Search

Seizures are common in term infants with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia. Although phenobarbital (PHB) is generally considered first-line therapy, some centers have embraced third-generation antiepileptic drugs (AEDs) such as levetiracetam (LEV) given the impression of comparable efficacy and superior tolerability. We set out to compare the efficacy of PHB and LEV in a large single-center cohort.We retrospectively identified consecutive newborns with HIE who were monitored with continuous video-electroencephalogram (VEEG) for the duration of therapeutic hypothermia. After identification of seizures, infants were treated with PHB or LEV at the discretion of treating physicians. We assessed time to seizure freedom as a function of AED choice, with adjustment for HIE severity and initial seizure frequency using the Kaplan-Meier procedure and multivariate Cox proportional hazards regression.We identified 78 infants with HIE. Among 44 (56%) patients who had VEEG-confirmed seizures, 34 became seizure-free during monitoring, and the remaining 10 died. Initial treatment with LEV, in comparison with PHB, predicted a shorter interval to seizure freedom in a univariate analysis (Hazard ratio (HR) = 2.58, P = 0.007), even after adjustment for initial seizure frequency and an unbiased ad hoc measure of HIE severity (adjusted HR = 2.57, P = 0.010). This effect was recapitulated in an analysis in which patients with treatment crossover were excluded. As expected, severity of HIE was an independent predictor of longer duration to seizure freedom (HR = 0.16, P 0.001) and remained a significant predictor after adjustment for initial seizure burden and treatment agent.Despite a relatively small sample size and retrospective design, this study suggests that LEV is a viable alternative to PHB in the treatment of neonatal seizures associated with HIE. A large-scale randomized controlled trial is needed to confirm these findings.

Preterm infants are at high risk for central nervous system injury, with seizures occurring in 6% to 48% of this population. Seizures are more likely to contribute to adverse neurodevelopmental outcomes in preterm infants. Preterm infants are also more likely to have subclinical seizures; therefore, electrographic detection is essential for their diagnosis. Once identified, seizures are traditionally treated with phenobarbital, but newer-generation antiepileptic medications have growing evidence for safety and efficacy. The treatment of seizures may also affect neurodevelopmental outcome.

PURPOSE Extracorporeal membrane oxygenation (ECMO) is a life-saving heart and lung bypass procedure that can cause substantial EEG artifact. Continuous EEG monitoring is nonetheless a helpful neuromonitoring tool for patients receiving ECMO therapy because neurologic complications are frequent, but factors such as sedation, neuromuscular blockade, and hemodynamic instability limit clinical and radiographic evaluation. We examined whether using conductive plastic electrodes in place of conventional gold electrodes reduces artifact in clinical EEG studies of pediatric ECMO patients. METHODS Four masked electroencephalographers assessed artifact and its impact on overall EEG interpretation in samples from 21 consecutive EEGs recorded during ECMO therapy (14 gold and 7 plastic). A spectral power analysis then quantified 50- to 70-Hz artifact in a larger group of 14 gold and 34 plastic electrode studies during ECMO and 4 non-ECMO gold electrode studies. RESULTS The masked electroencephalographers identified less artifact (P < 0.001) and indicated greater confidence in the accuracy of EEG interpretation (P < 0.001) among studies recorded with plastic electrodes. In quantitative analyses, ECMO was associated with greater 50- to 70-Hz power among studies using gold electrodes (P < 0.001) and gold electrodes exhibited greater 50- to 70-Hz power than plastic electrodes (P < 0.001). Contrasting studies in which most of the electroencephalographers believed that interpretation was (n = 12; 7 gold and 5 plastic) or was not (n = 7; all gold) compromised by artifact, 50- to 70-Hz power was similarly higher among the compromised studies (P < 0.001). CONCLUSION Plastic electrodes substantially reduce the burden of electrical artifact in EEG studies performed on pediatric ECMO patients and improve confidence in EEG interpretation.

A 48-hour-old male infant born at 38+3/7 weeks’ gestation is transported from home via ambulance to the emergency department (ED) for poor feeding, lethargy, duskiness, and rhythmic twitching of lower extremities. The mother received prenatal care from a midwife. The pregnancy was complicated by a maternal genital herpes outbreak in the first trimester. The mother was given valacyclovir for viral suppression and no herpetic lesions are noted at delivery. Clear artificial rupture of membranes is performed by the midwife 5 hours before delivery and the infant is born via vaginal delivery into a water birthing tub with a disposable liner. Apgar scores are 7, 8, and 9 at 1, 5, and 10 minutes. The umbilical cord is not cut based on the parents’ request for umbilical nonseverance. The placenta is washed and dried, wrapped in muslin, and left attached to the infant until the midwife cuts the cord with sterilized scissors before transfer to the ED. Postnatal history is remarkable for poor feeding. The infant has difficulty latching on and receives supplemental formula as well as donor unpasteurized breast milk from a lactation consultant. On the morning of admission, the infant has perioral cyanosis and is unresponsive. In the ED, he is cyanotic with shallow respirations and is found to be hypothermic (rectal temperature of 95.3°F [35.2°C]), and hypoglycemic (peripheral blood glucose level of 15 mg/dL [0.83 mmol/L]) with multifocal clonic seizures. He is tachycardic, with a …