Renée Shellhaas, MD, MS, on Managing Pediatric Epilepsy Emergencies
In 2015, 3 million adults and 470,000 children in the United States had active epilepsy, according to data from the Centers for Disease Control and Prevention (CDC). More-recent research has deepened our understanding and management of pediatric epilepsy emergencies.
To answer our questions about managing neonatal seizures in the hospital, Neurology Consultant reached out to Renée A. Shellhaas, MD, MS, who is a clinical professor in the Department of Pediatrics, Division of Pediatric Neurology, at the CS Mott Children’s Hospital and the University of Michigan in Ann Arbor, Michigan. She is also part of the Pediatric Epilepsy Research Consortium, the Neonatal Seizure Registry, and the Pediatric Epilepsy Learning Healthcare System.
She will also be speaking about this topic at the American Epilepsy Society (AES) 2019 Annual Meeting.
NEURO CON: What evidence-based management techniques are recommended for neonatal seizures?
Renee Shellhaas: Neonatal seizures typically are quite focal. Unless seizures originate in, or migrate to, the motor cortex, the infant will not show motor manifestations of a seizure. Also, a newborn will not alert a caregiver to a sensory phenomenon related to a seizure. It should, therefore, not be surprising that the vast majority of neonatal seizures have no outward manifestations. Thus, the only accurate way we have to diagnosis and quantify neonatal seizures is electroencephalography (EEG). The American Clinical Neurophysiology Society guideline1 suggests that EEG monitoring be considered for encephalopathic neonates who have known or suspected acute brain injury. This type of intense monitoring also needs to be coupled with local practice pathways to ensure that seizures are detected and treated promptly, and that their underlying causes are efficiently investigated and treated.
Evidence-based treatment of acute symptomatic neonatal seizures has not changed significantly for more than 20 years: phenobarbital remains the standard first-line treatment. There was a trend toward use of levetiracetam as a first-line therapy; however, the NEOLEV2 trial2 (presented at AES 2018) demonstrated clearly that phenobarbital is more effective than levetiracetam for controlling acute symptomatic seizures (80% vs 28%, p <0.001). However, emerging evidence suggests certain neonatal-onset genetic epilepsies may respond particularly well to carbamazepine/oxcarbazepine.
NEURO CON: What is the role of an interdisciplinary team in emergency seizure management? Who needs to be involved?
RS: Neonatal neurocritical care is a team sport! Every center needs to identify its own key partners. Generally, these include neonatologists (and often advanced practice nurses), neurologists, bedside nurses, pharmacists, EEG technologists, social workers, and a neurodevelopmental follow-up team. Others may be involved as well, such as residents, and fellows, and clinicians from the emergency department, inpatient pediatrics, and other intensive care units. Importantly, parents are key to the treatment team and ought to be consulted as local care pathways are developed and implemented.
NEURO CON: What are your tips for others working in hospitals for ensuring patient safety regarding neonatal seizures?
RS: It is critical to identify local stakeholders who are invested in reviewing the relevant literature, assessing the current local state of practice, developing local practice pathways/guidelines, and disseminating, implementing, and updating those pathways/guidelines as new information emerges. An emphasis on quality improvement with a focus on multidisciplinary teamwork is crucial.
- Shellhaas RA, Chang T, Tsuchida T, et al. The American Clinical Neurophysiology Society’s guideline on continuous electroencephalography monitoring in neonates. J Clin Neurophysiol. 2011;28(6):611-617. https://doi.org/10.1097/WNP.0b013e31823e96d7.
- Efficacy of Intravenous Levetiracetam in Neonatal Seizures (NEOLEV2). ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/results/NCT01720667. Accessed November 25, 2019. ClinicalTrials.gov Identifier: NCT01720667.