Outcome in preterm infants with seizures

Age-related impact of phenobarbital in suppressing prenatal alcohol exposure-related seizures in developing rats

Prenatal alcohol exposure (PAE) during pregnancy can increase the prevalence of N-methyl-d-aspartate (NMDA)-induced generalized tonic-clonic seizures (GTCSs) in developing rats. However, it is unclear whether phenobarbital (PB) can suppress these PAE-related seizures. To explore this knowledge gap, we investigated the effects of acute PB treatment on NMDA-induced seizures in postpartum rats, prenatally exposed to alcohol on gestational day 18 (GD18), at two developmental stages: day 7 (P7), the equivalent of pre-term neonates, and day 15 (P15), the equivalent of full-term neonates. Timed-pregnant female Sprague-Dawley rats were given a single dose of alcohol or its vehicle on GD18 during the second-trimester equivalent. Male and female postpartum rats were tested for the effectiveness of single-dose treatment with either PB or its vehicle in suppressing NMDA-induced seizures. These seizures include wild running-like behavior (WRLB), flexion seizures (FSs), clonic seizures (CSs), generalized tonic-clonic seizures (GTCSs), and tonic seizures (TSs) in P7 and P15 rats. Analyses revealed that P7 rats were more likely to develop GTCSs after PB administration than P15 rats; this effect was associated with shorter latencies to develop NMDA-induced seizures. Moreover, PAE-related seizure severity is less responsive to PB treatment in P7 rats than in P15 rats. These findings suggest that the PAE-related GTCS model in P7 rats can be used to investigate the mechanisms underlying PB-resistant seizures in developing rats.

Discussion of Spirituality in Family Conferences of Infants With Neurologic Conditions

INTRODUCTION

Spirituality serves as a mechanism to understand and cope with serious illness, yet little is known about how families and clinicians incorporate spirituality in pediatric family conferences.

OBJECTIVES

We sought to characterize the frequency and nature of spiritual statements in conferences between families and clinicians caring for infants with neurologic conditions.

METHODS

In this descriptive qualitative study, we used an existing dataset of audio-recorded, de-identified, transcribed family conferences of infants with neurologic conditions. Inclusion criteria for infants were 1) age < 1 year, 2) presence of a neurologic condition, and 3) planned conversation about neurologic prognosis or goals of care. We used a content analysis approach to code the data.

RESULTS

68 family conferences were held for 24 infants and 36 parents. Most parents (n = 32/36, 89%) self-identified as spiritual. References to spirituality occurred in the 32% of conferences (n = 22/68). Spiritual discussion included three domains: 1) Spiritual beliefs and practices, 2) Spiritual support, and 3) Parent-child connection as sacred. Clinicians' responses to family member spiritual statements were inconsistent and included providing affirmation, exploring goals of care, and continuing discussion of clinical information.

CONCLUSIONS

Spirituality was discussed in approximately one-third of family conferences. Clinician engagement with spirituality discussion was variable. These findings highlight a need for training on when and how to discuss spirituality in conversations with families of seriously ill infants.

Associated impairments among children with cerebral palsy: findings from a cross-sectional hospital-based study in Vietnam

OBJECTIVE

This study aims to explore the associated impairments of cerebral palsy (CP) and their correlates among children with CP in Vietnam.

DESIGN

Descriptive cross-sectional study using hospital-based surveillance.

SETTING

National Children's Hospital, Hanoi, Vietnam between June and November 2017.

PARTICIPANTS

765 children with CP were recruited.

OUTCOME MEASURES

We assessed clinical characteristics of CP, associated impairments (epilepsy, intellectual, visual, hearing, speech impairments) and their correlates. We performed descriptive analyses (median, IQR and proportion). χ2 test and Fisher's exact test were used for categorical variables. Univariate logistic regression and multivariate logistic regression models were established and associated impairments were included as independent variables.

RESULTS

The median age of children was 1.7 years (IQR=2.7). Quadriplegia was the predominant subtype (69.5%) and 46.5% were at Gross Motor Function Classification System level IV-V. Of children, 76.3% had ≥one associated impairment, most commonly speech or intellectual impairments (59.1% and 57.8%, respectively). Severity of motor impairment, type of CP, maternal and perinatal factors (eg, gestational age, perinatal asphyxia, timing of injury causing CP) were associated with greater risk of associated impairments.

CONCLUSION

Children with CP have a high burden of associated impairments. Findings from our study will inform the development and implementation of appropriate screening and interventions and reduce the long-term adverse effects of these impairments on individuals with CP and their socioeconomic impact.

Acute symptomatic seizures in newborns: a narrative review

Acute symptomatic seizures are the main sign of neurological dysfunction in newborns. This is linked to the unique characteristics of the neonatal brain, making it hyperexcitable compared to older ages, and to the common occurrence of some forms of acquired brain injury, namely hypoxic-ischemic encephalopathy. In this narrative review we will provide an overview of neonatal seizures definition, their main underlying etiologies, diagnostic work-up and differential diagnoses, and will discuss about therapeutic options and prognostic outlook. The latest publications from the ILAE Task Force on Neonatal Seizures will be presented and discussed. Of note, they highlight the current lack of robust evidence in this field of clinical neurology. We will also report on specificities pertaining to low-and-middle income countries in terms of incidence, main etiologies and diagnosis. The possibilities offered by telemedicine and automated seizures detection will also be summarized in order to provide a framework for future directions in seizures diagnosis and management with a global perspective. Many challenges and opportunities for improving identification, monitoring and treatment of acute symptomatic seizures in newborns exist. All current caveats potentially represent different lines of research with the aim to provide better care and reach a deeper understanding of this important topic of neonatal neurology.

Neonatal outcomes of preterm infants with in-utero exposure to drugs of substance use: US national data

BACKGROUND

Infants exposed prenatally to drugs of substance use are at increased risk for seizures, strabismus, feeding difficulty, and neurodevelopmental delays. Exposed preterm infants may have additional morbidities related to prematurity. There is limited literature on national outcomes of preterm infants exposed to drugs of substance use. We aimed to evaluate the trends and neonatal outcomes of preterm infants born in the USA who were exposed in-utero to drugs of substance use.

METHODS

Retrospective cohort study of preterm live born (<37 weeks gestation) exposed in-utero to opioids, hallucinogens, or cocaine in the Healthcare Cost and Utilization Project database from 2002 to 2017. Neonatal outcomes were identified using international classification of diseases 9&10 codes.

RESULTS

Of the 54,469,720 live-born infants, 7.7% (4,194,816) were preterm, and 58 679 (1.4%) were exposed in-utero to maternal opioids/hallucinogens (n = 39,335) or cocaine (n = 19,344). There was a trend for increased exposure to opioids/hallucinogens (Z score = 76.14, p < 0.001) during the study period. Exposed preterm infants had significantly more neurological anomalies, intra-ventricular hemorrhage and periventricular leukomalacia (p < 0.001).

CONCLUSIONS

There was a trend for increased in-utero exposure to opioids and hallucinogens in the preterm infants in the USA. Exposed preterm infants had more neurological morbidities.

Neuromonitoring in neonatal critical care part I: neonatal encephalopathy and neonates with possible seizures

The blooming of neonatal neurocritical care over the last decade reflects substantial advances in neuromonitoring and neuroprotection. The most commonly used brain monitoring tools in the neonatal intensive care unit (NICU) are amplitude integrated EEG (aEEG), full multichannel continuous EEG (cEEG), and near-infrared spectroscopy (NIRS). While some published guidelines address individual tools, there is no consensus on consistent, efficient, and beneficial use of these modalities in common NICU scenarios. This work reviews current evidence to assist decision making for best utilization of neuromonitoring modalities in neonates with encephalopathy or with possible seizures. Neuromonitoring approaches in extremely premature and critically ill neonates are discussed separately in the companion paper. IMPACT: Neuromonitoring techniques hold promise for improving neonatal care. For neonatal encephalopathy, aEEG can assist in screening for eligibility for therapeutic hypothermia, though should not be used to exclude otherwise eligible neonates. Continuous cEEG, aEEG and NIRS through rewarming can assist in prognostication. For neonates with possible seizures, cEEG is the gold standard for detection and diagnosis. If not available, aEEG as a screening tool is superior to clinical assessment alone. The use of seizure detection algorithms can help with timely seizures detection at the bedside.

EEG in neonatal seizures: where to look and what to see

INTRODUCTION

Neonatal seizures are frequent and carry a detrimental prognostic outlook. Diagnosis is based on EEG confirmation. Classification has recently changed.

AREAS COVERED

We consulted original papers, book chapters, atlases, and reviews to provide a narrative overview on EEG characteristics of neonatal seizures. We searched PubMed, without time restrictions (last visited: 31 May 2022). Additional papers were extracted from the references list of selected papers. We describe the typical neonatal ictal EEG discharges morphology, location, and propagation, together with age-dependent features. Etiology-dependent electroclinical features, when identifiable, are presented for both acute symptomatic neonatal seizures and neonatal-onset epilepsies and developmental/epileptic encephalopathies. The few ictal variables known to predict long-term outcome have been discussed.

EXPERT OPINION

Multimodal neuromonitoring in critically ill newborns, high-density EEG, and functional neuroimaging might increase our insight into the neurophysiological bases of seizures in newborns. Increasing availability of long-term monitoring with conventional video-EEG and automated detection methods will allow clinicians and researchers to gather an ever expanding bulk of clinical and neurophysiological data to enhance accuracy with deep phenotyping. The latest classification proposal represents an input for critically revising our diagnostic abilities with respect to seizure definition, duration, and semiology, possibly further promoting clinical research.

Diagnosis and Management of Seizures in the Preterm Infant

The risk of seizure is increased in premature neonates compared to full term infants, with a distinct profile of etiologies, timing and character. Despite improvements in neonatal care, preterm infants with seizure continue to have higher risk of abnormal neurodevelopmental outcomes when compared to preterm infants without seizures, or to full term infants with seizures. Very limited evidence guides the care of this challenging population, therefore, management of the preterm neonate with seizure is largely extrapolated from the care of full-term neonates. A critical need exists for well-designed clinical trials investigating and validating the safety, efficacy, and outcomes of seizure management in this vulnerable population.

Prenatal alcohol exposure in the second trimester-equivalent increases the seizure susceptibility in developing rats

We have previously reported that prenatal alcohol exposure (PAE) in the 2nd trimester-equivalent of gestation is associated with increased N-methyl-d-aspartate (NMDA)-induced generalized tonic-clonic seizures (GTCSs) prevalence in postpartum developing rats. Whether the 1st trimester-equivalent of gestation is also a vulnerable period for developing GTCSs following PAE is unknown. Here, we investigated the effects of a single episode of PAE at embryonic day 8 (E8, in the 1st trimester-equivalent) or E18 (in the 2nd trimester-equivalent) on NMDA-induced seizures in developing rats at postnatal day 7 (P7, the equivalent of preterm newborns) and P15 (the equivalent of term infants). Pregnant Sprague-Dawley rats were given a single oral dose of ethanol (5 g/kg body weight) at E8 or E18 and the postpartum rats were tested for the susceptibility to NMDA-induced seizures at either P7 or P15. NMDA-induced seizures consisted of wild running-like behavior (WRLB), flexion seizures (FSs), clonic seizures (CSs), GTCSs, and tonic seizures (TSs); these seizures were observed in both control-treated and PAE-treated, male and female, P7 and P15 rats. Quantification reveals that the overall prevalence of CSs, GTCSs and TSs occurrence were significantly increased in the E18-PAE group compared to E8-PAE group, adjusting for sex and postnatal day. Furthermore, the overall prevalence of FSs and TSs occurrence was significantly increased in PAE-treated males compared to females, adjusting for embryonic stage and postnatal day. The overall prevalence of WRLB and FSs occurrence was also increased in PAE-P7 rats compared to PAE-P15 rats, adjusting for sex and embryonic stage. We conclude that the susceptibility to develop GTCSs was higher when PAE occurred in the 2nd rather than in the 1st trimester-equivalent of gestation.