
- Renée A Shellhaas
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan, Ann Arbor, MI, United States.
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Dunbar M, Kirton A. Perinatal stroke: mechanisms, management, and outcomes of early cerebrovascular brain injury. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:666-676. [PMID: 30119760 DOI: 10.1016/s2352-4642(18)30173-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/24/2022]
Abstract
Perinatal stroke encompasses a heterogeneous group of focal neurological injuries early in brain development that probably affects more than 5 million people worldwide. Many such injuries are symptomatic in the first days of life, including neonatal arterial ischaemic stroke, cerebral sinovenous thrombosis, and neonatal haemorrhagic stroke. The remaining focal neurological injuries usually present later in the first year with motor asymmetry, such as arterial presumed perinatal ischaemic stroke, periventricular venous infarction, and presumed perinatal haemorrhagic stroke. The numerous sequelae of these injuries include hemiparesis (cerebral palsy), epilepsy, and cognitive, language, and behavioural challenges. In this Review we summarise each perinatal stroke disease, examining the epidemiology, pathophysiology, acute management, and outcomes, including the effect on parents and families, and emerging therapies to mitigate these lifelong morbidities.
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Affiliation(s)
- Mary Dunbar
- Department of Community Health Services, University of Calgary, Calgary, Alberta, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada.
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Glass HC, Numis AL, Gano D, Bali V, Rogers EE. Outcomes After Acute Symptomatic Seizures in Children Admitted to a Neonatal Neurocritical Care Service. Pediatr Neurol 2018; 84:39-45. [PMID: 29886041 DOI: 10.1016/j.pediatrneurol.2018.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Neonatal seizures due to acute brain injury are associated with high rates of death, disability, and epilepsy. Our objective was to examine incidence of and risk factors for epilepsy among survivors of acute symptomatic neonatal seizures who were cared for by a neonatal neurocritical care service. METHODS Neonates with acute symptomatic seizures who were admitted to UCSF Benioff Children's Hospital Neuro-Intensive Care Nursery from July 2008 to June 2014 were considered for inclusion. RESULTS A total of 144 children with acute symptomatic seizures met study criteria and 37 (26%) died before age one. Eighty-seven children (85% of eligible survivors) were followed up to one year or longer. Epilepsy was diagnosed in eight children at median age 4.9 (interquartile range 1.7, 6.1) years. The cumulative incidence risk of epilepsy at one year was 2% (95% confidence interval 0.6% to 9%) and at five years was 7% (95% confidence interval 3% to 20%). Cerebral palsy was diagnosed in 21%. Bayley-III cognitive subscale less than 85 was present in 13%. Children with epilepsy were more likely to be preterm, have brain injury, and be discharged home on antiseizure medication, although the results were not significant after adjusted analysis. CONCLUSIONS The risk of epilepsy was lower and age at onset was older than in previous reports, which may be related to multiple factors including a neurocritical care approach, treatment of hypoxic-ischemic encephalopathy with hypothermia, high rate of neonatal transition to palliative care, and the exclusion of neonatal onset epilepsies. Continuation of antiseizure medications in infancy did not decrease the risk of epilepsy. Long-term, multicenter studies are needed to understand whether neonatal seizure management can alter the risk of epilepsy.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Adam L Numis
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Dawn Gano
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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Abstract
Acute symptomatic seizures caused by either diffuse or focal perinatal hypoxic-ischemic insults and intracranial hemorrhage in term newborns make up the large majority of all neonatal seizures. Acute seizures are one of the most common neurological disorders in term newborns who require admission to the neonatal intensive care unit. Despite elucidation of seizure pathogenesis in this population using animal models, treatment is limited by a lack of good evidence-based guidelines because of a paucity of rigorously conducted clinical trials or prospective studies in human newborns. A result of this knowledge gap is that management, particularly drug choice, is guided by clinical experience rather than by data informing drug efficacy and safety. This review summarizes the common etiologies and pathogenesis of acute symptomatic seizures, and the current data informing their treatment, including potential novel drugs, together with a suggested treatment algorithm.
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Affiliation(s)
- Janet S. Soul
- Fetal–Neonatal Neurology Program, Boston Children’s Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Address: Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel.: +1 617-355-8994; fax: +1 617-730-0279. (J.S. Soul)
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47
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Berg AT, Goldman S. Getting serious about the early-life epilepsies. Neurology 2018; 90:842-848. [DOI: 10.1212/wnl.0000000000005423] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/15/2018] [Indexed: 12/15/2022] Open
Abstract
Early-life epilepsies represent a group of many individually rare and often complex developmental brain disorders associated with lifelong devastating consequences and high risk for early mortality. The quantity and quality of evidence needed to guide the evaluation and treatment to optimize outcomes of affected children is minimal; most children are treated within an evidence-free practice zone based solely on anecdote and lore. The remarkable advances in diagnostics and therapeutics are implemented haphazardly with no systematic effort to understand their effects and value. This stands in stark contrast to the evidence-rich practice of the Children's Oncology Group, where standard of care treatments are identified through rigorous, multicenter research studies, and the vast majority of patients are treated on protocols developed from that research. As a consequence, overall mortality for childhood cancers has declined from ∼90% in the 1950s to ∼20% today. The situations of these 2 rare disease specialties are contrasted, and some suggestions for moving early-life epilepsy onto a fast track for success are offered. Chief amongst these is that early-life epilepsy should be treated with the same urgency as pediatric cancer. The best diagnostics and evidence-based treatments should be used in a systematic fashion right from the start, not after the child and family have been subjected to the ravages of the disorder for months or years. This will require unity and cooperation among physicians, researchers, and institutions across state and national borders.
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Natarajan N, Beatty CW, Gust J, Hamiwka L. Provider Practices of Phenobarbital Discontinuation in Neonatal Seizures. J Child Neurol 2018; 33:153-157. [PMID: 29256315 DOI: 10.1177/0883073817745990] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neonatal seizures are treated with phenobarbital and prolonged treatment does not prevent postneonatal epilepsy. The authors documented factors influencing phenobarbital use and determined whether published data changed practice. A total of 83 neonates with symptomatic seizures, clinical or electrographic, were evaluated for treatment, incidence of postneonatal epilepsy, and associated factors. Median phenobarbital treatment was 81 days. Nineteen children (23%) developed postneonatal epilepsy. Longer duration of seizures and an infectious etiology were associated with postneonatal epilepsy suggesting no impact on duration of phenobarbital treatment. Treatment duration was associated with duration of seizures and use of a second antiseizure medication. This study supports early discontinuation of phenobarbital and suggests providers utilize factors such as use of a second antiseizure medication and time to seizure control to determine phenobarbital duration, despite prior studies suggesting no impact of treatment length.
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Affiliation(s)
- Niranjana Natarajan
- 1 Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Christopher W Beatty
- 1 Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Juliane Gust
- 1 Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Lorie Hamiwka
- 1 Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
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Abstract
The mainstay of treatment of childhood epilepsy is to administer antiepileptic drugs (AEDs). This article provides an overview of the clinical approach to drug treatment of childhood epilepsy, focusing on general principles of therapy and properties of recently introduced medications. Initiation and cessation of therapy, adverse medication effects, drug interactions, indications for the various AEDs, and off-label use of AEDs are reviewed. The distinct challenges in treatment of epileptic spasms and neonatal seizures are addressed. Finally, ideas for the future of drug treatment of childhood epilepsy are presented, with particular attention to precision medicine.
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Affiliation(s)
- Louis T Dang
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Room 12-733, 1540 East Hospital Drive, Ann Arbor, MI 48109-4279, USA.
| | - Faye S Silverstein
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, 8301 MSRB3, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5646, USA
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McNally MA, Hartman AL. Variability in Preferred Management of Electrographic Seizures in Neonatal Hypoxic Ischemic Encephalopathy. Pediatr Neurol 2017; 77:37-41. [PMID: 28982530 DOI: 10.1016/j.pediatrneurol.2017.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/05/2017] [Accepted: 06/13/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Seizures may cause added harm in neonates with hypoxic-ischemic encephalopathy (HIE). Specific recommendations about seizure treatment in this context are lacking. We sought to determine the scope of practice regarding management of non-status epilepticus electrographic-only seizures in this setting. METHODS A case-based survey was distributed to members of the Child Neurology Society. Providers were asked about their preferred management strategy for sequential clinical scenarios. RESULTS A total of 177 child neurologists responded to the survey. Seventy-seven percent of providers would treat 20 seconds or less of electrographic seizure activity. In a neonate with mild HIE and an electrographic-only seizure, there was no agreement among providers regarding whether to start maintenance therapy in addition to a one-time anti-seizure drug load. In a neonate with moderate HIE on phenobarbital for early electro-clinical seizures, most providers would escalate treatment for ongoing electrographic-only seizures by increasing phenobarbital dosing. In a neonate with severe HIE complicated by status epilepticus on phenobarbital who subsequently develops recurrent electrographic-only seizures, providers varied substantially in their management preferences. For all three cases, 75% to 85% of providers would not change their management preferences based on the absence of a clinical correlate with the electrographic seizure. CONCLUSIONS We found marked variability among providers regarding preferred management of non-status epilepticus electrographic-only seizures after HIE. Our results identified specific aspects of electrographic-only seizure management in neonatal HIE where there is limited consensus. These discrepancies may serve as opportunities for future investigation.
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Affiliation(s)
- Melanie A McNally
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Adam L Hartman
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland; Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.
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