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Research Article | DOI: https://doi.org/10.31579/2642-973X/035
1Department of Paediatric Neuroscience, Aster DM Healthcare, Dubai, United Arab Emirates
2Department of Neonatology, Medcare Women and Children Hospital, Aster DM Healthcare, Dubai, United Arab Emirates
3Department of Paediatric Neurology, Mediclinic City Hospital, Dubai, United Arab Emirates
4Department of Neonatology, Danat Al Emarat Hospital, Abu Dhabi, United Arab Emirates
*Corresponding Author: Prabhakar Patil, Department of Paediatrics, Aster DM Healthcare, Medcare Women and Children Hospital, Sheikh Zayed Road, Dubai, UAE.
Citation: Vivek Mundada, Prabhakar Patil, Sunny Phillip, Sridhar Kalayanasundaram, Ashish Dhemre. (2020). Attitude and Approach of Neonatologist and Pediatric Neurologist towards Neonatal Seizures: A Multicenter Study from the United Arab Emirates, J. Brain and Neurological Disorders. 5(4): DOI:10.31579/2642-973X/035
Copyright: © 2022, Prabhakar Patil. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 11 August 2022 | Accepted: 26 August 2022 | Published: 05 September 2022
Keywords: neonatal seizures, EEG, phenobarbital, neonates; UAE; neonatologist; paediatric; neurologist; WHO
Background: Neonatal seizures are difficult to diagnose due to their varied clinical presentation and they can be misdiagnosed or misinterpreted by an unexperienced clinician. Most of the studies in this area are retrospective and the clinical seizures have been included in such studies. The real seizure burden is known to be much higher as the electrographic seizures can often be missed and hence not treated. This study aims to assess the attitudes of neonatologists and pediatric neurologists in the United Arab Emirates (UAE) in diagnosing and managing neonatal seizures.
Materials and Methods: A self-administered questionnaire was sent to all the licensed neonatologists and pediatric neurologists in the UAE. The survey data was segregated into the demography of responders, diagnosis, and treatment approaches.
Results: A total of 31 responses were received, among which 25 (80%) were neonatologists and six (19%) were pediatric neurologists. About 80% of the responders felt that seizures cause no brain damage. Although 80% have access to Electroencephalogram (EEG) facility, only 54% of the respondents believe that it should be used in all the cases of suspected neonatal seizures. Phenobarbital remained the choice as the first-line drug by more than 80% of the responders to treat seizures in preterm and term neonates. Phenytoin was the second-line choice by 40% of responders.
Conclusion: There were variabilities noted in the clinical practice while managing the neonatal seizure management among the neonatologists and pediatric neurologists in the UAE. There seem to be a need for a national level standard guidelines for clinical management of neonatal seizures.
The incidence of epilepsy is highest in the youngest and oldest population [2]. The prevalence of seizures in the neonatal period was reported as 1-4 per 1000[3]. More cases are reported in developing nations than their counterparts [3, 4]. The prevalence of seizures among preterm neonates is almost 40 times more than the full-term newborns [5, 6]. Immature brain of premature infants does not produce the clinical events which are often noted in full-term neonates. This is due to the incomplete myelination of descending corticospinal tracts. The unique coincidental timing of risk factors such as infection, genetic disorders, metabolic derangement, and development of GABA and glutamate receptors are considered as the critical reasons for seizures. There is difference seen between the clinical correlates, incidence, etiology and outcomes in the term and preterm neonates [7]. Electrographic-only seizures or sub-clinical seizures only have EEG changes, without the apparent clinical correlate. Whereas clinical only seizures are sudden paroxysm of abnormal clinical changes without EEG association. Electro-clinical seizures have definite clinical signs along with electrographic seizure [8].
Accurate recognition of seizures among newborn infants is essential to prevent unnecessary exposure of them to anti-epileptic drugs. It is challenging to diagnose neonatal seizures, as most are electrographic only. Clinical seizures can be subtle and hard to distinguish from the usual repetitive movements of neonates [9]. The neonatal seizures are hence often misdiagnosed, leading to either under or overestimating clinically diagnosed seizure occurrence [10].
The neonatologists and the pediatric neurologist need to decide if the seizures need to be treated. There is no consensus on the threshold to treat the neonatal seizures. A rare or brief seizures may not require treatment, but EEG monitoring may be required to evaluate seizure burden. Seizure burden of >30–60 s per hour is often considered as an indication to start treatment [10]. There is also variation in practice when it comes to initiation of treatment including the decision on the drug dose to be administered, whether a single dose or regular maintenance dose [1]. Many antiepileptic drugs are available, but none of them have proved to be effective and safe in the long term. Therapeutic hypothermia is advocated in babies with perinatal asphyxia. Still, there is a need for a specific, effective, and safe pharmacological treatment for neonatal seizures. Phenobarbital has been recommended as the first-line drug for treating seizures in new-born infants by World Health Organization (WHO) [12]. There is low-quality evidence supporting its efficacy, potential side effects leading to long-term neurological damage, and adverse neurocognitive outcomes [13]. There is also lesser consensus among neonatologists and pediatric neurologists about when to stop the treatment post-initiation. However, early termination of pharmacological treatment and more cautious use of phenobarbital is recommended across the globe to decrease the side effects [14].
So far, no studies have been conducted in the UAE to understand the attitudes of the healthcare professionals regarding the diagnosis and the treatment of neonatal seizures. Here we have attempted to assess the similarities and variations in approach towards the management of neonatal seizures by neonatologists and pediatric neurologists through a pilot survey.
Through a questionnaire survey, we attempted to examine the approach in diagnosing and treating neonatal seizures in real-world settings by healthcare professionals. A self-administered Google questionnaire was e-mailed to all the licensed neonatologists and pediatric neurologists in the UAE (Annexure 1). The questionnaire was categorized to focus on the demography of respondents, diagnosis, and treatment of the neonatal seizures. The data was analyzed.
A total of thirty-one responses were collected between September 2021 and November 2021 which included 25 (80%) neonatologists and six (20%) pediatric neurologists. 27 (87%) were affiliated to a level 3 neonatal intensive care unit. Most of them were from Dubai (64%) whereas 22% were from Abu Dhabi and 10% were from Sharjah emirates. Most healthcare professionals (64%) dealt with less than one case of neonatal seizure per month. Also, most of the units (87%) had their own guidelines on the clinical management of neonatal seizures.
Most of the responders (84%) agreed that a clinical description of an event was not sufficient to diagnose neonatal seizures and they would prefer to gather more information like a video of the event. The same number of responders believed that any epileptic seizure could cause harm to the brain and hence should be treated in a timely manner.
Use of EEG is gold standard in the diagnosis of neonatal seizures and in absence of such facility, cerebral function monitoring with the help of amplitude EEG can be useful. There was a variation in such practice which was noted in our cohort. 87% mentioned that they have access to EEG facility. However, 61% usually use this facility in all the suspected cases of neonatal seizures for confirmation although 55
The neonatal period is the period of life which is most prone to the epileptic seizures due to higher excitability of the nerve cells. Both the diagnosis and the treatment of neonatal seizures have their challenges due to poor clinical correlate and unavailability of high standard evidence for their management. Although timely recognition and treatment of the seizure is needed, poor inter-observer agreement is known for identification of clinical seizures.
With this study, we have tried to understand the variation in the clinical practice of managing neonatal seizures. Our results are not different than the similar studies performed in the other countries [15, 16].
Most of the respondents in our study (80%) think that epileptic seizures cause damage to the brain. Studies have shown that there is enhanced susceptibility to further seizures and increased risk of brain injury with seizure in later life. In a retrospective analysis, seizures were not independently associated with cognitive outcome [17]. There is also an association between the frequency and duration of the neonatal seizures and the outcome in the later life years [18]. This subject will remain a matter of controversy until backed up by robust clinical trials.
In a UK-based population survey on neonatologists and pediatric neurologists, 66.7% of responders showed agreement for the treatment of clinical seizures (when no aEEG /EEG data was available for confirmation). In contrast, the diversity was found in the opinion of responders on the treatment of electrical seizures [15]. Although use of EEG or amplitude EEG, when EEG is not available, is required for the accurate diagnosis of neonatal seizures, most of the neonatal units may not have access to such facilities [8]. Interpretation of neonatal EEG also requires a trained clinical neurophysiologist or pediatric neurologist. This can be rarely seen in most of the secondary level hospitals.
Phenobarbital remains the first choice as the anti-epileptic drug for treating neonatal seizures in both the preterm and term neonates. This seems to be the first choice by most of the clinicians treating neonatal seizures [19, 20]. Phenytoin and Levetiracetam were most opted second line anti-epileptic medications. Levetiracetam seems to be gaining popularity among the neonatologists which is also seen in our cohort.
There is a wide variation in clinical practice and opinions on the duration of the treatment. This could be due to the lack of randomized clinical trials addressing this concern. A study from North America evidenced a more cautious use and short duration of continued phenobarbital treatment [14]. However, there is a need to shift the focus or consider prescribing safer treatment options.
Various parameters like birth weight, Apgar scores at first and fifth minutes, abnormal neurological examination, etiology of the neonatal seizures, treatment response to the seizures, EEG and cranial ultrasound findings are known to be the risk factors for developing future epilepsy in the neonates [21] . Although neonatal seizures are more common in the preterm neonates, gestational age does not seem to be an independent predictor for the epilepsy in the post neonatal period [22].
Limitation
The sample size for the survey was small. Our study was conducted in only Dubai and Abu Dhabi emirates. These two out of total seven emirates of the UAE have most of the hospitals and almost 68% of the population lives in these two emirates [23]. There is no possibility of determining whether the views and practices of individuals who responded are the same as those who did not. Our survey did not address the etiology of the neonatal seizures.
Our study shows the variation in the management of the neonatal seizures among the neonatologists and pediatric neurologists. Such variation seen in the study may reflect differences in the training, as most of the clinicians working in the UAE come from different countries. They are usually trained and worked in different countries before arriving in the UAE. The other reason for such variation could be lack of uniform or national guidelines. This study, hence, highlights the importance of designing and carrying out clinical trials determining the optimal treatment of neonatal seizures. Also, a uniform national clinical guideline for managing neonatal seizures is also needed to reduce such variation in the clinical practice.
Acknowledgement
The authors would like to thank all the participants who filled in the survey questionnaire
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