Abstract
Neonates are susceptible to seizures due to their unique physiology and combination of risks associated with gestation, delivery, and the immediate postnatal period. Advances in neonatal care have improved outcomes for some of our most fragile patients, but there are persistent challenges for epileptologists in identifying neonatal seizures, diagnosing etiologies, and providing the most appropriate care, with an ultimate goal to maximize patient outcomes. In just the last few years, there have been critical advances in the state of the science, as well as new evidence-based guidelines for diagnosis, classification, and treatment of neonatal seizures. This review will provide updated knowledge about the pathophysiology of neonatal seizures, classification of the provoked seizures and neonatal epilepsies, state of the art guidance on EEG monitoring in the neonatal ICU, current treatment guidelines for neonatal seizures, and potential for future advancement in treatment.
From the article:
Treatment Guidelines for Neonatal Seizures
Despite the relatively common occurrence of neonatal seizures, treatment remains challenging with limited options. Until recently, most recommendations were based on scant evidence and relied on expert consensus and historical practice with substantial management variability. However, the neonatal task force of the ILAE has now developed recommendations about the use of ASMs in neonates based on a systematic review and expert consensus where evidence was lacking, in accordance with ILAE standards. Six priority questions were formulated, a systematic literature review and evaluation of evidence via GRADE performed, and results reported following the PRISMA 2020 standards.15 Bias was evaluated using the Cochrane tool and ROBINS-I. The strength of recommendations was defined according to the ILAE Clinical Practice Guidelines development tool. If GRADE could not be applied but the Delphi process yielded an agreement of >66%, then a recommendation was made based on the Delphi process. Agreement was labeled “high” (>75% agreement) or “moderate” (66%-75% agreement). The 6 main recommendations are summarized in the Table.
Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options. While these guidelines are based on better evidence than earlier publications, several key limitations remain. These include lack of sufficiently powered randomized controlled trials, lack of EEG-based outcome evaluations, lack of ASM safety studies, and lack of long-term outcome evaluation. There is an urgent need to develop and evaluate safe and effective ASMs for neonates.
Conclusions
Neonatal seizures present multiple diagnostic and therapeutic challenges. The recent evidence summarized here aim to aid clinicians to provide evidence-based, standardized, high-quality care for neonates with seizures. Continuous EEG monitoring of high-risk infants and the growing integration of qEEG aim to identify seizures and evolving brain injury efficiently and accurately. Treatment guidelines aim to facilitate efficient and effective treatment while seizure and epilepsy classification can further guide testing and tailored therapies for neonatal epilepsies. Though these guidelines provide an exceptional contemporary framework to optimize care, additional work is necessary to further refine diagnostic and therapeutic interventions and maximize outcomes for neonates with seizures.
Partnerships between researchers and patient-family organizations must guide study designs. Families impacted by neonatal seizures experience significant anxiety and distress during their neonatal course, as well as into childhood, even when the seizures stop or are well-controlled. Patient-family communities highlight key unmet needs and unanswered questions, as well as insights into study design, results interpretation, and dissemination. Topics such as ASM use and duration, school-age outcomes, seizure recurrence, genetic influences in neonatal seizures, and others have already been coproduced in this patient and family-centered approach to research. These studies support a strong call to action for increased, consistent mental health screening of parents—both while infants are admitted and throughout childhood—the development and implementation of effective interventions, and education and prognostic assessment about risk factors for neurodevelopmental delays, specific types of post-neonatal epilepsy syndromes like infantile epileptic spasms, and additional concerns. Consistent implementation of the evidence-based guidelines in the diagnosis, classification, and treatment of neonatal seizures is the contemporary standard of care. Continued multidisciplinary research will support refined future guidelines and maximized neurodevelopmental outcomes in this vulnerable population.
No comments:
Post a Comment