The generally accepted clinical approaches to neonatal seizures were determined by questionnaires completed by pediatric neurologists and neonatologists representing all the pediatric neurology units and all departments of neonatology in Isrrael, and were evaluated at Tel Aviv Sourasky Medical Center. Responding 36/55 (65%) neurologists and 66/112 (59%) neonatologists chose similar antiepileptic drugs as first line (phenobarbital), second line (phenytoin), and third line (benzodiazepines) treatments. Treatment duration favored by both specialties varied widely from 1-52 weeks, neurologists tending to recommend longer treatment for seizures secondary to asphyxia or hemorrhage. For intractable neonatal seizures, neurologists favored valproic acid and topiramate, and neonatologists recommended lidocaine and benzodiazepines (P=0.0023). Continuous EEG monitoring after asphyxia was used by 70.5% of neonatologists contrasting with only 40% of neurologists (P=0.013). Specialties differed concerning the harmfulness of neonatal seizures: 76% neurologists cf 55% neonatologists answered “Yes” to “Could neonatal seizures harm the brain?” (P=0.065); 12% neurologists cf 34% neonatologists answered “Don’t know.” “Could electrographic seizures harm the brain?;” 43% neurologists and 47% neonatologists answered “Don’t know.” “Would you treat electrographic seizures?,” 40% neurologists and 38% neonatologists answered “Yes.” Controlled clinical trials to establish evidence-based guidelines for the management of neonatal seizures are indicated. [1]

COMMENT. Israeli neurologists and neonatologists agree on initial management, but differ on treatment of intractable neonatal seizures, the harmfulness of neonatal seizures on developing brain, and need to monitor subclinical seizure activity. “Don’t know” was a frequent answer by both specialties to questions regarding harmfulness of electrographic seizures and the need to treat them. Controversies in the literature need further research and answers.

Lamotrigine for partial seizures in patients aged 1 to 24 months was well tolerated and may be effective as adjunctive therapy, as shown by a randomized, double-blind, placebo-controlled study in 19 patients at Vanderbilt University, Nashville, TN [2]. Rash occurred in 15% during the open label phase; none was Stevens-Johnson syndrome or toxic epidermal necrolysis. Children <2 years of age are considered therapeutic orphans since antiepileptic drug trials are hampered by multiple restrictions. This study demonstrates that drug trials at this age can be completed. [3]