Treatment of Neonatal Seizures: Comparison of Treatment Pathways From 11 Neonatal Intensive Care Units.

Abstract Objective Seizures are a common neonatal neurologic emergency. Many centers have developed pathways to optimize management. We evaluated neonatal seizure management pathways at Level IV neonatal intensive care units (NICUs) in the United States to highlight areas of consensus and describe aspects of variability. Methods We conducted a descriptive analysis of 11 neonatal seizure management pathways from level IV NICUs that specialize in neonatal neurocritical care including guidelines for electroencephalographic (EEG) monitoring, antiseizure medication (ASM) choice, timing, and dose. Results Study center NICUs had a median of 70 beds (IQR 52-96). All sites had 24/7 conventional EEG initiation, monitoring, and review capability. Management pathways uniformly included prompt EEG confirmation of seizures. Most pathways included a provision for intravenous benzodiazepine administration if either EEG or loading of ASM was delayed. Phenobarbital 20mg/kg IV was the first line ASM in all pathways. Pathways included either fosphenytoin or levetiracetam as the second line ASM with variable dosing. Third line ASMs were most commonly fosphenytoin or levetiracetam with alternatives including topiramate or lacosamide. All pathways provided escalation to continuous midazolam infusion with variable dosing for seizures refractory to initial medication trials. Three pathways also included lidocaine infusion. Nine pathways discussed ASM discontinuation following resolution of acute symptomatic seizures with variable timing. Conclusions Despite a paucity of data from controlled trials regarding optimal neonatal seizure management, there are areas of broad agreement among institutional pathways. Areas of substantial heterogeneity which require further research include optimal second line ASM, dosage, and timing of ASM discontinuation.