Abstract
BackgroundNeonatal seizures are difficult to diagnose and, when they are, tradition dictates first line treatment is phenobarbital. There is little data on how consultants diagnose neonatal seizures, choose when to treat or how they choose aetiological investigations or drug treatments. The purpose of this study was to assess the variation across the UK in the management of neonatal seizures and explore paediatricians’ views on their diagnosis and treatment.MethodsAn explanatory sequential mixed methods approach was used (QUAN→QUAL) with equal waiting between stages. We collected quantitative data from neonatology staff and paediatric neurologists using a questionnaire sent to neonatal units and via emails from the British Paediatric Neurology Association. We asked for copies of neonatal unit guidelines on the management of seizures. The data from questionnaires was used to identify16 consultants using semi-structured interviews. Thematic analysis was used to interpret qualitative data, which was triangulated with quantitative questionnaire data.ResultsOne hundred questionnaires were returned: 47.7% thought levetiracetam was as, or equally, effective as phenobarbital; 9.2% thought it was less effective. 79.6% of clinicians had seen no side effects in neonates with levetiracetam. 97.8% of unit guidelines recommended phenobarbital first line, with wide variation in subsequent drug choice, aetiological investigations, and advice on when to start treatment. Thematic analysis revealed three themes: ‘Managing uncertainty with neonatal seizures’, ‘Moving practice forward’ and ‘Multidisciplinary team working’. Consultants noted collecting evidence on anti-convulsant drugs in neonates is problematic, and recommended a number of solutions, including collaboration to reach consensus guidelines, to reduce diagnostic and management uncertainty.ConclusionsThere is wide variation in the management of neonatal seizures and clinicians face many uncertainties. Our data has helped reveal some of the reasons for current practice and decision making. Suggestions to improve certainty include: educational initiatives to improve the ability of neonatal staff to describe suspicious events, greater use of video, closer working between neonatologists and neurologists, further research, and a national discussion to reach a consensus on a standardised approach to managing neonatal epileptic seizures.
Highlights
Neonatal seizures are difficult to diagnose and, when they are, tradition dictates first line treatment is phenobarbital
Seizures are common in the neonatal period because of the relative excitability of the neonatal brain and high risk of pathologies leading to acute symptomatic seizures [1,2,3,4,5,6,7]
[8] One reason why incidence figures may be inaccurate is because neonatal seizures are difficult to diagnose: multiple studies using EEG have shown that most neonatal seizures have no clinical features at all [9,10,11,12,13,14], and the accurate differentiation of epileptic seizures from nonepileptic events based on clinical skills alone is poor [9, 10, 15, 16]
Summary
Neonatal seizures are difficult to diagnose and, when they are, tradition dictates first line treatment is phenobarbital. Amplitude integrated EEG (aEEG) is used routinely on neonatal units, in term babies with hypoxic ischaemic encephalopathy (HIE) [17, 18], and can detect 1/ 3 of single seizures and 2/3 of repetitive seizures, missing those that are brief or distant from the EEG leads [17, 19]. Having two channels and the single lead EEG trace available for review on the aEEG monitor improves seizure detection rates [19,20,21]
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