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Implications of a New Classification System for Neonatal Seizures

October 6, 2022

It is often difficult to figure out if a neonate (defined as <28 days of age) is having a seizure. Seizures can be a subtle as lip smacking or not detectable at all without an electroencephalogram (EEG). However, many diagnoses of seizures in neonates have been made clinically—at least until recently, when the Task Force on Neonatal Seizures of the International League Against Epilepsy  published a new classification system that will likely change previously held clinical practice. This week, Pediatrics is early releasing a Pediatrics Perspectives by Dr. Eli Mizrahi and Dr. Ronit Pressler, on behalf of the Task Force on Neonatal Seizures for the International League Against Epilepsy, entitled, “The International League Against Epilepsy New Classification of Neonatal Seizures” (10.1542/peds.2022-058114), which briefly describes this new classification system.

The authors report that studies have demonstrated more than half of these seizures in the neonatal period are subclinical, meaning that they can only be detected on EEG. They also surmise that, if there is an early accurate diagnosis of seizures, treatment outcomes might improve.

Thus, the new classification system is based on EEG findings. Neonatal seizures are categorized as being electrographic-only (seizure activity on EEG only) or electroclinical (seizure activity on EEG plus clinical evidence of seizure).

What does this mean for the clinician? First, the algorithms presented in this Pediatrics Perspectives suggest that babies who are “critically ill or with clinical suspicion” or “with high risk for seizures” should have EEG monitoring. That means that probably every baby in the neonatal intensive care unit will need EEG monitoring, as there are as of yet no protocols that define which babies will fall into the high risk category.

Second, there are many hospitals where EEG monitoring for neonates is not readily available. Thus, this new classification system, while it may improve diagnostic accuracy for infants in well-resourced hospitals, it will not benefit infants in poorly-resourced hospitals, and disparities in diagnosis and treatment may increase.

It is important for all of us who care for infants to be aware of this new classification system,  so  read the article and talk with your neonatologist colleagues to understand the implications in your hospital.

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