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Anwar T, Triplett RL, Ahmed A, Glass HC, Shellhaas RA. Treating Seizures and Improving Newborn Outcomes for Infants with Hypoxic-Ischemic Encephalopathy. Clin Perinatol 2024; 51:573-586. [PMID: 39095097 DOI: 10.1016/j.clp.2024.04.013] [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] [Indexed: 08/04/2024]
Abstract
Hypoxic-ischemic encephalopathy is the most common cause of neonatal seizures. Continuous electroencephalographic monitoring is recommended given high rates of subclinical seizures. Prompt diagnosis and treatment of seizures may improve neurodevelopmental outcomes. International League Against Epilepsy guidelines indicate that (1) phenobarbital remains the first-line treatment of neonatal seizures and (2) early discontinuation of antiseizure medications following resolution of acute provoked seizures, and prior to discharge home, is recommended. Long-term follow-up of these infants is necessary to screen for postneonatal epilepsy and support neurodevelopment.
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Affiliation(s)
- Tayyba Anwar
- Department of Neurology, Children's National Hospital, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Regina L Triplett
- Department of Neurology, Washington University in St Louis, 1 Brookings Drive, Saint Louis, MO 63130, USA
| | - Afaf Ahmed
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University in St Louis, 1 Brookings Drive, Saint Louis, MO 63130, USA
| | - Hannah C Glass
- Department of Neurology, University of California San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Renée A Shellhaas
- Department of Neurology, Washington University in St Louis, MSC 8091-29-12400, 660 South Euclid Avenue, Saint Louis, MO 63110, USA.
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Cardona VQ, Byrne E, Mejia M, Joshi S, Menkiti O. Phenobarbital as a Sedation Strategy to Reduce Opioid and Benzodiazepine Burden in Neonatal Extracorporeal Membrane Oxygenation. Am J Perinatol 2024; 41:1586-1591. [PMID: 38365212 DOI: 10.1055/s-0044-1779255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The study aims to describe our experience with the implementation of phenobarbital as a primary sedation strategy during neonatal extracorporeal membrane oxygenation (ECMO). STUDY DESIGN Retrospective chart review in a level IV neonatal intensive care unit between 2011 and 2021 comparing neonatal ECMO patients before and after the implementation of a sedation-analgesia (SA) protocol using scheduled phenobarbital as the primary sedative. Groups were compared for neonatal and ECMO characteristics, cumulative SA doses, and in-hospital outcomes. Comparison between groups was performed using Mann-Whitney test on continuous variables and chi-square on nominal variables. RESULTS Forty-two patients were included, 23 preprotocol and 19 postprotocol. Birth, pre-ECMO, and ECMO clinical characteristics were similar between groups except for a lower birth weight in the postprotocol group (p = 0.024). After standardization of phenobarbital SA protocol, there was a statistically significant reduction in median total morphine dose (31.38-17.65 mg/kg, p = 0.006) and median total midazolam dose (36.21-6.36 mg/kg, p < 0.001). There was also a reduction in median total days on morphine by 7.5 days (p = 0.026) and midazolam by 6.6 days (p = 0.003). There were no differences in ECMO duration or in-hospital outcomes between groups. CONCLUSION In this cohort, short-term use of phenobarbital as primary sedation strategy during neonatal ECMO was associated with reduced opioid and midazolam burden. Such reduction, however, did not affect in-hospital outcomes. KEY POINTS · Prolonged sedation on ECMO puts infants at risk for iatrogenic withdrawal.. · Phenobarbital is a feasible sedation strategy for ECMO.. · Phenobarbital sedation strategy may mitigate risk by decreasing opioid and midazolam burden..
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Affiliation(s)
- Vilmaris Quinones Cardona
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Emma Byrne
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Michelle Mejia
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Swosti Joshi
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ogechukwu Menkiti
- Division of Neonatology, Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Quinlan S, Witherspoon E, Forcelli PA. Padsevonil suppresses seizures without inducing cell death in neonatal rats. Pharmacol Rep 2024:10.1007/s43440-024-00628-y. [PMID: 39028384 DOI: 10.1007/s43440-024-00628-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Padsevonil (PSL) is a rationally designed anti-seizure medication (ASM) which has overlapping mechanisms of action with the two most common ASMs used for neonatal seizures, phenobarbital (PB) and levetiracetam (LEV). Here we evaluated the anti-seizure properties of PSL across the neonatal and adolescent period in rats in the pentlyenetetrazole (PTZ) induced seizures model. METHODS Postnatal day (P)7, P14 and P21 Sprague-Dawley rat pups were pre-treated with PSL (1-30 mg/kg), and assessed for seizure latency and severity 30 min later following injection of PTZ. A separate cohort of P7 pups were treated with neonatal ASMs and euthanized 24 h later (on P8) to assess induction of cell death, a feature common to many ASMs when given to P7 rodents. This effect has been extensively reported with PB, but not with LEV. Cell death was assessed by PathoGreen staining. RESULTS PSL suppressed PTZ-evoked seizures across multiple age groups, particularly at higher doses, without producing increased cell death compared to vehicle. The effects of PSL were particularly notable at suppressing tonic-clonic seizure manifestations (82% of P7 and 100% of P14 and P21 animals were protected from tonic-clonic seizures with the 30 mg/kg dose). CONCLUSIONS PSL displayed dose-dependent anti-seizure effects in immature rodents in the PTZ model of seizures in immature rats. While many ASMs, including PB, induce cell death in neonatal rats, PSL does not. This suggests that PSL may offer therapeutic benefit and a favorable safety profile for the treatment of neonatal seizures.
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Affiliation(s)
- Sean Quinlan
- Department of Pharmacology & Physiology, Georgetown University, New Research Bldg., W209B, 3970 Reservoir Road NW, Washington, DC, 20007, USA
| | - Eric Witherspoon
- Department of Pharmacology & Physiology, Georgetown University, New Research Bldg., W209B, 3970 Reservoir Road NW, Washington, DC, 20007, USA
| | - Patrick A Forcelli
- Department of Pharmacology & Physiology, Georgetown University, New Research Bldg., W209B, 3970 Reservoir Road NW, Washington, DC, 20007, USA.
- Department of Neuroscience, Georgetown University, Washington, DC, USA.
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC, USA.
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Kontou A, Agakidou E, Chatziioannidis I, Chotas W, Thomaidou E, Sarafidis K. Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:871. [PMID: 39062320 PMCID: PMC11275925 DOI: 10.3390/children11070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.
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Affiliation(s)
- Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Ilias Chatziioannidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Evanthia Thomaidou
- Department of Anesthesia and Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, AHEPA University General Hospital of Thessaloniki, 54621 Thessaloniki, Greece;
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
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Witherspoon E, Williams G, Zuczek N, Forcelli PA. Cenobamate suppresses seizures without inducing cell death in neonatal rats. Epilepsy Behav 2024; 158:109898. [PMID: 39002273 DOI: 10.1016/j.yebeh.2024.109898] [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: 03/05/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/15/2024]
Abstract
GABA modulators such as phenobarbital (PB) and sodium channel blockers such as phenytoin (PHT) have long been the mainstay of pharmacotherapy for the epilepsies. In the context of neonatal seizures, both PB and PHT display incomplete clinical efficacy. Moreover, in animal models, neonatal exposure to these medications result in neurodegeneration raising concerns about safety. Cenobamate, a more recently approved medication, displays unique pharmacology as it is both a positive allosteric modulator of GABA-A receptors, and a voltage-gated sodium channel blocker. While cenobamate is approved for adult use, its efficacy and safety profile against neonatal seizures is poorly understood. To address this gap, we assessed the efficacy and safety of cenobamate in immature rodents. Postnatal day (P)7 rat pups were pretreated with cenobamate and challenged with the chemoconvulsant pentylenetetrazole (PTZ) to screen for anti-seizure effects. In a separate experiment, P7 rats were treated with cenobamate, and brains were processed to assess induction of cell death. Cenobamate displays dose-dependent anti-seizure efficacy in neonatal rats. Unlike PHB and PHT, it does not induce neurotoxicity in P7 rats. Thus, cenobamate may be effective at treating neonatal seizures while avoiding unwanted neurotoxic side effects such as cell death.
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Affiliation(s)
- Eric Witherspoon
- Department of Pharmacology & Physiology, Georgetown University, Washington, DC, USA
| | - Gabrielle Williams
- Department of Pharmacology & Physiology, Georgetown University, Washington, DC, USA
| | - Nicholas Zuczek
- Department of Pharmacology & Physiology, Georgetown University, Washington, DC, USA
| | - Patrick A Forcelli
- Department of Pharmacology & Physiology, Georgetown University, Washington, DC, USA; Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC, USA; Department of Neuroscience, Georgetown University, Washington, DC, USA.
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Castro Conde JR, González Campo C, González Barrios D, Reyes Millán B, Díaz González CL, Jiménez Sosa A. High Effectiveness of Midazolam and Lidocaine in the Treatment of Acute Neonatal Seizures. J Clin Neurophysiol 2024; 41:450-457. [PMID: 37099703 PMCID: PMC11210945 DOI: 10.1097/wnp.0000000000001013] [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] [Indexed: 04/28/2023] Open
Abstract
PURPOSE To assess the clinical effectiveness of treating acute seizures with midazolam and lidocaine infusion. METHODS This single-center historical cohort study included 39 term neonates with electrographic seizures who underwent treatment with midazolam (1st line) and lidocaine (2nd line). Therapeutic response was measured using continuous video-EEG monitoring. The EEG measurements included total s eizure burden (minutes), maximum ictal fraction (minutes/hour), and EEG-background (normal/slightly abnormal vs. abnormal). Treatment response was considered good (seizure control with midazolam infusion), intermediate (need to add lidocaine to the control), or no response. Using clinical assessments supplemented by BSID-III and/or ASQ-3 at 2 to 9 years old age, neurodevelopment was classified as normal, borderline, or abnormal. RESULTS A good therapeutic response was obtained in 24 neonates, an intermediate response in 15, and no response in any of the neonates. Babies with good response showed lower values in maximum ictal fraction compared with those with intermediate response (95% CI: 5.85-8.64 vs. 9.14-19.14, P = 0.002). Neurodevelopment was considered normal in 24 children, borderline in five, and abnormal in other 10 children. Abnormal neurodevelopment was significantly associated with an abnormal EEG background, maximum ictal fraction >11 minutes, and total s eizure burden >25 minutes (odds ratio 95% CI: 4.74-1708.52, P = 0.003; 1.72-200, P = 0.016; 1.72-142.86, P = 0.026, respectively) but not with the therapeutic response. Serious adverse effects were not recorded. CONCLUSIONS This retrospective study suggests that the midazolam/lidocaine association could potentially be efficacious in decreasing seizure burden in term neonates with acute seizures. These results would justify testing the midazolam/lidocaine combination as a first-line treatment for neonatal seizures in future clinical trials.
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Affiliation(s)
- José Ramón Castro Conde
- Pediatric Department, Faculty of Medicine, Universidad de La Laguna, S/C Tenerife, Spain
- Department of Neonatology, Hospital Universitario de Canarias, S/C Tenerife, Spain
| | - Candelaria González Campo
- Pediatric Department, Faculty of Medicine, Universidad de La Laguna, S/C Tenerife, Spain
- Department of Neonatology, Hospital Universitario de Canarias, S/C Tenerife, Spain
| | - Desiré González Barrios
- Department of Neonatology, Hospital Universitario Nuestra Señora de la Candelaria, S/C Tenerife, Spain
| | - Beatriz Reyes Millán
- Neuropediatrics Unit, Department of Pediatrics, Hospital Universitario Nuestra Señora de la Candelaria, S/C Tenerife, Spain; and
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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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Sharpe C, Yang DZ, Haas RH, Reiner GE, Lee L, Capparelli EV. Pharmacokinetic and pharmacodynamic data from the NEOLEV1 and NEOLEV2 studies. Arch Dis Child 2024:archdischild-2022-324952. [PMID: 38902005 DOI: 10.1136/archdischild-2022-324952] [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: 10/25/2022] [Accepted: 05/15/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVES To confirm that levetiracetam (LEV) demonstrates predictable pharmacokinetics(PK) at higher doses and to study the pharmacodynamics(PD) of LEV. DESIGN Pharmacokinetic data from the NEOLEV1 and NEOLEV2 trials were analysed using a non-linear mixed effects modelling approach. A post hoc analysis of the effect of LEV on seizure burden was conducted. SETTING Neonatal intensive care unit. PATIENTS Term neonates with electrographically confirmed seizures. INTERVENTIONS In NEOLEV1, neonates with seizures persisting following phenobarbital (PHB) received LEV 20 or 40 mg/kg bolus followed by 5 or 10 mg/kg maintenance dose(MD) daily. In NEOLEV2, patients received a 40 mg/kg intravenous LEV load, followed by 10 mg/kg doses 8 hourly. If seizures persisted, a further 20 mg/kg intravenous load was given. If seizures persisted, PHB was given. PK data were collected from 16 NEOLEV1 patients and 33 NEOLEV2 patients. cEEG data from 48 NEOLEV2 patients were analysed to investigate onset of action and seizure burden reduction. MAIN OUTCOME MEASURES Clearance (CL) and volume of distribution (Vd) were determined. Covariates that significantly affected LEV disposition were identified. RESULTS Primary outcome: The median initial LEV level was 57 µg/mL (range 19-107) after the first loading dose and at least 12 µg/mL at 48 hours in all infants. CL and Vd were estimated to be 0.0538 L/hour and 0.832 L, respectively. A direct relationship between postnatal age and CL was observed. The final population pharmacokinetic(PopPK) model described the observed data well without significant biases. CL and Vd were described as CL (L/hour)=0.0538×(weight in kg/3.34)0.75×(postnatal age in days/5.5) 0.402 and Vd (L)=0.832×(weight in kg/3.34).Seizure burden reduced within 30 min of LEV administration. 28% of patients were completely seizure free after LEV. In an additional 25% of patients, seizure burden reduced by 50%. CONCLUSIONS LEV pharmacokinetics remained predictable at higher doses. Very high-dose LEV can now be studied in neonates. TRIAL REGISTRATION NUMBER NCT01720667.
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Affiliation(s)
- Cynthia Sharpe
- Paediatric Neurology, Starship Children's Health, Auckland, New Zealand
- Department of Neurosciences, University of California, San Diego, La Jolla, California, USA
| | - Derek Z Yang
- Department of Pediatrics, University of California San Diego, La Jolla, California, USA
| | - Richard H Haas
- Department of Neurosciences, University of California, San Diego, La Jolla, California, USA
- Department of Neurology, Rady Children's Hospital-San Diego, San Diego, California, USA
| | - Gail E Reiner
- Department of Neurosciences, University of California, San Diego, La Jolla, California, USA
| | - Lilly Lee
- Department of Neurosciences, University of California, San Diego, La Jolla, California, USA
| | - Edmund V Capparelli
- Department of Pediatrics, University of California San Diego, La Jolla, California, USA
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Gleason A, Richter F, Beller N, Arivazhagan N, Feng R, Holmes E, Glicksberg BS, Morton SU, La Vega-Talbott M, Fields M, Guttmann K, Nadkarni GN, Richter F. Accurate prediction of neurologic changes in critically ill infants using pose AI. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.17.24305953. [PMID: 38699362 PMCID: PMC11064996 DOI: 10.1101/2024.04.17.24305953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Infant alertness and neurologic changes can reflect life-threatening pathology but are assessed by exam, which can be intermittent and subjective. Reliable, continuous methods are needed. We hypothesized that our computer vision method to track movement, pose AI, could predict neurologic changes in the neonatal intensive care unit (NICU). We collected 4,705 hours of video linked to electroencephalograms (EEG) from 115 infants. We trained a deep learning pose algorithm that accurately predicted anatomic landmarks in three evaluation sets (ROC-AUCs 0.83-0.94), showing feasibility of applying pose AI in an ICU. We then trained classifiers on landmarks from pose AI and observed high performance for sedation (ROC-AUCs 0.87-0.91) and cerebral dysfunction (ROC-AUCs 0.76-0.91), demonstrating that an EEG diagnosis can be predicted from video data alone. Taken together, deep learning with pose AI may offer a scalable, minimally invasive method for neuro-telemetry in the NICU.
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Affiliation(s)
- Alec Gleason
- Albert Einstein College of Medicine, New York, NY
| | | | - Nathalia Beller
- Department of Genetics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Naveen Arivazhagan
- Division of Data Driven and Digital Medicine (D3M), Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emma Holmes
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Newborn Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Sarah U Morton
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Maite La Vega-Talbott
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Madeline Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine Guttmann
- Division of Newborn Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girish N Nadkarni
- Division of Data Driven and Digital Medicine (D3M), Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Felix Richter
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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10
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Stieren ES, Rottkamp CA, Brooks-Kayal AR. Neonatal Seizures. Neoreviews 2024; 25:e338-e349. [PMID: 38821905 DOI: 10.1542/neo.25-6-e338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 06/02/2024]
Abstract
Neonatal seizures are common among patients with acute brain injury or critical illness and can be difficult to diagnose and treat. The most common etiology of neonatal seizures is hypoxic-ischemic encephalopathy, with other common causes including ischemic stroke and intracranial hemorrhage. Neonatal clinicians can use a standardized approach to patients with suspected or confirmed neonatal seizures that entails laboratory testing, neuromonitoring, and brain imaging. The primary goals of management of neonatal seizures are to identify the underlying cause, correct it if possible, and prevent further brain injury. This article reviews recent evidence-based guidelines for the treatment of neonatal seizures and discusses the long-term outcomes of patients with neonatal seizures.
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Affiliation(s)
- Emily S Stieren
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, CA
| | - Catherine A Rottkamp
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, CA
| | - Amy R Brooks-Kayal
- Department of Neurology, University of California, Davis, Sacramento, CA
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11
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Krishnan V, Ujjanappa V, Vegda H, Annayappa MK, Wali P, Fattepur S, Chandriah S, Devadas S, Kariappa M, Gireeshan VK, Thamunni AV, Montaldo P, Burgod C, Garegrat R, Muraleedharan P, Pant S, Newton CR, Cross JH, Bassett P, Shankaran S, Thayyil S, Pressler RM. Sequential levetiracetam and phenytoin in electroencephalographic neonatal seizures unresponsive to phenobarbital: a multicenter prospective observational study in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 25:100371. [PMID: 39021480 PMCID: PMC467079 DOI: 10.1016/j.lansea.2024.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/09/2024] [Accepted: 02/06/2024] [Indexed: 07/20/2024]
Abstract
Background Although levetiracetam and phenytoin are widely used antiseizure medications (ASM) in neonates, their efficacy on seizure freedom is unclear. We evaluated electroencephalographic (EEG) seizure freedom following sequential levetiracetam and phenytoin in neonatal seizures unresponsive to phenobarbital. Methods We recruited neonates born ≥35 weeks and aged <72 h who had continued electrographic seizures despite phenobarbital, from three Indian hospitals, between 20 June 2020 and 31 July 2022. The neonates were treated with intravenous levetiracetam (20 mg/kg x 2 doses, second line) followed by phenytoin (20 mg/kg x 2 doses, third line) if seizures persisted. The primary outcome was complete seizure freedom, defined as an absence of seizures on EEG for at least 60 min within 40 min from the start of infusion. Findings Of the 206 neonates with continued seizures despite phenobarbital, 152 received levetiracetam with EEG. Of these one EEG was missing, 47 (31.1%) were in status epilepticus, and primary outcome data were available in 145. Seizure freedom occurred in 20 (13.8%; 95% CI 8.6%-20.5%) after levetiracetam; 16 (80.0%) responded to the first dose and 4 (20.0%) to the second dose. Of the 125 neonates with persisting seizures after levetiracetam, 114 received phenytoin under EEG monitoring. Of these, the primary outcome data were available in 104. Seizure freedom occurred in 59 (56.7%; 95% CI 46.7%-66.4%) neonates; 54 (91.5%) responded to the first dose and 5 (8.5%) to the second dose. Interpretation With the conventional doses, levetiracetam was associated with immediate EEG seizure cessation in only 14% of phenobarbital unresponsive neonatal seizures. Additional treatment with phenytoin along with levetiracetam attained seizure freedom in further 57%. Safety and efficacy of higher doses of levetiracetam should be evaluated in well-designed randomised controlled trials. Funding National Institute for Health and Care Research (NIHR) Research and Innovation for Global Health Transformation (NIHR200144).
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Affiliation(s)
- Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Vidya Ujjanappa
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Hemadri Vegda
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Pooja Wali
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Savitha Chandriah
- Department of Obstetrics and Gynecology, Bangalore Medical College and Research Institute, Bengaluru, India
| | - Sahana Devadas
- Department of Pediatrics, Bangalore Medical College and Research Institute, Bengaluru, India
| | - Mallesh Kariappa
- Department of Pediatrics, Bangalore Medical College and Research Institute, Bengaluru, India
| | | | | | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
- Department of Neonatology, Università Degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Reema Garegrat
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - J Helen Cross
- UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
- University of Texas at Austin, Dell Children’s Hospital, Austin, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Ronit M. Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, United Kingdom
- Department of Clinical Neuroscience, UCL-Great Ormond Street Institute of Child Health, London, United Kingdom
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12
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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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13
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Jamali Z, Molaei-Farsangi MH, Ahmadipour H, Bahmanbijari B, Sabzevari F, Parizi ZD. Comparison of the effect of phenobarbital & levetiracetam in the treatment of neonatal abstinence syndrome (NAS) as adjuvant treatment in neonates admitted to the neonatal intensive care unit: a randomized clinical trial. BMC Pregnancy Childbirth 2024; 24:242. [PMID: 38580935 PMCID: PMC10996075 DOI: 10.1186/s12884-024-06433-y] [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: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Infants who are born from mothers with substance use disorder might suffer from neonatal abstinence syndrome (NAS) and need treatment with medicines. One of these medicines is phenobarbital, which may cause side effects in long-term consumption. Alternative drugs can be used to reduce these side effects. This study seeks the comparison of the effects of phenobarbital & levetiracetam as adjuvant therapy in neonatal abstinence syndrome. METHODS This randomized clinical trial was performed in one year from May 2021 until May 2022. The neonates who were born from mothers with substance use disorder and had neonatal abstinence syndrome in Afzalipoor Hospital of Kerman were studied. The treatment started with morphine initially and every four hours the infants were checked. The infants who were diagnosed with uncontrolled symptoms After obtaining informed consent from the parents were randomly divided into two groups and treated with secondary drugs, either phenobarbital or levetiracetam. RESULTS Based on the obtained results, it was clear that there was no significant difference between the hospitalization time of the two infant groups under therapy (phenobarbital: 18.59 days versus Levetiracetam 18.24 days) (P-value = 0.512). Also, there was no significant difference between both groups in terms of the frequency of re-hospitalization during the first week after discharge, the occurrence of complications, and third treatment line prescription (P-value = 0.644). CONCLUSIONS Based on the obtained results, like hospitalization duration time (P-value = 0.512) it seems that levetiracetam can be used to substitute phenobarbital in treating neonatal abstinence syndrome. TRIAL REGISTRATION The current study has been registered in the Iran registry of clinical trials website (fa.irct.ir) on the date 25/2/2022 with registration no. IRCT20211218053444N2.
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Affiliation(s)
- Zahra Jamali
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Hosein Molaei-Farsangi
- Department of Pediatrics, School of Medicine; Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran.
| | - Habibeh Ahmadipour
- Department of Social Medicine, School of Medicine, Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Bahareh Bahmanbijari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sabzevari
- Department of Pediatrics, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Daei Parizi
- Department of Pediatrics, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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14
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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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15
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Quinlan S, Khan T, McFall D, Campos-Rodriguez C, Forcelli PA. Early life phenobarbital exposure dysregulates the hippocampal transcriptome. Front Pharmacol 2024; 15:1340691. [PMID: 38606173 PMCID: PMC11007044 DOI: 10.3389/fphar.2024.1340691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/01/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction: Phenobarbital (PB) and levetiracetam (LEV) are the first-line therapies for neonates with diagnosed seizures, however, a growing body of evidence shows that these drugs given during critical developmental windows trigger lasting molecular changes in the brain. While the targets and mechanism of action of these drugs are well understood-what is not known is how these drugs alter the transcriptomic landscape, and therefore molecular profile/gene expression during these critical windows of neurodevelopment. PB is associated with a range of neurotoxic effects in developing animals, from cell death to altered synaptic development to lasting behavioral impairment. LEV does not produce these effects. Methods: Here we evaluated the effects of PB and Lev on the hippocampal transcriptome by RNA sequencing. Neonatal rat pups were given a single dose of PB, Lev or vehicle and sacrificed 72 h later-at time at which drug is expected to be cleared. Results: We found PB induces broad changes in the transcriptomic profile (124 differentially expressed transcripts), as compared to relatively small changes in LEV-treated animals (15 transcripts). PB exposure decreased GABAergic and oligodendrocyte markers pvalb and opalin, and increased the marker of activated microglia, cd68 and the astrocyte- associated gene vegfa. These data are consistent with the existing literature showing developmental neurotoxicity associated with PB, but not LEV. Discussion: The widespread change in gene expression after PB, which affected transcripts reflective of multiple cell types, may provide a link between acute drug administration and lasting drug toxicity.
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Affiliation(s)
- Seán Quinlan
- Department of Physiology and Pharmacology, Georgetown University, Washington, DC, United States
| | - Tahiyana Khan
- Department of Physiology and Pharmacology, Georgetown University, Washington, DC, United States
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC, United States
| | - David McFall
- Department of Physiology and Pharmacology, Georgetown University, Washington, DC, United States
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC, United States
| | | | - Patrick A. Forcelli
- Department of Physiology and Pharmacology, Georgetown University, Washington, DC, United States
- Interdisciplinary Program in Neuroscience, Georgetown University, Washington, DC, United States
- Department of Neuroscience, Georgetown University, Washington, DC, United States
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16
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Abbasi H, Davidson JO, Dhillon SK, Zhou KQ, Wassink G, Gunn AJ, Bennet L. Deep Learning for Generalized EEG Seizure Detection after Hypoxia-Ischemia-Preclinical Validation. Bioengineering (Basel) 2024; 11:217. [PMID: 38534490 DOI: 10.3390/bioengineering11030217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/12/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
Brain maturity and many clinical treatments such as therapeutic hypothermia (TH) can significantly influence the morphology of neonatal EEG seizures after hypoxia-ischemia (HI), and so there is a need for generalized automatic seizure identification. This study validates efficacy of advanced deep-learning pattern classifiers based on a convolutional neural network (CNN) for seizure detection after HI in fetal sheep and determines the effects of maturation and brain cooling on their accuracy. The cohorts included HI-normothermia term (n = 7), HI-hypothermia term (n = 14), sham-normothermia term (n = 5), and HI-normothermia preterm (n = 14) groups, with a total of >17,300 h of recordings. Algorithms were trained and tested using leave-one-out cross-validation and k-fold cross-validation approaches. The accuracy of the term-trained seizure detectors was consistently excellent for HI-normothermia preterm data (accuracy = 99.5%, area under curve (AUC) = 99.2%). Conversely, when the HI-normothermia preterm data were used in training, the performance on HI-normothermia term and HI-hypothermia term data fell (accuracy = 98.6%, AUC = 96.5% and accuracy = 96.9%, AUC = 89.6%, respectively). Findings suggest that HI-normothermia preterm seizures do not contain all the spectral features seen at term. Nevertheless, an average 5-fold cross-validated accuracy of 99.7% (AUC = 99.4%) was achieved from all seizure detectors. This significant advancement highlights the reliability of the proposed deep-learning algorithms in identifying clinically translatable post-HI stereotypic seizures in 256Hz recordings, regardless of maturity and with minimal impact from hypothermia.
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Affiliation(s)
- Hamid Abbasi
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
- Auckland Bioengineering Institute (ABI), University of Auckland, Auckland 1010, New Zealand
| | - Joanne O Davidson
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Simerdeep K Dhillon
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Kelly Q Zhou
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Guido Wassink
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Alistair J Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
| | - Laura Bennet
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand
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17
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Liddiard GT, Suryavanshi PS, Glykys J. Enhancing GABAergic Tonic Inhibition Reduces Seizure-Like Activity in the Neonatal Mouse Hippocampus and Neocortex. J Neurosci 2024; 44:e1342232023. [PMID: 38176909 PMCID: PMC10869160 DOI: 10.1523/jneurosci.1342-23.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/27/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
Approximately one-third of neonatal seizures do not respond to first-line anticonvulsants, including phenobarbital, which enhances phasic inhibition. Whether enhancing tonic inhibition decreases seizure-like activity in the neonate when GABA is mainly depolarizing at this age is unknown. We evaluated if increasing tonic inhibition using THIP [4,5,6,7-tetrahydroisoxazolo(5,4-c)pyridin-3-ol, gaboxadol], a δ-subunit-selective GABAA receptor agonist, decreases seizure-like activity in neonatal C57BL/6J mice (postnatal day P5-8, both sexes) using acute brain slices. Whole-cell patch-clamp recordings showed that THIP enhanced GABAergic tonic inhibitory conductances in layer V neocortical and CA1 pyramidal neurons and increased their rheobase without altering sEPSC characteristics. Two-photon calcium imaging demonstrated that enhancing the activity of extrasynaptic GABAARs decreased neuronal firing in both brain regions. In the 4-aminopyridine and the low-Mg2+ model of pharmacoresistant seizures, THIP reduced epileptiform activity in the neocortex and CA1 hippocampal region of neonatal and adult brain slices in a dose-dependent manner. We conclude that neocortical layer V and CA1 pyramidal neurons have tonic inhibitory conductances, and when enhanced, they reduce neuronal firing and decrease seizure-like activity. Therefore, augmenting tonic inhibition could be a viable approach for treating neonatal seizures.
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Affiliation(s)
- G T Liddiard
- Stead Family Department of Pediatrics, Iowa Neuroscience Institute, The University of Iowa, Iowa City 52242, Iowa
- Interdisciplinary Graduate Program in Neuroscience, The University of Iowa, Iowa City 52242, Iowa
| | - P S Suryavanshi
- Stead Family Department of Pediatrics, Iowa Neuroscience Institute, The University of Iowa, Iowa City 52242, Iowa
| | - J Glykys
- Stead Family Department of Pediatrics, Iowa Neuroscience Institute, The University of Iowa, Iowa City 52242, Iowa
- Interdisciplinary Graduate Program in Neuroscience, The University of Iowa, Iowa City 52242, Iowa
- Department of Neurology, The University of Iowa, Iowa City 52242, Iowa
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18
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Li Y, Su S, Zhang M, Yu L, Miao X, Li H, Sun Y. Risk assessment of arrhythmias related to three antiseizure medications: a systematic review and single-arm meta-analysis. Front Neurol 2024; 15:1295368. [PMID: 38419702 PMCID: PMC10899418 DOI: 10.3389/fneur.2024.1295368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Objective Antiseizure medications (ASMs) are first line therapy for seizure disorders. Their effects on arrhythmias, especially the risk of arrhythmias associated with lacosamide (LCM), levetiracetam (LEV), and perampanel (PER), have been intensely investigated. Methods We searched four databases (PubMed, EMBASE, Cochrane Library, and Web of Science) until August 6, 2023. We used a common effects model and reported data as pooled incidence with 95% CIs. Meta-analyses were conducted to elucidate the risk of arrhythmias with different drugs, and Egger's regression was performed to detect publication bias analysis. Results We included 11 clinical trials with 1,031 participants. The pooled incidence of arrhythmias in the LEV group was 0.005 (95% CI: 0.001-0.013), while it was 0.014 in the LCM group (95% CI: 0.003-0.030). Publication bias analyses indicated no significant bias in the LEV group (t = 0.02, df = 4, p-value = 0.9852) but a significant bias in the LCM group (t = 5.94, df = 3, p-value = 0.0095). We corrected for this bias in the LCM group using the trim-and-fill method, which yielded a similar pooled incidence of 0.0137 (95% CI: 0.0036-0.0280), indicating good reliability. Due to insufficient studies, we could not conduct a meta-analysis for PER, and we analyzed them in our systematic review. Conclusion The use of LCM significantly elevated the risk of arrhythmias, while LEV had non-significant arrhythmogenic effects. As for the arrhythmogenic effects of PER, more clinical trials are needed in the future.
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Affiliation(s)
- Yulong Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shen Su
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mengwen Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Limin Yu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinyuan Miao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongjun Li
- Department of Neurology, Tai’an City Central Hospital, Tai’an, China
| | - Yanping Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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19
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Numis AL, Glass HC, Comstock BA, Gonzalez F, Maitre NL, Massey SL, Mayock DE, Mietzsch U, Natarajan N, Sokol GM, Bonifacio S, Van Meurs K, Thomas C, Ahmad K, Heagerty P, Juul SE, Wu YW, Wusthoff CJ. Relationship of Neonatal Seizure Burden Before Treatment and Response to Initial Antiseizure Medication. J Pediatr 2024; 268:113957. [PMID: 38360261 DOI: 10.1016/j.jpeds.2024.113957] [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: 08/18/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To assess among a cohort of neonates with hypoxic-ischemic encephalopathy (HIE) the association of pretreatment maximal hourly seizure burden and total seizure duration with successful response to initial antiseizure medication (ASM). STUDY DESIGN This was a retrospective review of data collected from infants enrolled in the HEAL Trial (NCT02811263) between January 25, 2017, and October 9, 2019. We evaluated a cohort of neonates born at ≥36 weeks of gestation with moderate-to-severe HIE who underwent continuous electroencephalogram monitoring and had acute symptomatic seizures. Poisson regression analyzed associations between (1) pretreatment maximal hourly seizure burden, (2) pretreatment total seizure duration, (3) time from first seizure to initial ASM, and (4) successful response to initial ASM. RESULTS Among 39 neonates meeting inclusion criteria, greater pretreatment maximal hourly seizure burden was associated with lower chance of successful response to initial ASM (adjusted relative risk for each 5-minute increase in seizure burden 0.83, 95% CI 0.69-0.99). There was no association between pretreatment total seizure duration and chance of successful response. Shorter time-to-treatment was paradoxically associated with lower chance of successful response to treatment, although this difference was small in magnitude (relative risk 1.007, 95% CI 1.003-1.010). CONCLUSIONS Maximal seizure burden may be more important than other, more commonly used measures in predicting response to acute seizure treatments.
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Affiliation(s)
- Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Fernando Gonzalez
- Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Nathalie L Maitre
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Niranjana Natarajan
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Sonia Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kaashif Ahmad
- Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, San Antonio, TX
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
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20
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Battin MR, Davis SL, Gardner M, Joe P, Rasmussen M, Haas R, Sharpe C. Seizures after initiation of rewarming in cooled infants with hypoxic ischaemic encephalopathy. Pediatr Res 2024; 95:752-757. [PMID: 37914821 DOI: 10.1038/s41390-023-02863-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Seizures after initiation of rewarming from therapeutic hypothermia for neonatal encephalopathy are well recognised but not easy to predict. METHODS A secondary analysis was performed of NEOLEV2 trial data, a multicentre randomised trial of levetiracetam versus phenobarbital for neonatal seizures. Enrolled infants underwent continuous video EEG (cEEG) monitoring. The trial data were reviewed for 42 infants with seizures during therapeutic hypothermia and 118 infants who received therapeutic hypothermia but had no seizures on cEEG. RESULTS Overall, 112 of 160 (70%) had cEEG monitoring continued until rewarming was completed. Of the 42 infants with prior seizures, there were 30 infants with valid cEEG available and seizures occurred following the initiation of rewarming in 8 (26.6%). For the 118 seizure-naive infants, 82 (69.5%) continued cEEG until either rewarming was completed or 90 h of age and none had documented seizures. CONCLUSION Overall, just over a quarter of infants with prior seizures had cEEG evidence of at least one seizure in the 24 h after initiation of rewarming but no seizure-naive infant had cEEG evidence of seizure(s) on rewarming. Critically, by reporting the two groups separately, the data can provide guidance on the duration of EEG monitoring. IMPACT Infants with hypoxic ischaemic encephalopathy who have cEEG evidence of seizures during therapeutic hypothermia have a significant risk of further seizures on rewarming. For infants with hypoxic ischaemic encephalopathy but no cEEG evidence of seizures during therapeutic hypothermia, there is very little risk of de novo seizures. Ongoing work utilising large cohorts may generate EEG criteria that refine estimates of risk for rewarming seizures. Based on current experience, if seizures have occurred during therapeutic hypothermia for hypoxic ischaemic encephalopathy, the EEG monitoring should be continued during rewarming and for 12 h thereafter to minimise the risk of missing an event.
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Affiliation(s)
| | - Suzanne L Davis
- Paediatric Neurology, Starship Hospital, Auckland, New Zealand
| | - Marisa Gardner
- Pediatric Neurology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Maynard Rasmussen
- Neonatology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Richard Haas
- Department of Neurosciences and Pediatrics, University of California, San Diego, CA, USA
| | - Cynthia Sharpe
- Paediatric Neurology, Starship Hospital, Auckland, New Zealand
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Spenard S, Ivan Salazar Cerda C, Cizmeci MN. Neonatal Seizures in Low- and Middle-Income Countries: A Review of the Literature and Recommendations for the Management. Turk Arch Pediatr 2024; 59:13-22. [PMID: 38454256 PMCID: PMC10837585 DOI: 10.5152/turkarchpediatr.2024.23250] [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: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
Neonatal seizures are a common cause of neonatal intensive care unit (NICU) admission and a significant source of morbidity and mortality worldwide. Over the recent decades, there have been significant improvements in perinatal and neonatal medicine and electroencephalograp hic monitoring that have enhanced the diagnosis and treatment of neonatal seizures in highincome countries. However, the management of neonatal seizures remains a major challenge in low- to middle-income countries, where the availabilityof resources is limited. The purpose of this article is to present a comprehensive review of the current evidence on the etiology, pathophysiology, diagnosis, and treatment of neonatal seizures and to offer practical management recommendations that could be implemented in resource-limited settings. Cite this article as: Spenard S, Ivan Salazar Cerda C, Cizmeci MN. Neonatal seizures in low and middleincome countries: Review of the literature and recommendations for the management. Turk Arch Pediatr. 2024;59(1):13-22.
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Affiliation(s)
- Sarah Spenard
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Carlos Ivan Salazar Cerda
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mehmet N. Cizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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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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Rondagh M, De Vries LS, Peeters-Scholte CM, Tromp SC, Steggerda SJ. Efficacy of Levetiracetam as Add-On Therapy in the Treatment of Seizures in Neonates. Neonatology 2023; 121:233-243. [PMID: 38113859 PMCID: PMC10994567 DOI: 10.1159/000535499] [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: 09/27/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION There is no consensus regarding the efficacy of add-on therapy with levetiracetam (LEV) in the treatment of seizures in neonates. The aim of this study was to evaluate the efficacy of add-on therapy with LEV for achieving >80% seizure reduction after phenobarbital (PB) treatment. METHODS Retrospective cohort study of near term neonates admitted to the neonatal intensive care unit with EEG-confirmed seizures despite treatment with PB as first-line therapy and using LEV as 2nd-, 3rd- or 4th-line treatment. Antiseizure medication was administered according to national guidelines. All neonates were monitored with 2-channel amplitude-integrated electroencephalography. The total seizure burden in minutes, 2 h before and 4 h after administration of LEV, was calculated using raw EEG. Primary outcome was the efficacy of LEV in achieving >80% seizure reduction. The efficacy of additional midazolam (MDZ) and lidocaine (LDC) was also calculated. RESULTS A total of 47 full-term neonates were included. The mean total loading dose of LEV was 40 mg/kg (36-44 mg/kg). Seizure etiology consisted of hypoxic-ischemic encephalopathy (n = 11), hemorrhagic or ischemic stroke (n = 16), central nervous system infection (n = 8), genetic (n = 8), metabolic disorders (n = 3), and unknown (n = 1). Following LEV administration, >80% seizure reduction was observed in 17% (8/47) of neonates, whereas it was 23% (6/26) after MDZ and 92% (23/25) after LDC administration. DISCUSSION Although the cumulative loading dose of LEV was low and the group of infants studied was heterogeneous, the efficacy of LEV as add-on therapy for the treatment of seizures in neonates was limited. The highest seizure reduction rate was seen after LDC administration.
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Affiliation(s)
- Mathies Rondagh
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Linda S. De Vries
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Selma C. Tromp
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J. Steggerda
- Department of Pediatrics, Division of Neonatology, Willem-Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Hernández-Prieto A, Garrido-Martín M, Gómez-Martín H, Pablos-López A, Alonso-Díez C, Hernández-Fabián A, Justel-Rodríguez M, Garrido-Pedraz JM, Prieto-Matos P. [Neonatal seizures and progression to epilepsy in a tertiary hospital]. Rev Neurol 2023; 77:249-252. [PMID: 37962536 PMCID: PMC10831768 DOI: 10.33588/rn.7710.2023218] [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: 11/03/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Given the immaturity of the newborn, neonatal seizures are a diagnostic challenge. Most of them are secondary to an acute event. A small percentage constitute the onset of epilepsy. AIMS The aim was to analyse neonates with a diagnosis of seizures admitted to a tertiary hospital between November 2009 and May 2021, and their subsequent progression to epilepsy. MATERIAL AND METHODS A retrospective observational study was carried out using the hospital database. Information was collected on neonates with a discharge diagnosis of 'seizures' or 'moderate or severe hypoxic-ischaemic encephalopathy'. Different variables were analysed: aetiology of the seizures, type, persistence over time, treatment and electroclinical correlates. RESULTS Of 165 patients, 55 presented neonatal seizures. As regards aetiology, 43 patients (78%) had seizures secondary to an acute event, of which 19 (34%) were hypoxic-ischaemic encephalopathies, and 22 (40%) had other acute disorders. Genetic alteration was found in six of them (11%). Thirteen patients (24%) progressed to subsequent epilepsy, of whom seven had symptomatic epilepsy, with a period of latency after the acute event in two patients. Six patients had neonatal epilepsy with unprovoked seizures. Twenty-two (62%) showed electroclinical correlates. All of the confirmed crises (100%) were focal. All the seizures were treated. The drug of choice was phenobarbital. CONCLUSIONS Diagnosis of neonatal seizures requires high clinical suspicion and electroclinical confirmation. Most of them progress favourably, but a percentage constitute the onset of epilepsy, the identification of which will determine their therapeutic management.
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Affiliation(s)
| | | | | | - A Pablos-López
- Hospital Sant Joan de Déu, Esplugues de Llobregat, España
| | - C Alonso-Díez
- Hospital Universitario de Salamanca, Salamanca, España
| | | | | | | | - P Prieto-Matos
- Universidad de Salamanca, Salamanca, España
- Hospital Universitario de Salamanca, Salamanca, España
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Kumar J, Yadav B, Meena J, Yadav J, Sahu JK. Levetiracetam versus Phenobarbitone for Management of Neonatal Seizures: A Systematic Review and Meta-analysis. Indian J Pediatr 2023:10.1007/s12098-023-04905-1. [PMID: 37938514 DOI: 10.1007/s12098-023-04905-1] [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: 07/05/2023] [Accepted: 10/13/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES To review whether levetiracetam is non-inferior to phenobarbitone as the first-choice antiseizure medication (ASM). METHODS The authors searched Medline, Embase, Web of Science, Scopus, and Cochrane Library for randomized controlled trials (RCTs) published until May 31, 2023. RCTs comparing the efficacy and safety of levetiracetam and phenobarbitone as first-line ASM in neonatal seizures were included. Random effects meta-analysis was performed, and the Risk of Bias version 2 tool was used for quality assessment. RESULTS Eleven RCTs enrolling 821 neonates [mostly term, with hypoxic-ischemic encephalopathy (HIE)] were included. There was no significant difference in seizure control between levetiracetam and phenobarbitone (10 RCTs, 786 participants; relative risk RR: 1.11; 95% CI: 0.79, 1.54; I2- 88%). Neonates in the levetiracetam group had a significantly lower incidence of hypotension (RR: 0.28; 95% CI: 0.09, 0.86), respiratory depression (RR: 0.36, 95% CI: 0.19, 0.66), and depressed sensorium (RR: 0.52, 95% CI: 0.27, 1.00). Three studies compared neurodevelopmental outcomes; however two of them were cross-over trials where infants received both drugs. Only one RCT enrolled pure cohorts and showed better neurodevelopment in the levetiracetam group at one month of age. CONCLUSIONS With the limitation of very-low certainty evidence, the results of this systematic review suggest that levetiracetam may be non-inferior to phenobarbitone for managing neonatal seizures. Considering a better safety profile and marginally better neurodevelopment in the short term, levetiracetam may be considered an initial choice for managing neonatal seizures. REGISTRATION NUMBER PROSPERO (CRD42023438018).
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Affiliation(s)
- Jogender Kumar
- Neonatology Unit, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bharti Yadav
- Department of Neonatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jitendra Meena
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jaivinder Yadav
- Neonatology Unit, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jitendra Kumar Sahu
- Pediatric Neurology Unit, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Variane GFT, Dahlen A, Pietrobom RFR, Rodrigues DP, Magalhães M, Mimica MJ, Llaguno NS, Leandro DMK, Girotto PN, Sampaio LB, Van Meurs KP. Remote Monitoring for Seizures During Therapeutic Hypothermia in Neonates With Hypoxic-Ischemic Encephalopathy. JAMA Netw Open 2023; 6:e2343429. [PMID: 37966836 PMCID: PMC10652158 DOI: 10.1001/jamanetworkopen.2023.43429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/04/2023] [Indexed: 11/16/2023] Open
Abstract
Importance Neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH) frequently experience seizures, which are associated with adverse outcomes. Efforts to rapidly identify seizures and reduce seizure burden may positively change neurologic and neurodevelopmental outcomes. Objective To describe the onset, treatment, and evolution of seizures in a large cohort of newborns with HIE during TH assisted by a telehealth model and remote neuromonitoring approach. Design, Setting, and Participants This was a prospective, observational, multicenter cohort study performed between July 2017 and December 2021 in 32 hospitals in Brazil. Participants were newborns with HIE meeting eligibility criteria and receiving TH. Data were analyzed from November 2022 to April 2023. Exposure Infants with HIE receiving TH were remotely monitored with 3-channel amplitude-integrated electroencephalography (aEEG) including raw tracing and video imaging, and bedside clinicians received assistance from trained neonatologists and neurologists. Main Outcomes and Measures Data on modified Sarnat examination, presence, timing and seizure type, aEEG background activity, sleep-wake cycling, and antiepileptic drugs used were collected. Descriptive statistical analysis was used with independent t test, χ2, Mann-Whitney test, and post hoc analyses applied for associations. Results A total of 872 cooled newborns were enrolled; the median (IQR) gestational age was 39 (38-40) weeks, 518 (59.4%) were male, and 59 (6.8%) were classified as having mild encephalopathy by modified Sarnat examination, 504 (57.8%) as moderate, and 180 (20.6%) as severe. Electrographic seizures were identified in 296 newborns (33.9%), being only electrographic in 213 (71.9%) and clinical followed by electroclinical uncoupling in 50 (16.9%). Early abnormal background activity had a significant association with seizures. Infants with flat trace had the highest rate of seizures (58 infants [68.2%]) and the greatest association with the incidence of seizures (odds ratio [OR], 12.90; 95% CI, 7.57-22.22) compared with continuous normal voltage. The absence of sleep-wake cycling was also associated with a higher occurrence of seizures (OR, 2.22; 95% CI, 1.67-2.96). Seizure onset was most frequent between 6 and 24 hours of life (181 infants [61.1%]); however, seizure occurred in 34 infants (11.5%) during rewarming. A single antiepileptic drug controlled seizures in 192 infants (64.9%). The first line antiepileptic drug was phenobarbital in 294 (99.3%). Conclusions and Relevance In this cohort study of newborns with HIE treated with TH, electrographic seizure activity occurred in 296 infants (33.9%) and was predominantly electrographic. Seizure control was obtained with a single antiepileptic drug in 192 infants (64.9%). These findings suggest neonatal neurocritical care can be delivered at remote limited resource hospitals due to innovations in technology and telehealth.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Alex Dahlen
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California
| | - Rafaela Fabri Rodrigues Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Nathalie Salles Llaguno
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Danieli Mayumi Kimura Leandro
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Paula Natale Girotto
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Division of Neurosurgery, Associação Paulista para o Desenvolvimento da Medicina, Hospital de Transplantes Euryclides de Jesus Zerbini, São Paulo, São Paulo, Brazil
| | - Leticia Brito Sampaio
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Division of Pediatric Neurology, Faculdade de Medicina Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, Brazil
| | - Krisa Page Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Palo Alto, California
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Hunt RW. Neonatal seizures. Treat! But when, with what and for how long? Arch Dis Child Fetal Neonatal Ed 2023; 108:552-553. [PMID: 37527943 DOI: 10.1136/archdischild-2023-325324] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/18/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Rod W Hunt
- Department of Paediatrics, Monash University, Clayton 3168, Victoria, Australia
- Newborn Medicine, Monash Health, Clayton, Victoria, Australia
- CPA Research Foundation, Cerebral Palsy Alliance, Sydney, NSW, Australia
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Bidabadi E, Zarkesh M, Mirzaiichaghakabudi M. Thyroid Hormone Levels in Preterm Neonates with Birth Weight Less than 2500 g, Treated with Phenobarbital. IRANIAN JOURNAL OF CHILD NEUROLOGY 2023; 17:155-162. [PMID: 38074926 PMCID: PMC10704285 DOI: 10.22037/ijcn.v17i4.42583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/07/2023] [Indexed: 01/03/2024]
Abstract
Objectives Indicatively, phenobarbital can impair thyroid function in adults and children. The present research aims to evaluate the thyroid hormone levels in preterm neonates who had received phenobarbital treatment. Materials &Methods This study was conducted on preterm neonates who weighed less or equal to 2500 g when phenobarbital was prescribed for treatment in the first 15 days of life. TSH and total T4 measurements were performed before and three months after initiation of phenobarbital. Results In this study, the sum of preterm neonates stood at 94, of which 53 were girls, with a mean birth weight of 2004.41 ± 315.41g. Weight of 8.5% were under 1500 g. The mean gestational age was estimated at 33.64 ± 2.01 weeks. Mean T4 levels were 12.24 ± 1.96 and 12.07 ± 1.95 (p=0.334), and mean TSH levels were 5.34 ± 2.14 and5.15 ± 2.15 (p=0.376) before and after prescribing phenobarbital, respectively. The same results were compared based on sex, gestational age, birth weight, and height for T4 and TSH and T4 based on head circumference. The only significant difference was TSH in preterm infants with head circumference <32 cm before and after prescribing phenobarbital (p=0.030). Conclusion In preterm newborns that had less than 2500 g birth weight, phenobarbital did not significantly alter the serum thyroid hormone levels.
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Affiliation(s)
- Elham Bidabadi
- Pediatric Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran Elham Bidabadi and Marjaneh Zarkesh are equal contributions to this work and designated as cofirst authors
| | - Marjaneh Zarkesh
- Pediatric Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran Elham Bidabadi and Marjaneh Zarkesh are equal contributions to this work and designated as cofirst authors
| | - Maryam Mirzaiichaghakabudi
- Pediatric Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran Elham Bidabadi and Marjaneh Zarkesh are equal contributions to this work and designated as cofirst authors
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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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You Q, Lan XB, Liu N, Du J, Ma L, Yang JM, Niu JG, Peng XD, Jin GL, Yu JQ. Neuroprotective strategies for neonatal hypoxic-ischemic brain damage: Current status and challenges. Eur J Pharmacol 2023; 957:176003. [PMID: 37640219 DOI: 10.1016/j.ejphar.2023.176003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Abstract
Neonatal hypoxic-ischemic brain damage (HIBD) is a prominent contributor to both immediate mortality and long-term impairment in newborns. The elusive nature of the underlying mechanisms responsible for neonatal HIBD presents a significant obstacle in the effective clinical application of numerous pharmaceutical interventions. This comprehensive review aims to concentrate on the potential neuroprotective agents that have demonstrated efficacy in addressing various pathogenic factors associated with neonatal HIBD, encompassing oxidative stress, calcium overload, mitochondrial dysfunction, endoplasmic reticulum stress, inflammatory response, and apoptosis. In this review, we conducted an analysis of the precise molecular pathways by which these drugs elicit neuroprotective effects in animal models of neonatal hypoxic-ischemic brain injury (HIBD). Our objective was to provide a comprehensive overview of potential neuroprotective agents for the treatment of neonatal HIBD in animal experiments, with the ultimate goal of enhancing the feasibility of clinical translation and establishing a solid theoretical foundation for the clinical management of neonatal HIBD.
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Affiliation(s)
- Qing You
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Xiao-Bing Lan
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Ning Liu
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China; Ningxia Special Traditional Medicine Modern Engineering Research Center and Collaborative Innovation Center, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Juan Du
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Lin Ma
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Jia-Mei Yang
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Jian-Guo Niu
- Ningxia Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, 750004, China.
| | - Xiao-Dong Peng
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
| | - Gui-Lin Jin
- Fujian Key Laboratory of Drug Target Discovery and Structural and Functional Research, Fuzhou, 350108, Fujian, China; Department of Pharmacology, College of Pharmacy, Fujian Medical University, Fuzhou, 350108, Fujian, China.
| | - Jian-Qiang Yu
- Department of Pharmacology, School of Pharmacy, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China; Ningxia Special Traditional Medicine Modern Engineering Research Center and Collaborative Innovation Center, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, China.
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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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Carapancea E, Cilio MR. A novel approach to seizures in neonates. Eur J Paediatr Neurol 2023; 46:89-97. [PMID: 37544258 DOI: 10.1016/j.ejpn.2023.07.006] [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: 05/13/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
THE CHALLENGE OF SEIZURE RECOGNITION Recognition of seizures in neonates remains the foremost challenge to overcome. All neonates at risk for seizures, especially the critically ill, should undergo video-EEG monitoring. The initial step toward an accurate diagnosis is the accurate description and interpretation of the electro-clinical phenotype. THE IMPORTANCE OF SEIZURE SEMIOLOGY AND ASSOCIATION WITH ETIOLOGY: The early distinction between acute provoked seizures and neonatal-onset epilepsies serves as the primary determinant for guiding management, treatment choices, and duration. Seizures in neonates should be seen as a symptom, not a disease, and their semiology may suggest the etiology. TREATMENT OF ACUTE PROVOKED SEIZURES Neonates with hypoxic-ischemic encephalopathy respond best to phenobarbital, while levetiracetam is a better choice for neonates with congenital heart diseases. Anti-seizure medication can be discontinued after 72 h of seizure freedom, before discharge from the hospital. TREATMENT OF NEONATAL EPILEPSIES Neonates with epilepsy usually require a personalized, etiology-based approach in terms of choice and duration of treatment. Neonates with channelopathies tend to respond to sodium channel blockers such as carbamazepine, oxcarbazepine, or phenytoin. The surgical option should be considered early in cases of large brain malformations, such as hemimegalencephaly.
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Affiliation(s)
- Evelina Carapancea
- Institute of Neuroscience (IoNS), Université Catholique de Louvain, Brussels, Belgium
| | - Maria Roberta Cilio
- Institute of Neuroscience (IoNS), Université Catholique de Louvain, Brussels, Belgium; Division of Pediatric Neurology, Department of Pediatrics, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Pin JN, Leonardi L, Nosadini M, Cavicchiolo ME, Guariento C, Zarpellon A, Perilongo G, Raffagnato A, Toldo I, Baraldi E, Sartori S. Efficacy and safety of ketamine for neonatal refractory status epilepticus: case report and systematic review. Front Pediatr 2023; 11:1189478. [PMID: 37334223 PMCID: PMC10275409 DOI: 10.3389/fped.2023.1189478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/23/2023] [Indexed: 06/20/2023] Open
Abstract
Background Evidence-based data on treatment of neonatal status epilepticus (SE) are scarce. We aimed to collect data on the efficacy and safety of ketamine for the treatment of neonatal SE and to assess its possible role in the treatment of neonatal SE. Methods We described a novel case and conducted a systematic literature review on neonatal SE treated with ketamine. The search was carried out in Pubmed, Cochrane, Clinical Trial Gov, Scopus and Web of Science. Results Seven published cases of neonatal SE treated with ketamine were identified and analyzed together with our novel case. Seizures typically presented during the first 24 h of life (6/8). Seizures were resistant to a mean of five antiseizure medications. Ketamine, a NMDA receptor antagonist, appeared to be safe and effective in all neonates treated. Neurologic sequelae including hypotonia and spasticity were reported for 4/5 of the surviving children (5/8). 3/5 of them were seizure free at 1-17 months of life. Discussion Neonatal brain is more susceptible to seizures due to a shift towards increased excitation because of a paradoxical excitatory effect of GABA, a greater density of NMDA receptors and higher extracellular concentrations of glutamate. Status epilepticus and neonatal encephalopathy could further enhance these mechanisms, providing a rationale for the use of ketamine in this setting. Conclusions Ketamine in the treatment of neonatal SE showed a promising efficacy and safety profile. However, further in-depth studies and clinical trials on larger populations are needed.
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Affiliation(s)
- Jacopo Norberto Pin
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University Hospital of Padua, Padova, Italy
| | - Letizia Leonardi
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
| | - Margherita Nosadini
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute “Città della Speranza”, Padova, Italy
| | - Maria Elena Cavicchiolo
- Department of Women’s and Children’s Health, Neonatal Intensive Care Unit, University Hospital of Padua, Padova, Italy
| | - Chiara Guariento
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
| | - Anna Zarpellon
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
| | - Giorgio Perilongo
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
| | - Alessia Raffagnato
- Department of Women’s and Children’s Health, Child and Adolescent Neuropsychiatric Unit, University Hospital of Padua, Padova, Italy
| | - Irene Toldo
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
| | - Eugenio Baraldi
- Department of Women’s and Children’s Health, Neonatal Intensive Care Unit, University Hospital of Padua, Padova, Italy
| | - Stefano Sartori
- Department of Women’s and Children’s Health, Paediatric Neurology and Neurophysiology Unit, University Hospital of Padua, Padova, Italy
- Master in Pediatrics and Pediatric Subspecialties, University Hospital of Padua, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute “Città della Speranza”, Padova, Italy
- Department of Neuroscience, University Hospital of Padua, Padova, Italy
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Affiliation(s)
- Elissa Yozawitz
- From the Isabelle Rapin Division of Child Neurology of the Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Welzel B, Johne M, Löscher W. Bumetanide potentiates the anti-seizure and disease-modifying effects of midazolam in a noninvasive rat model of term birth asphyxia. Epilepsy Behav 2023; 142:109189. [PMID: 37037061 DOI: 10.1016/j.yebeh.2023.109189] [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: 01/19/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/12/2023]
Abstract
Birth asphyxia and the resulting hypoxic-ischemic encephalopathy (HIE) are highly associated with perinatal and neonatal death, neonatal seizures, and an adverse later-life outcome. Currently used drugs, including phenobarbital and midazolam, have limited efficacy to suppress neonatal seizures. There is a medical need to develop new therapies that not only suppress neonatal seizures but also prevent later-life consequences. We have previously shown that the loop diuretic bumetanide does not potentiate the effects of phenobarbital in a rat model of birth asphyxia. Here we compared the effects of bumetanide (0.3 or 10 mg/kg i.p.), midazolam (1 mg/kg i.p.), and a combination of bumetanide and midazolam on neonatal seizures and later-life outcomes in this model. While bumetanide at either dose was ineffective when administered alone, the higher dose of bumetanide markedly potentiated midazolam's effect on neonatal seizures. Median bumetanide brain levels (0.47-0.53 µM) obtained with the higher dose were in the range known to inhibit the Na-K-Cl-cotransporter NKCC1 but it remains to be determined whether brain NKCC1 inhibition was underlying the potentiation of midazolam. When behavioral and cognitive alterations were examined over three months after asphyxia, treatment with the bumetanide/midazolam combination, but not with bumetanide or midazolam alone, prevented impairment of learning and memory. Furthermore, the combination prevented the loss of neurons in the dentate hilus and aberrant mossy fiber sprouting in the CA3a area of the hippocampus. The molecular mechanisms that explain that bumetanide potentiates midazolam but not phenobarbital in the rat model of birth asphyxia remain to be determined.
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Affiliation(s)
- Björn Welzel
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Marie Johne
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany.
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Carrasco M, Bonifacio SL, deVeber G, Chau V. Early Discontinuation of Phenobarbital After Acute Symptomatic Neonatal Seizures in the Term Newborn. Neurol Clin Pract 2023; 13:e200125. [PMID: 36891461 PMCID: PMC9987207 DOI: 10.1212/cpj.0000000000200125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/07/2022] [Indexed: 02/18/2023]
Abstract
Acute symptomatic seizures in the term newborn are often seen after perinatal brain injury. Common etiologies include hypoxic-ischemic encephalopathy, ischemic stroke, intracranial hemorrhage, metabolic derangements, and intracranial infections. Neonatal seizures are often treated with phenobarbital, which may cause sedation and may have significant long-term effects on brain development. Recent literature has suggested that phenobarbital may be safely discontinued in some patients before discharge from the neonatal intensive care unit. Optimizing a strategy for selective early phenobarbital discontinuation would be of great value. In this study, we present a unified framework for phenobarbital discontinuation after resolution of acute symptomatic seizures in the setting of brain injury of the newborn.
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Affiliation(s)
- Melisa Carrasco
- Department of Neurology (MC), University of Wisconsin and University Hospital, Madison, WI; Department of Pediatrics (Neonatology) (SLB), Lucile Packard Children's Hospital and Stanford University, Stanford, CA; Department of Pediatrics (Neurology) (GdV), The Hospital for Sick Children, SickKids Research Institute (Child Health Evaluative Sciences) and University of Toronto, Toronto, Ontario, Canada; and Department of Pediatrics (Neurology) (VC), The Hospital for Sick Children, SickKids Research Institute (Neuroscience and Mental Health) and University of Toronto, Ontario, Canada
| | - Sonia Lomeli Bonifacio
- Department of Neurology (MC), University of Wisconsin and University Hospital, Madison, WI; Department of Pediatrics (Neonatology) (SLB), Lucile Packard Children's Hospital and Stanford University, Stanford, CA; Department of Pediatrics (Neurology) (GdV), The Hospital for Sick Children, SickKids Research Institute (Child Health Evaluative Sciences) and University of Toronto, Toronto, Ontario, Canada; and Department of Pediatrics (Neurology) (VC), The Hospital for Sick Children, SickKids Research Institute (Neuroscience and Mental Health) and University of Toronto, Ontario, Canada
| | - Gabrielle deVeber
- Department of Neurology (MC), University of Wisconsin and University Hospital, Madison, WI; Department of Pediatrics (Neonatology) (SLB), Lucile Packard Children's Hospital and Stanford University, Stanford, CA; Department of Pediatrics (Neurology) (GdV), The Hospital for Sick Children, SickKids Research Institute (Child Health Evaluative Sciences) and University of Toronto, Toronto, Ontario, Canada; and Department of Pediatrics (Neurology) (VC), The Hospital for Sick Children, SickKids Research Institute (Neuroscience and Mental Health) and University of Toronto, Ontario, Canada
| | - Vann Chau
- Department of Neurology (MC), University of Wisconsin and University Hospital, Madison, WI; Department of Pediatrics (Neonatology) (SLB), Lucile Packard Children's Hospital and Stanford University, Stanford, CA; Department of Pediatrics (Neurology) (GdV), The Hospital for Sick Children, SickKids Research Institute (Child Health Evaluative Sciences) and University of Toronto, Toronto, Ontario, Canada; and Department of Pediatrics (Neurology) (VC), The Hospital for Sick Children, SickKids Research Institute (Neuroscience and Mental Health) and University of Toronto, Ontario, Canada
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Romantsik O, Smit E, Odd DE, Bruschettini M. Postnatal phenobarbital for the prevention of intraventricular haemorrhage in preterm infants. Cochrane Database Syst Rev 2023; 3:CD001691. [PMID: 36924438 PMCID: PMC10019441 DOI: 10.1002/14651858.cd001691.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Intraventricular haemorrhage (IVH) is a major complication of preterm birth. Large haemorrhages are associated with a high risk of disability and hydrocephalus. Instability of blood pressure and cerebral blood in the newborn flow are postulated as causative factors. Another mechanism may involve reperfusion damage from oxygen free radicals. It has been suggested that phenobarbital stabilises blood pressure and may protect against free radicals. This is an update of a review first published in 2001 and updated in 2007 and 2013. OBJECTIVES To assess the benefits and harms of the postnatal administration of phenobarbital in preterm infants at risk of developing IVH compared to control (i.e. no intervention or placebo). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL and clinical trial registries in January 2022. A new, more sensitive search strategy was developed, and searches were conducted without date limits. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs in which phenobarbital was given within the first 24 hours of life to preterm infants identified as being at risk of IVH because of gestational age below 34 weeks, birth weight below 1500 g or respiratory failure. Phenobarbital was compared to no intervention or placebo. We excluded infants with serious congenital malformations. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all grades of IVH and severe IVH (i.e. grade III and IV); secondary outcomes were ventricular dilation or hydrocephalus, hypotension, pneumothorax, hypercapnia, acidosis, mechanical ventilation, neurodevelopmental impairment and death. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We included 10 RCTs (792 infants). The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH of any grade compared with control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.84 to 1.19; risk difference (RD) 0.00, 95% CI -0.06 to 0.07; I² for RD = 65%; 10 RCTs, 792 participants; low certainty evidence) and in severe IVH (RR 0.88, 95% CI 0.64 to 1.21; 10 RCTs, 792 participants; low certainty evidence). The evidence is very uncertain about the effect of phenobarbital on posthaemorrhagic ventricular dilation or hydrocephalus (RR 0.62, 95% CI 0.31 to 1.26; 4 RCTs, 271 participants; very low certainty evidence), mild neurodevelopmental impairment (RR 0.57, 95% CI 0.15 to 2.17; 1RCT, 101 participants; very low certainty evidence), and severe neurodevelopmental impairment (RR 1.12, 95% CI 0.44 to 2.82; 2 RCTs, 153 participants; very low certainty evidence). Phenobarbital may result in little to no difference in death before discharge (RR 0.88, 95% CI 0.64 to 1.21; 9 RCTs, 740 participants; low certainty evidence) and mortality during study period (RR 0.98, 95% CI 0.72 to 1.33; 10 RCTs, 792 participants; low certainty evidence) compared with control. We identified no ongoing trials. AUTHORS' CONCLUSIONS The evidence suggests that phenobarbital results in little to no difference in the incidence of IVH (any grade or severe) compared with control (i.e. no intervention or placebo). The evidence is very uncertain about the effects of phenobarbital on ventricular dilation or hydrocephalus and on neurodevelopmental impairment. The evidence suggests that phenobarbital results in little to no difference in death before discharge and all deaths during the study period compared with control. Since 1993, no randomised studies have been published on phenobarbital for the prevention of IVH in preterm infants, and no trials are ongoing. The effects of postnatal phenobarbital might be assessed in infants with both neonatal seizures and IVH, in both randomised and observational studies. The assessment of benefits and harms should include long-term outcomes.
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Affiliation(s)
- Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Elisa Smit
- Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - David E Odd
- Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
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Cannavò L, Perrone S, Gitto E. Brain-Oriented Strategies for Neuroprotection of Asphyxiated Newborns in the First Hours of Life. Pediatr Neurol 2023; 143:44-49. [PMID: 36996760 DOI: 10.1016/j.pediatrneurol.2023.02.015] [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: 05/19/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 04/01/2023]
Abstract
Perinatal asphyxia represents the first cause of severe neurological disabilities and the second cause of neonatal death in term-born babies. Currently, no treatment can prevent immediate cell death from necrosis, but some therapeutic interventions, such as therapeutic hypothermia (TH), can reduce delayed cell death from apoptosis. TH significantly improves the combined outcome of mortality or major neurodevelopmental disability, but the number of patients to be treated is 7 to get 1 child with no adverse neurological outcome. The aim of this educational review is to analyze the other care strategies to be implemented to improve the neurological outcome of children with hypoxic ischemic encephalopathy (HIE). Hypocapnia, hypoglycemia, pain control, and functional brain monitoring are recognized as appropriate approaches to improve outcome in critically ill infants with HIE. Pharmacologic neuroprotective adjuncts are currently under investigation. New drugs such as allopurinol and melatonin seem to provide positive effects although more randomized controlled trials are required to establish the effective therapeutic scheme. In the meantime, sustaining the respiratory, metabolic, and cardiovascular system during TH can be a valuable aid in managing and treating the patient with HIE in an optimal way.
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Affiliation(s)
- Laura Cannavò
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Serafina Perrone
- Neonatal Unit, University of Parma, Azienda Ospedaliero Universitaria di Parma, Parma, Italy.
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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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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Gyandeep G, Behura SS, Sahu SK, Panda SK. Comparison between Phenobarbitone and Levetiracetam as the initial anticonvulsant in preterm neonatal seizures - a pilot randomized control trial in developing country setup. Eur J Pediatr 2023; 182:2133-2138. [PMID: 36823477 PMCID: PMC9950002 DOI: 10.1007/s00431-023-04864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/29/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
This study aimed to compare the efficacy and safety of intravenous Levetiracetam and Phenobarbitone in the treatment of seizures in preterm neonates. It was an open-labeled, parallel randomized controlled trial conducted in a tertiary Neonatal Intensive Care Unit, India. Total 48 preterm neonates (28-36+6 weeks) with clinical seizures were randomized to receive either Levetiracetam (LEV; 40 mg/kg, then 20 mg/kg) or Phenobarbitone (PB; 15 mg/kg, then 10 mg/kg) intravenously as first loading dose in ratio 1:1; second loading was given for persistent seizure. Efficacy was denoted by cessation of clinical seizures with first or second doses of the allotted antiepileptic, and remaining seizure-free for the next 24 h. The demographic characteristics of preterm neonates and seizure types were comparable between both groups. Clinical seizure was controlled in 19 (79%) neonates in LEV group and 17 (70%) neonates in PB group, RR 1.12 (95% CI: 0.80 to 1.55), p = 0.504. There was increased respiratory support in PB group 9 (38%) vs. 3 (13%) in LEV group, RR 3.0 (95% CI: 0.92 to 9.74), p = 0.06. Conclusion: Levetiracetam and Phenobarbitone were equally efficacious for clinical neonatal seizure control, but increased respiratory support was found with Phenobarbitone use. What is Known: • Preterm neonates are at higher risk of neonatal seizure and Phenobarbitone is commonly used as the first line antiepileptic drugs in treating them. What is New: • Levetiracetam found equally efficacious as Phenobarbitone for cessation of clinical seizures in preterm neonates, with less adverse effect.
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Affiliation(s)
- Gummalla Gyandeep
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Sushree Smita Behura
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Sanjay Kumar Sahu
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Santosh Kumar Panda
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
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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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43
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Ning J. EBNEO Commentary: Need to further study levetiracetam as first-line drug for neonatal convulsions. Acta Paediatr 2023; 112:166-167. [PMID: 36251620 DOI: 10.1111/apa.16563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/17/2022] [Accepted: 10/05/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Junjie Ning
- Department of pediatrics, First People's Hospital of Zigong City, Zigong, China
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Improving child health through Big Data and data science. Pediatr Res 2023; 93:342-349. [PMID: 35974162 PMCID: PMC9380977 DOI: 10.1038/s41390-022-02264-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022]
Abstract
Child health is defined by a complex, dynamic network of genetic, cultural, nutritional, infectious, and environmental determinants at distinct, developmentally determined epochs from preconception to adolescence. This network shapes the future of children, susceptibilities to adult diseases, and individual child health outcomes. Evolution selects characteristics during fetal life, infancy, childhood, and adolescence that adapt to predictable and unpredictable exposures/stresses by creating alternative developmental phenotype trajectories. While child health has improved in the United States and globally over the past 30 years, continued improvement requires access to data that fully represent the complexity of these interactions and to new analytic methods. Big Data and innovative data science methods provide tools to integrate multiple data dimensions for description of best clinical, predictive, and preventive practices, for reducing racial disparities in child health outcomes, for inclusion of patient and family input in medical assessments, and for defining individual disease risk, mechanisms, and therapies. However, leveraging these resources will require new strategies that intentionally address institutional, ethical, regulatory, cultural, technical, and systemic barriers as well as developing partnerships with children and families from diverse backgrounds that acknowledge historical sources of mistrust. We highlight existing pediatric Big Data initiatives and identify areas of future research. IMPACT: Big Data and data science can improve child health. This review highlights the importance for child health of child-specific and life course-based Big Data and data science strategies. This review provides recommendations for future pediatric-specific Big Data and data science research.
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45
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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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46
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Miller SL, Bennet L, Sutherland AE, Pham Y, McDonald C, Castillo‐Melendez M, Allison BJ, Mihelakis J, Nitsos I, Boyd BJ, Hirst JJ, Walker DW, Hunt RW, Jenkin G, Wong F, Malhotra A, Fahey MC, Yawno T. Ganaxolone versus Phenobarbital for Neonatal Seizure Management. Ann Neurol 2022; 92:1066-1079. [PMID: 36054160 PMCID: PMC9828769 DOI: 10.1002/ana.26493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Seizures are more common in the neonatal period than at any other stage of life. Phenobarbital is the first-line treatment for neonatal seizures and is at best effective in approximately 50% of babies, but may contribute to neuronal injury. Here, we assessed the efficacy of phenobarbital versus the synthetic neurosteroid, ganaxolone, to moderate seizure activity and neuropathology in neonatal lambs exposed to perinatal asphyxia. METHODS Asphyxia was induced via umbilical cord occlusion in term lambs at birth. Lambs were treated with ganaxolone (5mg/kg/bolus then 5mg/kg/day for 2 days) or phenobarbital (20mg/kg/bolus then 5mg/kg/day for 2 days) at 6 hours. Abnormal brain activity was classified as stereotypic evolving (SE) seizures, epileptiform discharges (EDs), and epileptiform transients (ETs) using continuous amplitude-integrated electroencephalographic recordings. At 48 hours, lambs were euthanized for brain pathology. RESULTS Asphyxia caused abnormal brain activity, including SE seizures that peaked at 18 to 20 hours, EDs, and ETs, and induced neuronal degeneration and neuroinflammation. Ganaxolone treatment was associated with an 86.4% reduction in the number of seizures compared to the asphyxia group. The total seizure duration in the asphyxia+ganaxolone group was less than the untreated asphyxia group. There was no difference in the number of SE seizures between the asphyxia and asphyxia+phenobarbital groups or duration of SE seizures. Ganaxolone treatment, but not phenobarbital, reduced neuronal degeneration within hippocampal CA1 and CA3 regions, and cortical neurons, and ganaxolone reduced neuroinflammation within the thalamus. INTERPRETATION Ganaxolone provided better seizure control than phenobarbital in this perinatal asphyxia model and was neuroprotective for the newborn brain, affording a new therapeutic opportunity for treatment of neonatal seizures. ANN NEUROL 2022;92:1066-1079.
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Affiliation(s)
- Suzanne L. Miller
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Laura Bennet
- Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Amy E. Sutherland
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Yen Pham
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Courtney McDonald
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Margie Castillo‐Melendez
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Beth J. Allison
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Jamie Mihelakis
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ilias Nitsos
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ben J. Boyd
- Monash Institute of Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Jonathan J. Hirst
- School of Biomedical Sciences and Pharmacy, University of NewcastleNewcastleNew South WalesAustralia
| | - David W. Walker
- School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia
| | - Rodney W. Hunt
- Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Graham Jenkin
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Flora Wong
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Atul Malhotra
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Michael C. Fahey
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Tamara Yawno
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
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Langton RL, Sharma S, Tiarks GC, Bassuk AG, Glykys J. Lacosamide decreases neonatal seizures without increasing apoptosis. Epilepsia 2022; 63:3051-3065. [PMID: 36168798 PMCID: PMC9742288 DOI: 10.1111/epi.17423] [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] [Received: 06/02/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Many seizing neonates fail to respond to first-line anticonvulsant medications. Phenobarbital, an allosteric modulator of γ-aminobutyric acid type A (GABAA ) receptors, has low efficacy in treating neonatal seizures and causes neuronal apoptosis. Nonetheless, it is one of the most used anticonvulsants in this age group. In neonatal mice, phenobarbital's poor effectiveness is due in part to high intraneuronal chloride concentration, which causes GABA to exert depolarizing actions. Therefore, another approach to treat neonatal seizures could be to use anticonvulsants that do not rely on GABAergic modulation. We evaluated whether lacosamide decreases seizures in neonatal mice and whether it increases apoptosis in vitro and in vivo. METHODS In vitro, we measured the effect of different lacosamide concentrations on seizure-like activity induced by the pro-convulsant drug 4-aminopyridine in neocortical brain slices (layer IV/V) from neonatal (postnatal day 8-11) and adult (1-1.6 months old) C57BL/6J mice. In vivo, we recorded the effect of different lacosamide concentrations on neonatal behavioral seizures induced by kainic acid. We studied neocortical apoptosis in vitro and in vivo, measuring terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labeling signal and cleaved-caspase 3. RESULTS Lacosamide reduced epileptiform activity in neocortical brain slices of neonates and adults in a concentration-dependent manner. In vivo, lacosamide reduced the duration and number of behavioral seizures. Lacosamide did not increase total or neuronal apoptosis in the neocortex in vitro or in vivo. SIGNIFICANCE Lacosamide reduces neocortical seizure-like activity in neonatal mice in vitro and in vivo without an acute increase in apoptosis. Our results support the use of lacosamide to treat neonatal seizures, with the advantage of not increasing apoptosis acutely.
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Affiliation(s)
- Rachel L Langton
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Shaunik Sharma
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Grant C Tiarks
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Alexander G Bassuk
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Joseph Glykys
- Department of Pediatrics, Division of Child Neurology, University of Iowa, Iowa City, Iowa, USA.,Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA.,Department of Neurology, University of Iowa, Iowa City, Iowa, USA
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48
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He Y, Ying J, Tang J, Zhou R, Qu H, Qu Y, Mu D. Neonatal Arterial Ischaemic Stroke: Advances in Pathologic Neural Death, Diagnosis, Treatment, and Prognosis. Curr Neuropharmacol 2022; 20:2248-2266. [PMID: 35193484 PMCID: PMC9890291 DOI: 10.2174/1570159x20666220222144744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/04/2022] [Accepted: 02/18/2022] [Indexed: 12/29/2022] Open
Abstract
Neonatal arterial ischaemic stroke (NAIS) is caused by focal arterial occlusion and often leads to severe neurological sequelae. Neural deaths after NAIS mainly include necrosis, apoptosis, necroptosis, autophagy, ferroptosis, and pyroptosis. These neural deaths are mainly caused by upstream stimulations, including excitotoxicity, oxidative stress, inflammation, and death receptor pathways. The current clinical approaches to managing NAIS mainly focus on supportive treatments, including seizure control and anticoagulation. In recent years, research on the pathology, early diagnosis, and potential therapeutic targets of NAIS has progressed. In this review, we summarise the latest progress of research on the pathology, diagnosis, treatment, and prognosis of NAIS and highlight newly potential diagnostic and treatment approaches.
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Affiliation(s)
- Yang He
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Junjie Ying
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Jun Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Ruixi Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Haibo Qu
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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Swarnalingam E, Woodward K, Esser M, Jacobs J. Management and prognosis of pediatric status epilepticus. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Pediatric status epilepticus is a neurological emergency with the potential for severe developmental and neurological consequences. Prompt diagnosis and management are necessary.
Objectives
To outline the existing best available evidence for managing pediatric and neonatal status epilepticus, in the light of emerging randomized controlled studies. We also focus on short and long-term prognoses.
Materials and methods
This is a systematic overview of the existing literature.
Results
Status epilepticus, its treatment, and prognosis are usually based on the continuation of seizure activity at 5 and 30 min. Refractory and super-refractory status epilepticus further complicates management and requires continuous EEG monitoring with regular reassessment and adjustment of therapy. Benzodiazepines have been accepted as the first line of treatment on the basis of reasonable evidence. Emerging randomized controlled trials demonstrate equal efficacy for parenterally administered phenytoin, levetiracetam, and valproic acid as second-line agents. Beyond this, the evidence for third-line options is sparse. However, encouraging evidence for midazolam and ketamine exists with further data required for immunological, dietary, and surgical interventions.
Conclusion
Our overview of the management of pediatric and neonatal status epilepticus based on available evidence emphasizes the need for evidence-based guidelines to manage status epilepticus that fails to respond to second-line treatment.
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Analysis of the risk factors of post-operative seizure in pediatric patients with hydrocephalus undergoing endoscopic third ventriculostomy. Childs Nerv Syst 2022; 38:2141-2148. [PMID: 36190523 DOI: 10.1007/s00381-022-05634-0] [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: 05/09/2022] [Accepted: 08/02/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The cause and mechanism of epilepsy after endoscopic third ventriculostomy (ETV) have still remained elusive. This single-center study aimed to explore and analyze the risk factors of post-operative seizure in pediatric patients with hydrocephalus undergoing ETV. METHODS Data of pediatric patients with hydrocephalus who were treated with ETV from October 1, 2015, to November 31, 2021, were retrospectively analyzed. Basic demographic characteristics, etiology of hydrocephalus, surgical details, and laboratory measurements were collected. An early postoperative seizure was defined as the occurrence of at least one clinical seizure within 24 h of ETV. RESULTS A total of 50 participants were included in the study, of whom 5 (10.00%) cases were in postoperative epilepsy group and 45 (90.00%) cases were in non-epilepsy group. Epilepsy patients were younger than those without epilepsy, while no statistically significant difference was found (P = 0.0836). In the age subgroup, children with epilepsy were younger than 2 years old. All patients with epilepsy received Ringer's solution intraoperatively. The mean postoperative serum calcium and potassium concentrations were significantly lower in patients with epilepsy than in those without epilepsy (Pcalcium = 0.0429; Ppotassium = 0.0250). Moreover, a faster decrease of serum potassium and calcium levels was found in children with epilepsy compared with those without epilepsy after ETV. CONCLUSION The decrease of serum calcium and potassium levels, younger age, and using Ringer's solution as irrigation fluid were risk factors for epilepsy after ETV.
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