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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Anti-seizure medications for neonates with seizures. Cochrane Database Syst Rev 2023; 10:CD014967. [PMID: 37873971 PMCID: PMC10594593 DOI: 10.1002/14651858.cd014967.pub2] [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] [Indexed: 10/25/2023]
Abstract
BACKGROUND Newborn infants are more prone to seizures than older children and adults. The neuronal injury caused by seizures in neonates often results in long-term neurodevelopmental sequelae. There are several options for anti-seizure medications (ASMs) in neonates. However, the ideal choice of first-, second- and third-line ASM is still unclear. Further, many other aspects of seizure management such as whether ASMs should be initiated for only-electrographic seizures and how long to continue the ASM once seizure control is achieved are elusive. OBJECTIVES 1. To assess whether any ASM is more or less effective than an alternative ASM (both ASMs used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 2. To assess maintenance therapy with ASM versus no maintenance therapy after achieving seizure control. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 3. To assess treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, Epistemonikos and three databases in May 2022 and June 2023. These searches were not limited other than by study design to trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that included neonates with EEG-confirmed or clinically diagnosed seizures and compared (1) any ASM versus an alternative ASM, (2) maintenance therapy with ASM versus no maintenance therapy, and (3) treatment of clinical or EEG seizures versus treatment of clinical seizures alone. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility, risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence interval (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 18 trials (1342 infants) in this review. Phenobarbital versus levetiracetam as first-line ASM in EEG-confirmed neonatal seizures (one trial) Phenobarbital is probably more effective than levetiracetam in achieving seizure control after first loading dose (RR 2.32, 95% CI 1.63 to 3.30; 106 participants; moderate-certainty evidence), and after maximal loading dose (RR 2.83, 95% CI 1.78 to 4.50; 106 participants; moderate-certainty evidence). However, we are uncertain about the effect of phenobarbital when compared to levetiracetam on mortality before discharge (RR 0.30, 95% CI 0.04 to 2.52; 106 participants; very low-certainty evidence), requirement of mechanical ventilation (RR 1.21, 95% CI 0.76 to 1.91; 106 participants; very low-certainty evidence), sedation/drowsiness (RR 1.74, 95% CI 0.68 to 4.44; 106 participants; very low-certainty evidence) and epilepsy post-discharge (RR 0.92, 95% CI 0.48 to 1.76; 106 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Phenobarbital versus phenytoin as first-line ASM in EEG-confirmed neonatal seizures (one trial) We are uncertain about the effect of phenobarbital versus phenytoin on achieving seizure control after maximal loading dose of ASM (RR 0.97, 95% CI 0.54 to 1.72; 59 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Maintenance therapy with ASM versus no maintenance therapy in clinically diagnosed neonatal seizures (two trials) We are uncertain about the effect of short-term maintenance therapy with ASM versus no maintenance therapy during the hospital stay (but discontinued before discharge) on the risk of repeat seizures before hospital discharge (RR 0.76, 95% CI 0.56 to 1.01; 373 participants; very low-certainty evidence). Maintenance therapy with ASM compared to no maintenance therapy may have little or no effect on mortality before discharge (RR 0.69, 95% CI 0.39 to 1.22; 373 participants; low-certainty evidence), mortality at 18 to 24 months (RR 0.94, 95% CI 0.34 to 2.61; 111 participants; low-certainty evidence), neurodevelopmental disability at 18 to 24 months (RR 0.89, 95% CI 0.13 to 6.12; 108 participants; low-certainty evidence) and epilepsy post-discharge (RR 3.18, 95% CI 0.69 to 14.72; 126 participants; low-certainty evidence). Treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates (two trials) Treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation (MD -1871.16, 95% CI -4525.05 to 782.73; 68 participants; low-certainty evidence), mortality before discharge (RR 0.59, 95% CI 0.28 to 1.27; 68 participants; low-certainty evidence) and epilepsy post-discharge (RR 0.75, 95% CI 0.12 to 4.73; 35 participants; low-certainty evidence). The trials did not report on mortality or neurodevelopmental disability at 18 to 24 months. We report data from the most important comparisons here; readers are directed to Results and Summary of Findings tables for all comparisons. AUTHORS' CONCLUSIONS Phenobarbital as a first-line ASM is probably more effective than levetiracetam in achieving seizure control after the first loading dose and after the maximal loading dose of ASM (moderate-certainty evidence). Phenobarbital + bumetanide may have little or no difference in achieving seizure control when compared to phenobarbital alone (low-certainty evidence). Limited data and very low-certainty evidence preclude us from drawing any reasonable conclusion on the effect of using one ASM versus another on other short- and long-term outcomes. In neonates who achieve seizure control after the first loading dose of phenobarbital, maintenance therapy compared to no maintenance ASM may have little or no effect on all-cause mortality before discharge, mortality by 18 to 24 months, neurodevelopmental disability by 18 to 24 months and epilepsy post-discharge (low-certainty evidence). In neonates with hypoxic-ischaemic encephalopathy, treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation, all-cause mortality before discharge and epilepsy post-discharge (low-certainty evidence). All findings of this review apply only to term and late preterm neonates. We need well-designed RCTs for each of the three objectives of this review to improve the precision of the results. These RCTs should use EEG to diagnose seizures and should be adequately powered to assess long-term neurodevelopmental outcomes. We need separate RCTs evaluating the choice of ASM in preterm infants.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, KMCH Institute of Health Sciences and Research (KMCHIHSR), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Ronit Pressler
- Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
- Clinical Neurophysiology and Neonatology, Cambridge University Hospital, Cambridge, UK
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Francesco Brigo
- Neurology, Hospital of Merano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Merano-Meran, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano-Bozen, Italy
| | - Hans Hartmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Pressler RM, Abend NS, Auvin S, Boylan G, Brigo F, Cilio MR, De Vries LS, Elia M, Espeche A, Hahn CD, Inder T, Jette N, Kakooza-Mwesige A, Mader S, Mizrahi EM, Moshé SL, Nagarajan L, Noyman I, Nunes ML, Samia P, Shany E, Shellhaas RA, Subota A, Triki CC, Tsuchida T, Vinayan KP, Wilmshurst JM, Yozawitz EG, Hartmann H. Treatment of seizures in the neonate: Guidelines and consensus-based recommendations-Special report from the ILAE Task Force on Neonatal Seizures. Epilepsia 2023; 64:2550-2570. [PMID: 37655702 DOI: 10.1111/epi.17745] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Seizures are common in neonates, but there is substantial management variability. The Neonatal Task Force of the International League Against Epilepsy (ILAE) developed evidence-based recommendations about antiseizure medication (ASM) management in neonates in accordance with ILAE standards. Six priority questions were formulated, a systematic literature review and meta-analysis were performed, and results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 standards. Bias was evaluated using the Cochrane tool and risk of Bias in non-randomised studies - of interventions (ROBINS-I), and quality of evidence was evaluated using grading of recommendations, assessment, development and evaluation (GRADE). If insufficient evidence was available, then expert opinion was sought using Delphi consensus methodology. The strength of recommendations was defined according to the ILAE Clinical Practice Guidelines development tool. There were six main recommendations. First, phenobarbital should be the first-line ASM (evidence-based recommendation) regardless of etiology (expert agreement), unless channelopathy is likely the cause for seizures (e.g., due to family history), in which case phenytoin or carbamazepine should be used. Second, among neonates with seizures not responding to first-line ASM, phenytoin, levetiracetam, midazolam, or lidocaine may be used as a second-line ASM (expert agreement). In neonates with cardiac disorders, levetiracetam may be the preferred second-line ASM (expert agreement). Third, following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings (expert agreement). Fourth, therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy (evidence-based recommendation). Fifth, treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcome (expert agreement). Sixth, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM (expert agreement). Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, UCL-Great Ormond Street Institute of Child Health, London, UK
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stéphan Auvin
- Department Medico-Universitaire Innovation Robert-Debré, Robert Debré Hospital, Public Hospital Network of Paris, Pediatric Neurology, University of Paris, Paris, France
| | - Geraldine Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of Paracelsus Medical Private University, Bolzano-Bozen, Italy
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Saint-Luc University Hospital, and Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Linda S De Vries
- Department of Neonatology, University Medical Center, Utrecht, the Netherlands
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Alberto Espeche
- Department of Neurology, Hospital Materno Infantil, Salta, Argentina
| | - Cecil D Hahn
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Terrie Inder
- Department of Pediatrics, Newborn Medicine, Children's Hospital of Orange County, University of California, Irvine, Irvine, California, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Silke Mader
- Scientific Affairs, European Foundation for the Care of Newborn Infants, Munich, Germany
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
- Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, New York, USA
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital and University of Western Australia, Nedlands, Western Australia, Australia
| | - Iris Noyman
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Pediatric Neurology Unit, Pediatric Division, Soroka Medical Center, Beer-Sheva, Israel
| | - Magda L Nunes
- Pontifícia Universidade Católica do Rio Grande do Sul-PUCRS School of Medicine and the Brain Institute, Porto Alegre, Brazil
| | - Pauline Samia
- Departments of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Eilon Shany
- Department of Neonatology, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Renée A Shellhaas
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Ann Subota
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Hospital, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - Tammy Tsuchida
- Departments of Neurology and Pediatrics, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, USA
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa G Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Sourbron J, Auvin S, Arzimanoglou A, Cross JH, Hartmann H, Pressler R, Riney K, Sugai K, Wilmshurst JM, Yozawitz E, Lagae L. Medical treatment in infants and young children with epilepsy: Off-label use of antiseizure medications. Survey Report of ILAE Task Force Medical Therapies in Children. Epilepsia Open 2023; 8:77-89. [PMID: 36281833 PMCID: PMC9977757 DOI: 10.1002/epi4.12666] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Antiseizure medications (ASMs) remain the mainstay of epilepsy treatment. These ASMs have mainly been tested in trials in adults with epilepsy, which subsequently led to market authorization (MA). For treatment of - especially young - children with epilepsy, several ASMs do not have a MA and guidelines are lacking, subsequently leading to "off-label" use of ASMs. Even though "off-label" ASM prescriptions for children could lead to more adverse events, it can be clinically appropriate and rational if the benefits outweigh the risks. This could be the case if "on-label" ASM, in mono- or polytherapy, fails to achieve adequate seizure control. METHODS The Medical Therapies Task Force of the International League Against Epilepsy (ILAE) Commission for Pediatrics performed a survey to study the current treatment practices in six classic, early life epilepsy scenarios. Our aim was not only to study first- and second-line treatment preferences but also to illustrate the use of "off-label" drugs in childhood epilepsies. RESULTS Our results reveal that several ASMs (e.g. topiramate, oxcarbazepine, benzodiazepines) are prescribed "off-label" in distinct scenarios of young children with epilepsy. In addition, recent scientific guidelines were not always adopted by several survey respondents, suggesting a potential knowledge gap. SIGNIFICANCE We report the relatively common use of "off-label" prescriptions that underlines the need for targeted and appropriately designed clinical trials, including younger patients, which will also result in the ability to generate evidence-based guidelines.
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Affiliation(s)
- Jo Sourbron
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
| | - Stéphane Auvin
- A PHP, Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France.,INSERM NeuroDiderot, Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
| | - Alexis Arzimanoglou
- Epilepsy Department, Member of the ERN EpiCARE, Sant Joan de Déu Hospital, Barcelona, Spain.,Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, University Hospitals of Lyon (HCL), Lyon, France
| | - J Helen Cross
- Great Ormond Street Hospital for Children, London, UK.,Programme of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Ronit Pressler
- Great Ormond Street Hospital for Children, London, UK.,Programme of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Kate Riney
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Neurosciences Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Kenji Sugai
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa Yozawitz
- Isabelle Rapin Division of Child Neurology of the Saul R Korey Department of Neurology, Montefiore Medical Center, New York City, New York, USA
| | - Lieven Lagae
- Section Pediatric Neurology, Department of Development and Regeneration, University Hospital KU Leuven, Leuven, Belgium
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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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MOHAMMADI M, KADIVAR M, SANGSARI R, MIRNIA K, SAEEDI M, ADHAMI P. Comparing the Efficacy and Safety of Levetiracetam Versus Phenytoin for Treating the Acute Phase of Neonatal Seizures. IRANIAN JOURNAL OF CHILD NEUROLOGY 2023; 17:65-71. [PMID: 36721831 PMCID: PMC9881830 DOI: 10.22037/ijcn.v17i1.36008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 03/03/2022] [Indexed: 02/02/2023]
Abstract
Objectives Neonatal seizure is a significant problem in this life course, and its timely and effective treatment is crucial. In this study, we compared the efficacy of levetiracetam versus phenytoin for treating the acute phase of neonatal seizures. Materials & Methods In this single-blind case-control study, 60 consecutive children with neonatal seizures referred to the Children's medical center in Tehran, Iran, in 2018 were studied. Those neonates who had at least 30 minutes of seizure after Phenobarbital treatment were assigned to receive either phenytoin (20 mg/kg) or levetiracetam (initial dose of 40-60 mg/kg) through block randomization. The efficacy and safety of the two drugs were compared between the groups. Results The response rate was 83.3% and 86.7% in phenytoin and Levetiracetam groups, respectively, which was not significantly different between groups (P=1.000). Adverse effects were nearly similar between groups (6.7% in the phenytoin group and 3.3% in the Levetiracetam group, P=1.000). Conclusion Levetiracetam and phenytoin are both practical and safe for treating neonatal seizures.
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Affiliation(s)
- Mahmoud MOHAMMADI
- Department of Pediatrics, Tehran University of Medical Sciences, Children’s Medical Center ,Tehran, Iran
| | - Maliheh KADIVAR
- Department of Pediatrics, Division of Neonatology – School of Medicine, Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran
| | - Razieh SANGSARI
- Department of Pediatrics, Division of Neonatology – School of Medicine, Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran
| | - Kayvan MIRNIA
- Department of Pediatrics, Division of Neonatology – School of Medicine, Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran
| | - Maryam SAEEDI
- Department of Pediatrics, Division of Neonatology – School of Medicine, Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran
| | - Pegah ADHAMI
- Department of Pediatrics, Division of Neonatology – School of Medicine, Tehran University of Medical Sciences, Children’s Medical Center, Tehran, Iran
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Akeel NE, Suliman HA, Al-Shokary AH, Ibrahim AO, Kamal NM, Abdelgalil AA, Elmala MK, Elshorbagy HH, Nasef KA, Attia AM, Fathallah MGED. A Comparative Study of Levetiracetam and Phenobarbital for Neonatal Seizures as a First Line Treatment. Glob Pediatr Health 2022; 9:2333794X221143572. [PMID: 36578326 PMCID: PMC9791297 DOI: 10.1177/2333794x221143572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/05/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives We aimed to evaluate the use of intravenous levetiracetam as the first-line treatment of neonatal seizures compared with phenobarbital. Methods The study was conducted on 104 neonates (0-28 days) with clinical seizures after inclusion criteria. They were assigned in equal ratio into 2 groups; 1 included neonates who received phenobarbitone, and the other included neonates who received levetiracetam. Neonates were loaded with 20 mg/kg of intravenous drug-A (phenobarbitone) or drug-B (levetiracetam). In persistent seizures, a second loading dose of the same drug was given. Crossover to other drugs occurred if seizures persisted after the second dose of the same drug. The proportion of neonates who achieved cessation of seizures following the first or second loading dose of either drug-A or drug-B (PB or LEV) was the main outcome measure provided that they remained free of seizure for the following 24 hours. Results After 1 or 2 doses of Levetiracatam or Phenobarbitone, clinical seizures stopped (and remained seizure-free for 24 hours) in 41 (78.84%) and 34 (65.38%) patients, respectively (P = .01). Neonates in the LEV group showed better seizure control than neonates in the PB group (RR = 0.57; 95% CI (0.17, 0.80). We did not report any adverse drug reactions in the LEV group. However, 12 (23.07%) neonates developed adverse drug reactions in the PB Group. Conclusion Levetiracetam is considered an effective and safe drug as a first-line AED in neonatal seizures.
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Affiliation(s)
| | | | | | | | | | | | | | - Hatem Hamed Elshorbagy
- Professor of Pediatrics and Pediatric Neurology, Faculty of medicine, Menoufia University, Shebeen Elkom, Egypt,Hatem Hamed Elshorbagy, Department of Pediatric, Menoufia University, Gamal Abdel Naser street, Shebeen Elkom 32511, Egypt.
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Vesoulis ZA, Alexopoulos D, Rogers C, Neil J, Smyser C. Seizure burden in preterm infants and smaller brain volume at term-equivalent age. Pediatr Res 2022; 91:955-961. [PMID: 33903729 PMCID: PMC8546006 DOI: 10.1038/s41390-021-01542-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/02/2021] [Accepted: 04/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Seizures are underrecognized in preterm infants, and little is known about their impact on brain growth. We aimed to define the association between early seizures and subsequent brain growth. METHODS Infants <30 weeks gestation underwent 72 h of prospective amplitude-integrated electroencephalography (aEEG) monitoring, term-equivalent age (TEA) magnetic resonance imaging (MRI), and 2-year neurodevelopmental testing. Seizures were defined as trains of sharp waves >10 s, evolving in frequency/amplitude/morphology, and identified using automated algorithms with manual review. Using T2-weighted images, cortical surface area (CSA) and gyrification index (GI) were calculated and volumes were segmented into five tissue classes: cerebrospinal fluid, gray matter, white matter (WM), deep nuclear gray matter, and cerebellum. Correlations between total seizure burden and tissue-specific volumes were evaluated, controlling for clinical variables of interest. RESULTS Ninety-nine infants underwent aEEG/MRI assessments (mean GA = 26.3 weeks, birthweight = 899 g). Seizure incidence was 55% with a median of two events; median length = 66 s and mean burden = 285 s. Greater seizure burden was associated with smaller CSA and volumes across all tissue types, most prominently in WM (R2 = -0.603, p < 0.01), even after controlling for confounders. There was no association with GI. CONCLUSIONS Seizures in preterm infants are common and associated with smaller TEA brain volumes. This relationship was strongest for WM and independent of clinical factors. IMPACT Seizures in preterm infants are common. Little is known about the association between early seizures and later brain growth. Greater seizure burden is linked with smaller volumes of all brain tissue types, most prominently the WM. This relationship is true even controlling for other factors. Additional study is needed to identify the optimal EEG monitoring and seizure treatment strategy for improved brain growth and neurodevelopmental outcomes.
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Affiliation(s)
- Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University, St. Louis, MO, USA.
| | - Dimitrios Alexopoulos
- Division of Child Neurology, Department of Neurology, Washington University, St. Louis, MO, USA
| | - Cynthia Rogers
- Division of Newborn Medicine, Department of Pediatrics, Washington University, St. Louis, MO, USA
- Department of Psychiatry, Washington University, St. Louis, MO, USA
| | - Jeffrey Neil
- Division of Newborn Medicine, Department of Pediatrics, Washington University, St. Louis, MO, USA
- Division of Child Neurology, Department of Neurology, Washington University, St. Louis, MO, USA
- Department of Radiology, Washington University, St. Louis, MO, USA
| | - Christopher Smyser
- Division of Newborn Medicine, Department of Pediatrics, Washington University, St. Louis, MO, USA
- Division of Child Neurology, Department of Neurology, Washington University, St. Louis, MO, USA
- Department of Radiology, Washington University, St. Louis, MO, USA
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Qiao MY, Cui HT, Zhao LZ, Miao JK, Chen QX. Efficacy and Safety of Levetiracetam vs. Phenobarbital for Neonatal Seizures: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:747745. [PMID: 34867732 PMCID: PMC8636327 DOI: 10.3389/fneur.2021.747745] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/30/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Neonatal seizures are a common neurological emergency in newborns. Phenobarbital (PB) is the first-line antiepileptic drug (AED). However, PB has some side effects, such as hypotension and respiratory depression, and it can accelerate neuronal apoptosis in the immature brain. Levetiracetam (LEV), a new antiepileptic drug, has been used as a second-line drug for the treatment of neonatal seizures. Compared with PB, LEV has many advantages, including a low incidence of side effects and better neurodevelopmental outcomes. However, there are only a few systematic reviews of LEV for the treatment of neonatal seizures. Objective: To evaluate the efficacy and safety of LEV for neonatal seizures and to compare the efficacy, side effects, and neurological outcomes between LEV and PB in the treatment of neonatal seizures. Methods: The keywords LEV, PB, and neonatal seizure were searched in the MEDLINE, Cochrane Library, Web of Science, EMBASE, clinicaltrials.gov, and China National Knowledge Internet (CNKI) databases with a last update in July 2021 to collect high-quality studies. We collected studies studying the efficacy or safety of LEV and PB in the treatment of neonatal seizures applying strict inclusion and exclusion criteria. The data were extracted and outcome measures, including efficacy, side effect rate, neurological score, and mortality rate, were analyzed with RevMan 5.3 software. Results: Ten articles were finally included in the meta-analysis. The meta-analysis showed that there was no difference in efficacy between LEV and PB in the treatment of neonatal seizures. Compared with PB, the incidence of side effects of LEV was lower. The incidence of hypotension and respiratory depression in the LEV group was significantly lower than that in the PB group. In terms of long-term neurodevelopmental outcomes, there was no significant difference in the Bayley Scales of Infant Development (BSID) scores between LEV and PB. Conclusion: PB is still the first-line AED recommended by the WHO for the treatment of neonatal seizures. The new AEDs LEV may not have better efficacy than PB. At the same time, LEV is associated with better neurodevelopment outcomes and a lower risk of adverse effects. In addition, continuous EEG monitoring should be used to diagnose neonatal seizures to evaluate the severity of the seizures, remission, and drug efficacy. Systematic Review Registration: PROSPERO, identifier: CRD42021279029.
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Affiliation(s)
- Meng-Yuan Qiao
- Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Hong-Tao Cui
- Chongqing Traditional Chinese Medicine Hospital, Chongqing, China.,Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ling-Zhi Zhao
- Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Jing-Kun Miao
- Chongqing Health Center for Women and Children, Chongqing, China
| | - Qi-Xiong Chen
- Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
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9
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Li L, Chen GD, Salvi R. Effect of antiepileptic drug levetiracetam on cochlear function. Hear Res 2021; 415:108396. [PMID: 34903423 DOI: 10.1016/j.heares.2021.108396] [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: 06/07/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Levetiracetam (LEV, 5-100 mg/kg) has been shown to prevent audiogenic seizures in a dose-dependent manner. This chemical is known to bind to synaptic vesicle protein 2A and inhibit l-type calcium channels, affecting neurotransmitter release. We hypothesize that the drug prevents audiogenic seizures partially by affecting cochlear neural response. METHODS To test this hypothesis, rats were given 1000, 500, 50, or 0 mg/kg (saline control) LEV-injection. Distortion product otoacoustic emissions (DPOAE), reflecting outer hair cell (OHC) function, and cochlear compound action potentials (CAP), reflecting cochlear neural output, were recorded and compared pre- and post-LEV. RESULTS 1000 mg/kg LEV-injection did not significantly affect DPOAE. The high dose LEV-injection, however, significantly reduced CAP amplitude resulting threshold shift (TS), prolonged CAP latency, and enhanced CAP forward masking. CAP latency and forward masking were significantly affected at the 500 mg/kg dose, but CAP-TS remained unchanged after LEV-injection. Interestingly, CAP latency wassignificantly prolonged, at least at the low stimulation levels, although the amplitude of CAP remained constant after a clinical dose of LEV-injection (50 mg/kg). DISCUSSION Since the clinical dose of LEV-injection does not reduce CAP amplitude, the reduction of cochlear neural output is unlikely to be the underlying mechanism of LEV in the treatment of audiogenic seizure. The delayed cochlear neural response may be partially related to the prevention of audiogenic seizure. However, neuropharmacological changes in the central nervous system must play a major role in the treatment of audiogenic seizure, as it does in the treatment of focal epilepsy.
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Affiliation(s)
- Li Li
- Center for Hearing and Deafness, SUNY at Buffalo, Buffalo, NY 14214, USA
| | - Guang-Di Chen
- Center for Hearing and Deafness, SUNY at Buffalo, Buffalo, NY 14214, USA.
| | - Richard Salvi
- Center for Hearing and Deafness, SUNY at Buffalo, Buffalo, NY 14214, USA
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10
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Kanmaz S, Altun Köroğlu Ö, Terek D, Serin HM, Simsek E, Dokurel Cetin İ, Yilmaz S, Yalaz M, Aktan G, Akisu M, Kultursay N, Gokben S, Tekgul H. Efficacy of levetiracetam as first-line therapy for neonatal clinical seizures and neurodevelopmental outcome at 12 months of age. Acta Neurol Belg 2021; 121:1495-1503. [PMID: 32424740 DOI: 10.1007/s13760-020-01366-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
Appropriate treatment of neonatal seizures with an effective therapy is important in reducing long-term neurologic disabilities. Sixty-seven neonates, who received intravenous (IV) levetiracetam (LEV) as first-line therapy for treating seizures between 2013 and 2017 were evaluated retrospectively to investigate the efficacy of LEV and its neurodevelopmental outcome at 12 months of age. Of the 67 neonates (44 preterm and 23 term babies) evaluated for seizures, 55 (82%) had a defined etiology. EEG confirmation was obtained in 36 (57.1%) of the neonates with clinical seizures. On the 7th day of the treatment (mean seizure control time 7.4 ± 15.1 days), LEV was effective as monotherapy in 43 (64%), whereas add-on therapy was required in 24 (36%) neonates. At the 1-year follow-up, 76% of infants achieved drug-free state, nine (18%) infants remained on LEV monotherapy and three (6%) needed add-on therapy. Neurodevelopmental outcome of the infants was assessed with Ankara Development Screening Inventory and results suggested favorable neurodevelopmental outcome in 69.7% of the infants with at the end of the 1-year follow-up with LEV monotherapy. In conclusion, this retrospective cross-sectional study demonstrated that IV LEV is an effective first-line therapy for treating neonatal clinical seizures and LEV monotherapy effect was sustained during the first year follow-up.
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11
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Hooper RG, Ramaswamy VV, Wahid RM, Satodia P, Bhulani A. Levetiracetam as the first-line treatment for neonatal seizures: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:1283-1293. [PMID: 34124790 DOI: 10.1111/dmcn.14943] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/19/2022]
Abstract
AIM To assess the effectiveness and safety of levetiracetam when used as first-line treatment of neonatal seizures. METHOD Four electronic databases, Medline, Embase, Web of Science, and ClinicalTrials.gov were systematically searched from inception until 20th November 2020. Randomized controlled trials (RCTs) and observational studies that included neonates born preterm and term were eligible for inclusion. The primary outcome measure was levetiracetam effectiveness, defined as seizure cessation within 24 hours of starting treatment. Secondary outcomes included short-term adverse events, mortality before discharge, and long-term neurodevelopmental outcomes. RESULTS Fourteen studies assessing 1188 neonates were included: four RCTs, three observational trials with phenobarbital as the control arm, and seven observational studies of levetiracetam with no control arm. Pooled efficacy of levetiracetam from observational studies was 45% (95% confidence interval [CI] 34-57%) (GRADE - very low). Meta-analysis of RCTs evaluating levetiracetam versus phenobarbital showed that both were equally effective (risk ratio [95% CI] 0.6 [0.30-1.20]) (GRADE - very low). Levetiracetam resulted in a lower risk of short-term adverse events compared to phenobarbital (risk ratio [95% CI] 0.24 [0.06-0.92]) (GRADE - moderate). INTERPRETATION Very low certainty of evidence suggests levetiracetam might not be more effective than phenobarbital. Moderate certainty of evidence indicates levetiracetam is associated with a lower risk of adverse events. Future trials on neonatal antiseizure medication therapy should include continuous electroencephalogram (EEG) monitoring as standard of care and enrol a homogenous population with similar seizure aetiology. What this paper adds Levetiracetam is effective in 45% of neonatal seizures. Levetiracetam might not be more effective than phenobarbital. Levetiracetam is likely to be safer than phenobarbital. Evidence available is limited and of very low certainty.
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Affiliation(s)
- Robert G Hooper
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Rachael M Wahid
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Prakash Satodia
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Adarsh Bhulani
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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12
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Cokyaman T, Elli M, Aydin ÖF, Albayrak C, Albayrak D, Özyürek E. Neuroprotective Efficacy of Prophylactic Antiepileptic Therapies in Busulfan Conditioning Regimen. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1708833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractBusulfan (BU) is commonly used in the anticancer treatment and bone marrow/hematopoietic stem cell transplantation (BM/HSCT) conditioning regimen. This study aimed to evaluate the neuroprotective efficacy of antiepileptic therapies in the BU conditioning regimen. Patients who underwent BM/HSCT between January 1, 2009, and January 1, 2014, were evaluated retrospectively. Diagnosis, demographic characteristics, neurological side effects, electroencephalography (EEG) abnormalities, and antiepileptic drugs were determined. Levetiracetam was given to 49% and phenytoin to 23% of patients as antiepileptic prophylaxis. After BU treatment, seizures developed in three patients, posterior reversible leukoencephalopathy in two patients, and peripheral neuropathy in two patients. Forty-five patients who underwent EEG before and after BU treatment were identified. The effects of antiepileptic prophylaxis over the electroencephalographic abnormalities after the BU conditioning regimen were found to be not different (p = 0.491). Neurological side effects and electroencephalographic abnormalities following BU conditioning regimen under antiepileptic prophylaxis are comparable.
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Affiliation(s)
- Turgay Cokyaman
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Murat Elli
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ömer F. Aydin
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Canan Albayrak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Davut Albayrak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Emel Özyürek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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13
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Falsaperla R, Scalia B, Giugno A, Pavone P, Motta M, Caccamo M, Ruggieri M. Treating the symptom or treating the disease in neonatal seizures: a systematic review of the literature. Ital J Pediatr 2021; 47:85. [PMID: 33827647 PMCID: PMC8028713 DOI: 10.1186/s13052-021-01027-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 01/08/2023] Open
Abstract
Aim The existing treatment options for neonatal seizures have expanded over the last few decades, but no consensus has been reached regarding the optimal therapeutic protocols. We systematically reviewed the available literature examining neonatal seizure treatments to clarify which drugs are the most effective for the treatment of specific neurologic disorders in newborns. Method We reviewed all available, published, literature, identified using PubMed (published between August 1949 and November 2020), that focused on the pharmacological treatment of electroencephalogram (EEG)-confirmed neonatal seizures. Results Our search identified 427 articles, of which 67 were included in this review. Current knowledge allowed us to highlight the good clinical and electrographic responses of genetic early-onset epilepsies to sodium channel blockers and the overall good response to levetiracetam, whose administration has also been demonstrated to be safe in both full-term and preterm newborns. Interpretation Our work contributes by confirming the limited availability of evidence that can be used to guide the use of anticonvulsants to treat newborns in clinical practice and examining the efficacy and potentially harmful side effects of currently available drugs when used to treat the developing newborn brain; therefore, our work might also serve as a clinical reference for future studies.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Bruna Scalia
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy.
| | - Andrea Giugno
- Post graduate programme in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Piero Pavone
- Unit of Clinical Pediatrics, A.O.U. "Policlinico", P.O. "G. Rodolico", University of Catania, Catania, Italy
| | - Milena Motta
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Martina Caccamo
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine Section of Pediatrics and Child Neuropsychiatry, A.O.U. San Marco- Policlinico, University of Catania, Catania, Italy
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14
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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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15
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Alix V, James M, Jackson AH, Visintainer PF, Singh R. Efficacy of Fosphenytoin as First-Line Antiseizure Medication for Neonatal Seizures Compared to Phenobarbital. J Child Neurol 2021; 36:30-37. [PMID: 32811255 DOI: 10.1177/0883073820947514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Currently used treatment protocols for neonatal seizures vary among centers with limited evidence to support the choice of a given antiseizure medication. Because of concerns about the potential negative impact of phenobarbital on long-term neurodevelopment outcomes, our unit transitioned to fosphenytoin as the first-line antiseizure medication. A retrospective observational cohort study was conducted to compare the acute and long-term outcomes of fosphenytoin and phenobarbital as first-line antiseizure medication for neonatal seizure treatment. The 2 study groups had similar baseline characteristics for neonatal variables as well as maternal antenatal complications. We did not find any differences in the acute outcomes between the 2 groups. However, significantly fewer infants in the fosphenytoin group had moderate-to-severe neurodevelopmental delay at the 18- and 24-month assessments. In conclusion, although both medications were equally efficacious for acute neonatal seizure control, fosphenytoin had the potential for significantly better neurodevelopmental outcomes at 18-24 months of age.
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Affiliation(s)
- Veronica Alix
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
| | - Mansi James
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
| | - Anthony H Jackson
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
- Department of Neurology, UMMS-Baystate, Springfield, MA, USA
| | - Paul F Visintainer
- Epidemiology & Biostatistics, Office of Research, UMMS-Baystate, Springfield, MA, USA
| | - Rachana Singh
- Department of Pediatrics, Baystate Children's Hospital, UMMS-Baystate, Springfield, MA, USA
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16
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Sharma D, Hussain AM, Sharma SS. Efficacy of Levetiracetam in neonatal seizures: a systematic review. J Matern Fetal Neonatal Med 2020; 35:3923-3930. [PMID: 33172319 DOI: 10.1080/14767058.2020.1844651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Neonatal seizures represent the most frequent presenting sign of any neurological abnormality secondary to various etiologies in the neonatal period. Phenobarbitone (PB) has been used as first-line anti-epileptic drug in the treatment of seizures but concerns have been raised regarding its neuro-apoptotic effects over the developing brain. Levetiracetam (LEV) is a newer anti-epileptic drug with neuroprotective property and has been used in adults and pediatric patient but its use in neonates have very limited experience. Recently many neonatal studies have sought the role of LEV in the management of neonatal seizures. AIMS AND OBJECTIVE To evaluate the efficacy of Levetiracetam in the management of neonatal seizures. SEARCH METHODS The literature search was done for this systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), and other various electronic databases including PubMed and various sites for ongoing trials and abstracts of conferences. RESULTS Two eligible studies were analyzed that fulfilled the inclusion criteria of the systematic review. Fifteen studies were excluded due to the non-fulfillment of inclusion criteria. The primary outcome of both studies was to see the efficiency of LEV in controlling neonatal seizures when compared to PB. Better seizure control after a single loading dose of LEV was seen. Rates of seizure cessation at 24 h was also better in the LEV arm. Neonatal seizures secondary to hypoxic-ischemic encephalopathy (HIE) and receiving therapeutic hypothermia were better controlled with LEV. The side effect of LEV was significantly less when compared to PB. CONCLUSION Levetiracetam has shown to have promising anti-epileptic properties for the management of neonatal seizure with better efficacy and less or no side effects. There is a need to conduct more randomized controlled trials seeking the role of LEV in the acute management of neonatal seizures and also for assessing its neuroprotective role and neurodevelopmental outcome in these neonates.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical and Sciences Medical College, Jaipur, India
| | - Ansar Murtuza Hussain
- Department of Pediatrics, Vijay Marie Hospital and Education society, Khairtabad, Hyderabad, India
| | - Sweta Shastri Sharma
- Department of Pathology, National Institute of Medical and Sciences Medical College, Jaipur, India
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17
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Menéndez Méndez A, Smith J, Engel T. Neonatal Seizures and Purinergic Signalling. Int J Mol Sci 2020; 21:ijms21217832. [PMID: 33105750 PMCID: PMC7660091 DOI: 10.3390/ijms21217832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Neonatal seizures are one of the most common comorbidities of neonatal encephalopathy, with seizures aggravating acute injury and clinical outcomes. Current treatment can control early life seizures; however, a high level of pharmacoresistance remains among infants, with increasing evidence suggesting current anti-seizure medication potentiating brain damage. This emphasises the need to develop safer therapeutic strategies with a different mechanism of action. The purinergic system, characterised by the use of adenosine triphosphate and its metabolites as signalling molecules, consists of the membrane-bound P1 and P2 purinoreceptors and proteins to modulate extracellular purine nucleotides and nucleoside levels. Targeting this system is proving successful at treating many disorders and diseases of the central nervous system, including epilepsy. Mounting evidence demonstrates that drugs targeting the purinergic system provide both convulsive and anticonvulsive effects. With components of the purinergic signalling system being widely expressed during brain development, emerging evidence suggests that purinergic signalling contributes to neonatal seizures. In this review, we first provide an overview on neonatal seizure pathology and purinergic signalling during brain development. We then describe in detail recent evidence demonstrating a role for purinergic signalling during neonatal seizures and discuss possible purine-based avenues for seizure suppression in neonates.
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Affiliation(s)
- Aida Menéndez Méndez
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
| | - Jonathon Smith
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
- FutureNeuro, Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland
| | - Tobias Engel
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
- FutureNeuro, Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland
- Correspondence: ; Tel.: +35-314-025-199
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18
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Arican P, Olgac Dundar N, Mete Atasever N, Akkaya Inal M, Gencpinar P, Cavusoglu D, Akbay S, Tekgul H. Comparison of the neurocognitive outcomes in term infants treated with levetiracetam and phenobarbital monotherapy for neonatal clinical seizures. Seizure 2020; 80:71-74. [DOI: 10.1016/j.seizure.2020.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 01/26/2023] Open
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19
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Padiyar S, Nusairat L, Kadri A, Abu-Shaweesh J, Aly H. Neonatal seizures in the U.S. National Inpatient Population: Prevalence and outcomes. Pediatr Neonatol 2020; 61:300-305. [PMID: 31937508 DOI: 10.1016/j.pedneo.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/15/2019] [Accepted: 12/20/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Seizures are the most frequent neurological manifestation in neonates. Prevalence of neonatal seizures has not been well described in relationship with gestational age (GA). Also, the impact of seizures on neonatal mortality has not been quantified. This study aims to determine 1) prevalence of neonatal seizures in all GA groups, 2) associated mortality in each GA group and 3) impact of seizures on length of stay (LOS) of survivors in each GA group. METHODS Data from the national Kids' Inpatient Database (KID) for the years 2006, 2009 and 2012 was used in the study. All admitted infants with a documented GA were included in the study. All categorical variables were analyzed using Chi-square test, continuous variables were analyzed using t-test, and logistic regression analysis used to calculate odds ratio (OR) and 95% confidence intervals (CI). RESULTS A total of 10, 572,209 infants were included, of whom 4400 infants (0.04%) had seizures. The highest prevalence was at 24 weeks (0.12%). Overall mortality rate of patients with seizures was 4% with OR = 2.24 (95% CI = 1.90-2.65, p < 0.001). The correlation of seizure with mortality was significant after 33 weeks GA with greatest impact at 33-36 weeks GA (OR = 46.38 (95% CI = 26.86-80.08, p < 0.001). Seizures were associated with increased median LOS from 2 to 4 days (p < 0.001). CONCLUSION The prevalence of seizures varies according to gestational age ranging from 0.02% to 0.12%. The highest prevalence is at 24 weeks GA. The greatest impact for seizures on mortality is at 33-36 weeks GA.
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Affiliation(s)
- Swetha Padiyar
- Department of Neonatology, Metrohealth Medical Center/Case Western Reserve University School of Medicine, Cleveland, OH, USA; Cleveland Clinic Children's, Cleveland, OH, USA.
| | | | - Amer Kadri
- Cleveland Clinic Children's, Cleveland, OH, USA
| | | | - Hany Aly
- Cleveland Clinic Children's, Cleveland, OH, USA
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20
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Evaluation of the efficacy and safety of levetiracetam treatment for neonatal seizures in extremely preterm infants. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.724986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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21
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Karaoğlu P, Hız S, İşcan B, Polat AI, Ayanoğlu M, Duman N, Yiş' U. Intravenous Levetiracetam for Treatment of Seizures in Term and Preterm Neonates. J Pediatr Neurosci 2020; 15:15-20. [PMID: 32435300 PMCID: PMC7227750 DOI: 10.4103/jpn.jpn_66_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/18/2019] [Indexed: 01/15/2023] Open
Abstract
Context: Seizures are the most frequent neurological disturbance in the neonatal period, and there are no evidence-based guidelines for the treatment of neonatal seizures. Here we report a study on the use of levetiracetam as second-line therapy in the treatment of seizures in term and preterm neonates. Aim: The aim of this study was to assess the efficacy and safety of levetiracetam for seizures of term and preterm neonates. Settings and Design: We retrospectively analyzed data of the patients who had seizures and who were treated with levetiracetam as an add-on therapy to phenobarbital during the neonatal period. Statistical Analysis: The Statistical Package for the Social Sciences (SPSS) software, version 15.0 (SPSS, Chicago, Illinois), was used for statistical analysis. Continuous variables were expressed as mean values and standard deviations. Results: Thirty-six patients (8 term and 28 preterm) received levetiracetam. Mean dose of levetiracetam was 31.67 ± 14.83mg/kg/day. Twenty-five of the patients (69.4%) were seizure free with levetiracetam treatment. Electroencephalography recordings improved in 28 (77.8%) of the patients after levetiracetam. No severe adverse effects were observed. Conclusion: Our data suggest that levetiracetam may be a safe and effective treatment for neonatal seizures, which are unresponsive to phenobarbital.
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Affiliation(s)
- Pakize Karaoğlu
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Semra Hız
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Burçin İşcan
- Department of Neonatology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Ayşe I Polat
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Müge Ayanoğlu
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Nuray Duman
- Department of Neonatology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Uluç Yiş'
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
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He Y, Tang J, Zhang M, Xiong T, Ojha S, Choonara I, Mu D. Efficacy of antiepileptic drugs in neonatal seizures: a systematic review protocol. BMJ Paediatr Open 2020; 4:e000683. [PMID: 32626827 PMCID: PMC7326240 DOI: 10.1136/bmjpo-2020-000683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Seizures are one of the most common neurological disorders of neonates, which is also an emergency in the neonatal intensive care unit. For neonates, the recommended first-line antiepileptic drugs (AEDs) include phenobarbitone, which may be effective in only 50% of seizures. Some new AEDs, such as levetiracetam, have been shown to be effective in adults and older children. However, their efficacy for neonatal seizures remains uncertain. The aim of this investigation is to conduct a systematic review to evaluate the efficacy of all AEDs in neonates. Additionally, the long-term outcomes following neonatal seizures, in relation to the development of cerebral palsy and epilepsy, will be studied. METHOD We will perform a systematic review including randomised controlled studies (RCTs), cohort studies, case-controlled studies and case series studies which evaluated the efficacy of AEDs and short-term and long-term outcomes in neonatal seizures. PubMed, Embase, Web of Science, Cochrane Library and Clinical trial.gov will be searched. There will be no language restriction. Risk bias in RCTs will be evaluated by the Cochrane risk-of-bias tool, while cohort and case-control studies will be evaluated by the Newcastle-Ottawa Scale. A network meta-analysis will be performed by the Bayesian model using WinBUGS V.1.4.3 and R software if there is a high degree of homogeneity among studies. Otherwise, we will perform a narrative review without pooling. Subgroup analyses will be performed in different AEDs and dosage groups. OUTCOME The primary outcomes will be seizure cessation confirmed by electroencephalogram and long-term neurodevelopmental outcome. Secondary outcomes will be neonatal mortality during hospitalisation and suspected drug toxicity. ETHICS AND DISSEMINATION Formal ethical approval is not required as no primary data are collected. This systematic review will be disseminated through a peer-reviewed publication.
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Affiliation(s)
- Yang He
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jun Tang
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Meng Zhang
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Tao Xiong
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shalini Ojha
- Academic Child Health, University of Nottingham, Nottingham, UK
| | - Imti Choonara
- School of Medicine, University of Nottingham, Derby, UK
| | - Dezhi Mu
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Lack of response to treatment with levetiracetam in extreme preterm infants with seizures. J Perinatol 2019; 39:1480-1484. [PMID: 31548579 DOI: 10.1038/s41372-019-0498-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of monotherapy with levetiracetam (LEV) in achieving seizure cessation in a retrospective cohort of extreme preterm infants with seizures. STUDY DESIGN Charts of infants with a diagnosis of neonatal seizures admitted to the NICU between 2013 and 2017 were reviewed. Seizures were diagnosed using continuous video electroencephalography. All infants were initially started on LEV and reached a dose of 80 mg/kg/day. Other ASMs were added to LEV if seizures continued after 2 days. Data on additional clinical variables were collected for each infant. RESULT Sixty-one infants born <28 weeks of gestation met inclusion criteria. Seventy-four percent of patients did not respond to LEV monotherapy and required additional medications. CONCLUSIONS LEV monotherapy stopped seizures in only a small portion of cases.
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Zavadenko AN, Medvedev MI, Degtyareva MG. [Assessment of neurodevelopment in children of different gestational age with neonatal seizures]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 118:35-42. [PMID: 30585602 DOI: 10.17116/jnevro201811811135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess psychomotor development in infants with neonatal seizures (NS) born with different gestational age, by means of Bayley-III scales of infant and toddler development, in their corrected age of 1 year. MATERIAL AND METHODS The study included 52 infants, who had NS and were born with different gestational age: 28 weeks or less (n=26) - group I, 29-32 weeks (n=16) - group II, 33-36 weeks (n=3) - group III, 37-41 weeks (n=7) - group IV. The infants' neurodevelopment was evaluated in their corrected age of 1 year by means of N. Bayley scales of infant and toddler development, third edition: Cognitive, Language, Motor, Social-Emotional, and Adaptive Behavior. RESULTS AND CONCLUSION Only 17 (32,7%) of 52 examined infants did not demonstrate any developmental delay on each of five Bayley-III scales. Significant developmental delay (composite score <70) on at least one scale was revealed in 23 (44,2%) patients, including 12 (46,2%) in group I, 5 (31,3%) in group II, 6 (60%) of 10 in the combined group III-IV. In most cases, neurodevelopmental delays were attributed to only one domain and could be indicated as partial. The conclusion about global developmental retardation (the composite scores 55 or less on all five scales) was done in 3 patients, each of whom had a co-morbidity of cerebral palsy and epilepsy.
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Affiliation(s)
- A N Zavadenko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M I Medvedev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M G Degtyareva
- Pirogov Russian National Research Medical University, Moscow, Russia
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Spagnoli C, Falsaperla R, Deolmi M, Corsello G, Pisani F. Symptomatic seizures in preterm newborns: a review on clinical features and prognosis. Ital J Pediatr 2018; 44:115. [PMID: 30382869 PMCID: PMC6211591 DOI: 10.1186/s13052-018-0573-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/16/2018] [Indexed: 01/23/2023] Open
Abstract
Neonatal seizures are the most common neurological event in newborns, showing higher prevalence in preterm than in full-term infants. In the majority of cases they represent acute symptomatic phenomena, the main etiologies being intraventricular haemorrhage, hypoxic-ischemic encephalopathy, central nervous system infections and transient metabolic derangements.Current definition of neonatal seizures requires detection of paroxysmal EEG-changes, and in preterm newborns the incidence of electrographic-only seizures seems to be particularly high, further stressing the crucial role of electroencephalogram monitoring in this population. Imaging work-up includes an integration of serial cranial ultrasound and brain magnetic resonance at term-equivalent age. Unfavourable outcomes following seizures in preterm infants include death, neurodevelopmental impairment, epilepsy, cerebral palsy, hearing and visual impairment. As experimental evidence suggests a detrimental role of seizures per se in determining subsequent outcome, they should be promptly treated with the aim to reduce seizure burden and long-term disabilities. However, neonatal seizures show low response to conventional anticonvulsant drugs, and this is even more evident in preterm newborns, due to intrinsic developmental factors. As a consequence, as literature does not provide any specific guidelines, due to the lack of robust evidence, off-label medications are often administered in clinical practice.
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Affiliation(s)
- Carlotta Spagnoli
- Child Neuropsychiatry Unit, Department of Pediatrics, Arcispedale Santa Maria Nuova, IRCSS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, Santo Bambino Hospital, University Hospital "Policlinico-Vittorio Emanuele", Via Tindaro 2, 95124, Catania, Italy.
| | - Michela Deolmi
- Pediatrics Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Giovanni Corsello
- Department of Maternal and Child Health, University of Palermo, Palermo, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Medicine & Surgery Department, Neuroscience Division, University of Parma, Parma, Italy
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