Abstracts

Rationale: Seizures are the most common manifestation of neurologic disease in the neonate, and they are most often due to acute injuries such as hypoxic ischemic encephalopathy (HIE). Given that high seizure burden is associated with worse brain injury, most clinicians treat neonatal seizures with antiseizure medication (ASM), but there is no formal consensus on the duration of ASM treatment following acute symptomatic seizures. In 2017, an observational cohort study at our institution indicated that early discontinuation of ASM for neonates with HIE and seizures did not increase the long-term risk of developing epilepsy or neurodevelopmental disorders (Fitzgerald MP et al. Early discontinuation of antiseizure medications in neonates with hypoxic-ischemic encephalopathy. Epilepsia 2017 Jun;58(6):1047-1053). Thereafter, we initiated a practice change initiative aimed at reducing use of ASM that consisted of formal educational sessions with our Neuro-ICU Consultation Team and incorporation into a neonatal seizure pathway. In this study, we compared ASM discontinuation practice before and after our 2017 data and related practice changes.

Methods: We conducted an interim analysis of early ASM discontinuation rates in a prospectively acquired cohort of consecutive neonates with seizures due to HIE treated at Children’s Hospital of Philadelphia between 1/2012–6/2019. All neonates had clinically suspected and/or electroencephalogram (EEG)-confirmed seizures, were monitored on continuous EEG, and received an ASM acutely. We analyzed a pre-cohort from 1/2012–6/2017 and a post-cohort from 7/2017–6/2019. Descriptive data were presented as counts (%) and medians (interquartile range). Comparative measures were analyzed with Fisher’s exact test, Pearson Chi-squared, and Wilcoxon Rank Sum.

Results: Demographics and seizure characteristics did not vary between the pre- and post- cohorts (Table 1). The percentage of neonates discharged off an ASM or on a taper increased significantly (58% pre to 95% post; p=0.001). The percentage of neonates discharged off an ASM also increased (54% pre to 77% post; p=0.05). Among neonates discharged on an ASM, the percentage discharged on a taper increased significantly (8% pre to 80% post; p=0.003). The post-cohort was less likely to be discharged on phenobarbital (83% pre to 60% post, p=0.01).

Conclusions: Our analyses show that initial reporting of safe early discontinuation of ASM impacted clinical care at our center, with a demonstrable increase in the number of neonates discharged without ASM or with an ASM taper following acute symptomatic seizures. Additionally, fewer neonates were discharged on phenobarbital, decreasing long-term exposure to potential neurotoxic effects. These changes were achieved with a relatively simple change management approach focused on education of a core group of clinicians involved in ASM decisions with inter-disciplinary support provided by pathway incorporation.

Funding: Please list any funding that was received in support of this abstract.: None.