Table of contents
Expand All Topics
Neonatal seizures
Background
Overview
Definition
Neonatal seizures are abnormal electrical discharges in the brain of a newborn, typically occurring within the first 28 days of life, often with an acute brain injury or insult.
1
Pathophysiology
Neonatal seizures arise when normal asynchronous cortical activity becomes synchronous, detected on electroencephalography as spike-and-slow-wave patterns. This aberrant firing often reflects a combination of enhanced neuronal connectivity, heightened excitatory transmission, and failed inhibitory mechanisms, all of which are influenced by developmental factors such as transient overexpression of glutamate receptors and the immature expression of GABA receptors. Most common causes of neonatal seizures are hypoxic-ischemic encephalopathy, stroke, infections, and intraventricular hemorrhage. Other causes may include hypoglycemia, CNS infections, subarachnoid hemorrhage, brain malformations, metabolic disorders, genetic causes (such as mutations in KCNQ2, STXBP1, SCN2A, PNKP, ARX genes), and drug withdrawal syndrome.
1
2
Epidemiology
The incidence of neonatal seizures is estimated at 1-5 per 1,000 live births in full-term neonates and 14 per 1,000 in preterm neonates.
3
4
Risk factors
Risk factors for neonatal seizures include smoking during pregnancy, nulliparity, advanced maternal age, increased maternal BMI, diabetes mellitus during pregnancy, hypertensive disorders of pregnancy, maternal fever, chorioamnionitis, shoulder dystocia, placental abruption, assisted vaginal delivery, induced labor, and occiput posterior position at birth.
5
Disease course
Seizures may present clinically or be detectable only on electroencephalography (subclinical). Seizure activity often begins focally but may generalize and involve the entire body. The clinical presentation varies widely depending on gestational age, underlying etiology, and concurrent medical conditions. Clinical seizures can include automatisms, clonic, myoclonic, or tonic seizures, epileptic spasms, autonomic seizures, behavioral arrest, sequential seizures, and other unclassified seizure types.
2
Prognosis and risk of recurrence
Neonatal seizures are associated with a 20% mortality rate and poor neurodevelopmental outcomes, including worsened motor and cognitive function compared with neonates without seizures, as well as an increased risk of remote seizures and epilepsy.
6
7
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of neonatal seizures are prepared by our editorial team based on guidelines from the American Clinical Neurophysiology Society (ACNS 2025), the International League Against Epilepsy (ILAE 2023), and the World Health Organization (WHO 2011).
1
2
3
4
5
6
7
8
9
10
Diagnostic investigations
EEG: as per ACNS 2025 guidelines, consider obtaining continuous EEG rather than clinical observation alone, amplitude-integrated EEG alone, or routine/spot EEG in neonates to improve the accuracy of seizure diagnosis in clinically suspected seizures.
C
Show 5 more
More topics in this section
Glucose measurement
Calcium measurement
Diagnostic imaging
Diagnostic procedures
Lumbar puncture
As per WHO 2011 guidelines:
Perform a lumbar puncture to rule out CNS infection if clinical signs suggest sepsis or meningitis, and administer appropriate antibiotics if infection is confirmed.
A
Consider administering empirical antibiotics in neonates with clinical signs of sepsis or meningitis if lumbar puncture facilities are not available.
C
Medical management
Indications for treatment: as per WHO 2011 guidelines, administer treatment for clinically apparent seizures in neonates if they persist for ≥ 3 minutes or occur as brief serial seizures.
A
Show 2 more
More topics in this section
Antiepileptic drugs (first-line)
Antiepileptic drugs (second-line)
Antiepileptic drugs (duration)
Pyridoxine
Therapeutic procedures
Therapeutic hypothermia
As per ILAE 2023 guidelines:
Consider performing therapeutic hypothermia to reduce seizure burden in neonates with hypoxic-ischemic encephalopathy.
E
Consider treating neonatal seizures, including electrographic-only seizures, to achieve a lower seizure burden and potentially improve outcomes such as neurodevelopment and reduction of subsequent epilepsy.
E