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Suspected Neonatal Seizures Care Guidelines

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The Suspected Neonatal Seizures Care Guideline, originally written in 2015, aids pediatric care teams at the University of Utah (UU) Hospital’s Well Baby and Intermediate Care Nurseries (WBN and ICN) to recognize and appropriately intervene when newborns have abnormal movements concerning for possible seizures. The guideline aligns with the Neonatal Seizures Management Guideline developed in 2020 for use at the University of Utah and Intermountain facilities, including Primary Children’s Hospital (PCH), to recognize and appropriately manage or transfer care for newborns with suspected seizures.

Key Points

Symptomatic
Seizures in newborns are often symptomatic seizures stemming from a brain injury, electrolyte abnormalities, or infection, not primary epilepsy.
Focal
In neonates, seizures tend to be focal rather than generalized.

When to consult neurology
Use the Seizure versus Jitteriness Comparison Table (below) and consider the clinical context to determine the likelihood of a neonatal seizure, but when in doubt, urgently consult the Pediatric Neurology team and transfer the infant to the NICU for an EEG.

Treat promptly
Promptly initiate treatment with phenobarbital or other medications if there is strong clinical suspicion of seizures or as soon as seizures are confirmed on EEG. See Management & Treatment below for details.

Suspected Neonatal Seizures Care Guidelines

Cause of Neonatal Seizures

Seizures in a neonate are usually a symptom of brain injury rather than primary epilepsy. Eighty percent of neonatal seizures are caused by one or more of the following:
  • Stroke
  • Hypoxic ischemic encephalopathy
  • Infection
  • Electrolyte abnormalities: hypoglycemia, hypocalcemia, hypomagnesemia
Try to identify and treat the underlying cause at the same time you are confirming and treating seizures. See Evaluation for Seizure Etiology on page 1 of the Neonatal Seizures Management Guideline PDF for a detailed workup plan.

Clinical Presentation

In neonates, seizures tend to be focal. It is unusual to have a generalized seizure in a baby because of immature brain development.
Seizure vs. Jitteriness
A table to differentiate the characteristics of seizures vs. jitteriness in newborns

Diagnosis

Seizures in neonates can be difficult to identify clinically, and electrographic monitoring is essential to correctly diagnose and effectively treat seizures. EEG monitoring can be initiated 24 hours a day, 7 days a week at PCH and the University of Utah Neonatal Intensive Care Unit (UNICU).

Management and Treatment

If you suspect that a neonate may be having a seizure, this is an urgent issue. Resident physicians for the newborn in the WBN/ICN should contact their attending and discuss immediate NICU consultation and/or transfer for further evaluation, monitoring, and treatment. EEGs cannot be performed in the WBN or ICN, only at the UNICU or Primary Children’s NICU (PNICU).
If there is strong clinical suspicion for seizure, you do not need to wait for EEG confirmation prior to initiating treatment.
  1. First-line treatment in neonates:
    • Phenobarbital 20mg/kg IV x 1 dose STAT, can give additional 10mg/kg x 1 if seizure persists. Monitor for respiratory depression. Check PHB level prior to starting maintenance.
  2. Second-line treatment:
      • Ativan 0.1mg/kg IV x 1 dose (has a very long half-life in neonates, between 24-40 hours)
      • Fosphenytoin 20mg/kg IV x 1 dose
Consult Pediatric Neurology to assist with evaluation and management recommendations.

Neonatal Seizure Management Guideline

Page 1 of the 3-page Neonatal Seizure Management Guideline PDF is included here to guide initial recognition and management of suspected neonatal seizures. Pages 2 and 3 of this guideline, not included here, are used internally in the PNICU and UNICU by pediatric neurologists and neonatologists.
Neonatal Seizure Mgmt Guideline Jan 2020

Referral & Services

Pediatric Neurology (see UT providers [8])
Consult pediatric neurology for input on diagnosis and treatment of neonatal seizures and to arrange outpatient follow-up.

Patient Education

Neonatal Seizures (UCSF)
Causes, symptoms, diagnosis, and treatment of seizures in newborns; University of California, San Francisco.

Resources

Information & Support

Related Portal Content

For Professionals

Critical Congenital Heart Screening (UDOH)
Screening for Critical Congenital Heart Disease (CCHD) by pulse oximetry is mandatory for all Utah newborns effective October 1, 2014. This page has contact information for the Utah CCHD Screening Program and a link to screening results reporting form; Utah Department of Health.

Information & Support

For Professionals

Neonatal Seizure (StatPearls)
This article reviews the evaluation and treatment of neonatal seizures and highlights the role of the interprofessional team in evaluating and treating patients with this condition. CME available.

Neonatal Seizures (UCSF)

Services for Patients & Families in Utah (UT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: October 2023
Current Authors and Reviewers:
Author: Betsy Ostrander, MD
Contributing Author: Jennifer Goldman, MD, MRP, FAAP