Approach to neonatal seizures

Comparative efficacy of anti-epileptic drugs for neonatal seizures: A network meta-analysis

BACKGROUND

Anti-epileptic drugs have different effects on neonatal seizures, and new agents have been widely used in recent years. Meanwhile, significant differences still exist in the treatment for neonatal seizures, whether in choice of drug or in duration of treatment. And with the increase in options for treatment, the best choice of second-line treatment has not been recommended.

METHODS

The MEDLINE, the Cochrane Library, Web of Science, Embase and clinicaltrials.gov databases were searched (January 1, 1960 to October 20, 2020). Randomized controlled trials (RCTs) or observational investigations studying anti-epileptic drugs for neonatal seizures were selected. And then we conducted a network meta-analysis and examined comparative efficacy of the first-line and second-line anti-epileptic drugs for neonatal seizures.

RESULTS

Data were extracted from 11 included studies by 2 independent investigators. Random effects models were used to estimate odds ratios (ORs). We performed direct meta-analyses with a random effects model and network meta-analyses for first-line and second-line drugs. Five published RCTs and 6 observational investigations with 1333 patients and 6 interventions contributed to the analysis.

CONCLUSION

We recommend phenobarbital as the first-line drug for neonatal seizures. In addition, there is a tendency for levetiracetam to be an effective second-line treatment for neonatal seizures after failure of first-line drugs.

Score for Neonatal Acute Physiology-II Predicts Outcome in Congenital Diaphragmatic Hernia Patients

OBJECTIVE

Accurate and validated predictors of outcome for infants with congenital diaphragmatic hernia are needed. Score for Neonatal Acute Physiology-II has been validated to predict mortality in newborns. We investigated whether Score for Neonatal Acute Physiology-II scores in congenital diaphragmatic hernia could predict mortality, need for extracorporeal membrane oxygenation (in patients born in a center with extracorporeal membrane oxygenation availability), and development of bronchopulmonary dysplasia (oxygen dependency beyond 28 d after birth) in survivors.

DESIGN

Data were obtained from a prospective, multicenter randomized controlled trial of initial ventilation strategy carried out by the Congenital Diaphragmatic Hernia EURO Consortium (NTR 1310).

SETTING

ICUs of level III university children's hospitals.

PATIENTS

Congenital diaphragmatic hernia infants without severe chromosomal anomalies or severe cardiac anomalies born between November 2008 and December 2013.

INTERVENTIONS

Randomization for initial ventilation strategy (high-frequency oscillation/ conventional mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

Logistic regression analyses were used to evaluate associations between Score for Neonatal Acute Physiology-II and outcome parameters. Of the 171 included patients, 46 died (26.9%), 40 of 108 (37.0%) underwent extracorporeal membrane oxygenation, and 39 of 125 survivors (31.2%) developed bronchopulmonary dysplasia. In nonsurvivors, the median Score for Neonatal Acute Physiology-II was 42.5 (interquartile range, 33.5-53.8) and 16.5 (interquartile range, 9.0-27.5) in survivors (p < 0.001). Score for Neonatal Acute Physiology-II also significantly differed between extracorporeal membrane oxygenation and non-extracorporeal membrane oxygenation-treated patients (p < 0.001), and survivors with and without bronchopulmonary dysplasia (p < 0.001). Multivariable logistic regression analyses adjusted for hernia side, liver position, ventilation mode, gestational age, center and observed-to-expected lung-to-head-ratio showed that Score for Neonatal Acute Physiology-II was associated with mortality (odds ratio, 1.16 [1.09-1.23]; p < 0.001) and need for extracorporeal membrane oxygenation support (odds ratio, 1.07 [1.02-1.13]; p = 0.01), but not for the development of bronchopulmonary dysplasia (odds ratio, 1.04 [0.99-1.09]; p = 0.14).

CONCLUSIONS

The Score for Neonatal Acute Physiology-II predicts not only mortality but also need for extracorporeal membrane oxygenation in congenital diaphragmatic hernia patients. We, therefore, recommend to implement this simple and rapid scoring system in the evaluation of severity of illness in patients with congenital diaphragmatic hernia and thereby have insight into the prognosis within 1 day after birth.

Adverse neurodevelopmental outcomes after exposure to phenobarbital and levetiracetam for the treatment of neonatal seizures

OBJECTIVE

Compare neurodevelopment after levetiracetam (LEV) and phenobarbital (PB) for neonatal seizures.

STUDY DESIGN

Retrospective study of infants who received antiepileptic drugs (AEDs) for neonatal seizures. Effect of cumulative exposure to LEV and PB on outcomes of death, cerebral palsy (CP) and Bayley Scales of Infant Development (BSID) scores were evaluated at 24 months corrected age. Analyses were adjusted for number of electrographic seizures and gestational age.

RESULT

In 280 infants with comparable seizure etiology and cranial imaging results, increased exposure to PB was associated with worse BSID cognitive and motor scores (8.1- and 9-point decrease per 100 mg kg(-1); P=0.01). The effect was less with LEV (2.2- and 2.6-point decrease per 300 mg kg(-1) LEV (P=0.01)). CP probability increased by 2.3-fold per 100 mg kg(-1) PB and was not associated with increasing LEV.

CONCLUSION

Increased exposure to PB is associated with worse neurodevelopmental outcomes than LEV. Prospective studies of outcomes of neonatal exposure to AEDs are essential.

Levetiracetam

The incidence of neonatal seizures varies according to gestational age, weight, and cause. Seizures occur in an estimated 1.0-3.5 per 1,000 term infants1 with an increased incidence of 10-130/1,000 in preterm infants.2 Most neonatal seizures have a specific cause.3 Hypoxic-ischemic encephalopathy has been identified as the most common etiology associated with neonatal seizures, accounting for 50-60 percent of the cases.4 Table 1 outlines common causes of neonatal seizures. Early recognition of seizures and appropriate treatment is vital in preventing multiorgan dysfunction and permanent brain damage.