Convulsive syndrome in newborns - symptoms and signs, treatment
Symptoms and signs, treatment of convulsive syndrome in newborns.
Convulsive syndrome in newborns
Neonatal seizures- These are abnormal electrical impulses in the CNS of a newborn, usually manifested as stereotypical muscle movements or autonomous changes. The diagnosis is confirmed on the EEG; a survey is conducted to identify causative factors. Treatment depends on the cause.
Seizures occur in almost 1.4% of full-term newborns and 20% of premature newborns. Seizures can be a serious problem in the newborn period ™ and require an immediate examination of the baby. The most part is convoluted, probably due to the fact that the generalization of electrical activity is hampered by insufficient myelination and incomplete formation of dendrites and synapses in the brain.Some newborns who underwent an EEG during an examination for encephalopathy show clinically non-manifest convulsions. Sometimes not manifested clinically electrical activity persists for a long time, more than 20 minutes; in this case, it is defined as electrical epileptic status.
Convulsive syndrome in newborns - etiology
Anomalous electrical impulses in the CNSmay be caused by the primary intracranial process or be a consequence of a systemic disorder. According to clinical signs, convulsions due to the intracranial process are usually difficult to distinguish from convulsions due to systemic disorders.
Hypoxia-ischemia, the most common cause of cramps in newborns, may occur during or after birth. Such seizures can be severe and difficult to treat, but they tend to subside after about 3-4 days.
Ischemic strokemore likely in children with polycythemia and thrombophilia due to a genetic defect, but it can also develop in the absence of risk factors. A stroke usually develops in the pool of the middle cerebral artery or areas of the adjacent blood circulation.Seizures due to stroke are often local and can cause apnea.
Infectionsfor example, meningitis and sepsis, can cause the development of convulsive syndrome; in such cases, seizures are usually accompanied by other symptoms and signs. Streptococcus group B and gram-negative bacteria are frequent causative agents of these diseases in newborns. Encephalitis caused by cytomegalovirus, herpes simplex virus, rubella, Treponema pallidum or Toxoplasma gondii can also cause seizures.
Hypoglycaemiaoften seen in newborns from mothers with diabetes, small to gestation, or with hypoxia-ischemia or other stress. Convulsions of hypoglycemia are usually local and variable. Prolonged or recurrent hypoglycemia can cause persistent damage to the central nervous system.
Intracranial hemorrhage, including subarachnoid, intracerebral and intraventricular, may cause convulsions. Intracranial hemorrhages developing in premature newborns are a consequence of hemorrhage into the terminal matrix.
Hypernatremia and hyponatremiamay cause convulsions.Hypernatraemia may be due to accidental ingestion of excess sodium chloride orally or intravenously. Hyponatremia may be due to dilution or loss of sodium with stools and urine.
Hypocalcemia[Serum calcium levels below 7.5 mg / dL] are usually accompanied by an increase in phosphorus levels above 3 mg / dL and may also be asymptomatic. Risk factors for hypocalcemia include prematurity and difficult childbirth.
Hypomagneemia- This is a rare cause of convulsions, which can be observed with a decrease in the level of magnesium of less than 1.4 mEq / L. Hypomagnemia often develops with hypocalcemia and should be kept in mind in newborns with hypocalcemia, if convulsions persist after adequate therapy with calcium supplements.
Congenital metabolic disorders can cause neonatal convulsive syndrome. Rarely, pyridoxin deficiency or dependence on pyridoxine cause convulsions; they respond well to therapy.
Other reasonsinclude the developmental defects of the central nervous system. Abuse of drugs or psychoactive substances by the mother is an increasingly common problem; convulsions can occur after birthwithdrawal syndrome. Neonatal seizures can be familial; in some cases, genetic causes are noted.
Convulsive syndrome in newborns - symptoms and signs
Neonatal convulsions are usually local and are difficult to detect. Often there are migratory clonic convulsive jerking of limbs, alternating hemis-roads or primitive subcortical convulsions. Generalized, then-no-clonic seizures are rare.
Not clinically manifested convulsive activity is often observed after hypoxic-ischemic stroke, including perinatal asphyxia or stroke, and in newborns with CNS infections.
Anxiety should be distinguished from true convulsive activity. Anxiety is usually triggered by a stimulus, and can be stopped by holding the limb. Spasms occur spontaneously, and motor activity is felt, even if you hold the limb.
The survey begins with a detailed collection of family history and physical examination. Conducting an EEG is necessary, especially if it is difficult to determine if there are l and convulsions in a child; EEG is also useful for monitoring response to treatment.EEG should cover a period of fast and slow sleep, and therefore it may take 2 hours or more to conduct a study. A normal EEG with the expected differences between sleep phases is a good prognostic sign; EEG with diffuse severe disorders is a poor prognostic sign.
Other studies should include pulse oximetry; determination of glucose, sodium, potassium, chlorides, HC03, calcium and magnesium in plasma; investigation and culture of cerebrospinal fluid. Also conduct blood and urine culture. The need for other research or determination of the most frequently used drugs depends on the clinical data.
Most of the newborns should undergo CT, as this can exclude intracranial hemorrhage and some malformations of the brain. Ultrasound of the brain can reveal intraventricular hemorrhage, however, it is not informative for subarachnoid hemorrhage; It is necessary to give preference to ultrasound during the examination directly at the bedside of children in serious condition who cannot be delivered to the radiology department.Diffuse-weighted MRI can detect ischemic tissue for several hours, but is usually performed after the 2nd day to determine parenchymal damage.
Convulsive syndrome in newborns - prognosis
Approximately 50% of newborns with convulsions due to hypoxia - ischemia develop normally. Most newborns with convulsions due to subarachnoid hemorrhage, hypoglycemia, or hyponatremia later recover and feel good. In idiopathic convulsions or convulsions due to congenital malformations, early onset is associated with higher morbidity and mortality.
It is not known whether neonatal convulsions cause injuries other than those that cause them, although it is believed that metabolic stress during the prolonged excitation of nerve cells during prolonged convulsions may cause additional brain damage. If hypoxia is caused by ischemia, stroke, or infection, a series of seizures may occur in a newborn, but usually, after about 3-4 days, the seizures disappear; they may reappear months or years later if brain damage occurs.Seizures due to other causes may be more stubborn in the newborn period.
Convulsive syndrome in newborns - treatment
First of all, treatment is aimed at treating the underlying disease, and only secondarily - at treating convulsive syndrome.
With a low level of glucose in the blood serum, infusion therapy with 10% glucose is administered at 2 ml / kg intravenously and the plasma glucose level is monitored; additional infusions are carried out as needed. In hypocalcemia, 10% calcium gluconate is administered at 1 ml / kg intravenously; this dose can be re-administered with persistent hypocalcemic convulsions. Calcium gluconate infusion rate should not exceed 50 mg / min; continuous monitoring of cardiac function during infusion is necessary. It is necessary to avoid the entry of calcium gluconate into the tissue, as this may cause further necrosis. In case of hypomagnesaemia, a 50% solution of magnesium sulfate is injected intramuscularly at the rate of 0.2 ml / kg. For bacterial infections, antibiotic therapy is prescribed.
Anticonvulsants are used unless convulsions stop quickly after correction of hypoglycemia, hypocalcemia, hypomagnesemia,hyponatremia or other conditions causing seizures. Phenobarbital is the drug of choice; a starting dose of 20 mg / kg is administered intravenously. If the seizures are not starting, 5 mg / kg is administered every 30 minutes until the convulsions are stopped or the total dose reaches 40 mg / kg. Maintenance therapy begins in about 12 hours from 1.5-2 mg / kg 2 times a day and rises to 2.5 mg / kg 2 times a day on the basis of clinical data, response to treatment according to EEG or the level of the drug in serum . Phenobarbital continues to be administered intravenously, especially if the cramps are frequent or prolonged. When it is possible to achieve control over convulsions, it is possible to switch to the intake of phenobarbital. The therapeutic level of phenobarbital in serum is 15-40 µg / ml.
If a 2nd drug is needed, apply phosphentoin or phenytoin. The starting dose is 20 mg PE / kg intravenously. This dose is administered in 15 minutes to avoid hypotension or arrhythmias. The maintenance dose then starts at 2-3 mg / kg every 12 hours and is adjusted based on the clinical response or serum level. The therapeutic level of phenytoin in serum is 10–20 µg / ml.
Lorazepam at 0.1 mg / kg intravenously can be used for resistant seizures, can be re-administered at 5–10-minute intervals, up to 3 doses over 8 hours.
Newborns receiving intravenous anticonvulsant therapy should be monitored continuously; overdose can lead to respiratory depression.
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