Variability in Preferred Management of Electrographic Seizures in Neonatal Hypoxic Ischemic Encephalopathy

  • Melanie A. McNally
    Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
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  • Adam L. Hartman
    Communications should be addressed to:Division of Clinical Research, National Institute of Neurological Disorders and Stroke, 6001 N. Executive Boulevard, Rockville, MD 20852.
    Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland

    Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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      Seizures may cause added harm in neonates with hypoxic-ischemic encephalopathy (HIE). Specific recommendations about seizure treatment in this context are lacking. We sought to determine the scope of practice regarding management of non–status epilepticus electrographic-only seizures in this setting.


      A case-based survey was distributed to members of the Child Neurology Society. Providers were asked about their preferred management strategy for sequential clinical scenarios.


      A total of 177 child neurologists responded to the survey. Seventy-seven percent of providers would treat 20 seconds or less of electrographic seizure activity. In a neonate with mild HIE and an electrographic-only seizure, there was no agreement among providers regarding whether to start maintenance therapy in addition to a one-time anti-seizure drug load. In a neonate with moderate HIE on phenobarbital for early electro-clinical seizures, most providers would escalate treatment for ongoing electrographic-only seizures by increasing phenobarbital dosing. In a neonate with severe HIE complicated by status epilepticus on phenobarbital who subsequently develops recurrent electrographic-only seizures, providers varied substantially in their management preferences. For all three cases, 75% to 85% of providers would not change their management preferences based on the absence of a clinical correlate with the electrographic seizure.


      We found marked variability among providers regarding preferred management of non–status epilepticus electrographic-only seizures after HIE. Our results identified specific aspects of electrographic-only seizure management in neonatal HIE where there is limited consensus. These discrepancies may serve as opportunities for future investigation.


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