Doctor reviews: Neonatal SEIZURE or SOMETHING else??!!

One of the problems with neonatal seizures is that babies make so many weird or unusual movements anyway that it's often really difficult to differentiate what actually is a seizure and what isn't. These abnormal movements have been labeled as non-epileptic paroxysmal disorders which means that they may look like they could be a seizure but if you get an EEG you won't see any abnormal electrical activity that you'd normally see with a seizure. Hi I'm Dr. Tala and I've been a neonatologist for 17 years now so taking care of a lot of babies with seizures and a lot without seizures and today we're going to go over those slightly funny movements that babies can make that don't indicate a seizure. So really get used to noticing these patterns. Also as another quick aside just because it's not a seizure does not mean that it's necessarily normal behavior. One, apnea. As you all know apnea is when babies stop breathing for 20 seconds so no respiratory effort not making any effort to breathe for the full 20 seconds. As you all know this is very common in preterm babies we call it apnea or prematurity and as babies get older they can still have apnea or prematurity it's just a lot less likely. So at 37-38 weeks babies can still have apnea or prematurity that they need to outgrow. In term babies apneas can indicate a seizure but it can also indicate many many other things as well. For example it could be a brain bleed, it could be sepsis or a cardiac abnormality or really anything to do with the respiratory system whether it's the lungs or the airway. Really the list of things that can cause apnea in a baby is almost endless. So yes do consider seizures just because obviously we should always be considering seizures with any abnormal movements but also make sure that you're not missing any of the other diagnoses as well. Two, jitteriness. This is something that we see really commonly in the first few days of life and it's normally triggered by something whether it's a loud noise or unwrapping the baby. You've all seen it it's like the really high frequency tremor so it's going very rapidly that's what the high frequency means but it's a low amplitude it's not like going like this it's just a very kind of fine tremor like that. Often we see it in the feet and we can usually stop the jitteriness by actually holding the baby's leg. The jitteriness can happen just in a normal baby or it could also be a sign that something else is going on for example hypoglycemia or hypocalcemia. We can also see jitteriness with abnormal magnesium levels, abnormal sodium levels or for example a baby that's actually withdrawing from drugs. If the jitteriness isn't really caused by anything then babies usually outgrow it within about two weeks otherwise if it's caused to like is if it's because of a metabolic derangement or something then obviously it will go away after you correct the low glucose or the low calcium or whatever. Some experts also separate tremors or shuddering from jitteriness which is basically jitteriness with a slightly higher amplitude so like their body's moving a little bit more. The same things that cause jitteriness can also cause the kind of tremors or the shuddering. Also cold babies are more likely to have kind of like the higher amplitude tremors as well. Three, benign neonatal sleep myoclonus. I'm sure that you've all seen this it's very similar to that movement that we make sometimes adults when we're like just about to fall asleep and it's that like sudden spasming of the whole body like that sudden muscle contraction which is really very brief. The same is true in babies normally it's a very brief jerking movement really normally it's bilaterally of the arms and the legs so like a lot of the body is involved and it happens very quickly usually when the baby's asleep especially if the baby's going between different states so if the baby's going into kind of a quiet to an active sleep or the baby is like going into wakefulness then those are the most likely times that they'll get that sudden jerking. Myoclonus can be a type of seizure but usually this doesn't just happen once usually with a myoclonic seizure that kind of overall spasming continues more than once. Obviously if the baby is completely awake when that's happening that's also a lot more concerning for it to be a seizure and like we keep saying if you can hold the baby and stop the myoclonic jerking from happening then it's less likely to be a seizure. Four, the startle reflex or the Moreau. You've all seen this it's when a baby is stimulated by a loud noise or by falling or something that kind of scares the baby and the baby will extend out its arms and legs, throw the head back, start crying and then retract the arms and legs again. It is a normal primitive reflex and we love seeing a good symmetrical Moreau in a healthy baby. Like we said it's normal but this can be really scary for parents especially if they're doing it like a few times in a row if the door keeps slamming or something so reassure parents if you actually do see this movement. While I'm talking about primitive reflexes remember there are other primitive reflexes which can sometimes look like they could be abnormal activities so for example the rooting reflex when you stroke the side of the mouth or the cheek and the baby moves towards that side like hoping to try to eat so that can kind of look a bit abnormal especially if it's not a finger the baby is just moving towards something in the crib that they can feel on their cheek. Same thing with the sucking reflex if you put something if you touch the roof of the mouth of the baby the baby will start sucking on it so we kind of see this in the unit a lot if babies are intubated they start sucking on their endotracheal tube and we can't figure out is that a seizure or are they just like having their sucking reflex in full flow. Again though I know you know this by now the primitive reflexes are going to be stimulated by something and we should be able to stop them by moving the baby or by stopping the stimulus or whatever it is. A seizure will start and stop and we can't really do anything to make it start or make it stop. 5. Hypereplexia. This is a really interesting one and I didn't learn about this until I was out of fellowship for a few years and we actually had a baby with this diagnosis. This is also called stiff baby syndrome and it's not a seizure but there are some forms of hypereplexia which are associated with genetic or hereditary forms so literally can be inherited from your family. Babies with hypereplexia have a triad of symptoms. The first one is hypertonia or like stiffness of the whole body and this is really kind of the main symptom that affects babies in the newborn period. The second one is an exaggerated startle reflex with eye blinking. This can be elicited by actually tapping the nose as well and then the third one is the myoclonus so spasming of the trunk just like the benign sleep myoclonus that we've seen before. Generally it's that hypertonicity that can just kind of suddenly happen in response to like a loud noise or some sort of stimulation which is the scariest part of the hypereplexia. So when babies suddenly do become really hypertonic they're not doing anything. They're just kind of stuck in this like oppositonic posturing and they aren't taking a breath or anything so really it could end up being like this prolonged phase of apnea for the baby. Obviously when the babies do become very hypertonic and have a prolonged apnea that in itself can be very dangerous to the brain where the brain may not be getting enough oxygen or blood during that period of hypertonicity. You can resolve the attack by the Vigavano maneuver. I don't know if that's how you pronounce it. I've only ever seen it written but basically where you are like flexing at the level of the hips as well as the neck to try to just break up the attack. These babies are often also put on clonazepam. We start at like 0.01 mgs per kg per day and then titrate up to 0.1 mgs per kg per day or until the attack stops. Like I said we had an infant once who had this diagnosis who like kept having these attacks. Baby was on full feeds, room air, but every time they had an event obviously the clock would restart and we'd want five event-free days before the baby went home. Eventually a neurologist diagnosed this and we started the baby on clonazepam and the events just stopped. Like all babies with hyperplexia if you get an EEG you're not going to see any seizure activity. Again though still it's not a normal movement and it still needed treatment and it was still potentially very dangerous but it was not a seizure. Okay I hope that you learned something. 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