Abstracts

Seizures are most common in neonates.They are a challenge to diagnose and treat. Current treatment options leave a lot to be desired. I present a neonate whose seizures were controlled with adjunctive use of rectal(PR) levetiracetam (LEV). An SGA black male born at 23 weeks gestation via C Section with an Apgar score of 1 at 1 and 5 minutes(min) and 7 at 10 min, to a G2, P1, A0 25 year old,with PIH who smoked cigarettes and drank beer daily during pregnancy. At delivery she had UTI and PROM. After a septic workup baby was started on antibiotics and put on respirator for RDS. He had Anemia,Thrombocytopenia, prolonged PT/PTT and developed pulmonary hemorhages, direct hyperbilirubinemia, bilateral IVH with hydrocephalus. Indomethacin used for PDA, caused intestinal perforation and pneumoperitoneum. 2 palliative surgeries were done awaiting transfer acceptance to a hospital with pediatric surgeon.
Seizures started on 2nd day of life and were treated with Phenobarbital(PB). They were uncontrolled on PB level of 74.2 mg/L.His BUN was 46, Albumin 1.6,other chemistries were normal. EEG on day 13 showed a discontinuous patter,flat periods were 1-2 minutes long and active periods of theta [lt]70microvolts lasting under 1 second. Occasional ictal events starting at 15 HZ and tapering off to 8HZwere seen. Baby was very irritable so was on minimal stimulation. If touched would start with myoclonic jerks, so examination was limited to observation mostly. As far as I could see it was normal.Anterior fontanel was slightly full. The baby was PB toxic,NPO and had abnormal LFTs so we needed an AED with no affect on liver which could be given IV or PR. Options were Gabapentin and LEV. Only LEV had good bioavailability PR as per an adult case report.
After considering the many facets of his gigantic problems we decided on LEV. On 15 th day,based on earlier pediatric studies, we gave him 0.1 ml (12.5mg/kg/day) of LEV PR and held PB. Next day his provoked and unprovoked seizures all got under control and stayed thus till his transfer 2 days later. It worked so quickly with no side effects in him. The present first line options available to treat neonatal seizures are PB, Dilantin and benzodiazepines. Few well controlled studies checked their tolerability, safety and effectiveness. They were found to be [lt]50% effective. All are metabolized in liver and eliminated via kidneys, the two organs most often affected in tiny premies.
To our knowledge this is the first time LEV has been used effectively in this age and also the first time it[apos]s been used PR in a baby. This warrants further evaluation of LEV in treatment of neonatal seizures and it[apos]s absorption PR. We are in the process of doing just that.[figure1]