Rwanda National Neonatal Protocol:
Neurology with Dr. Febronie Mushimiyimana.
Introduction.
Hello, I'm Febronie Mushimiyimana,
a pediatrician from Rwanda Pediatric Association.
And today we are going to talk about neurology.
Overview.
By the end of this chapter, participants
will be able to identify appropriate temperature
for newborns with a hypoxic ischemic encephalopathy, HIE.
Explain the diagnosis and the management
procedures for seizures.
Identify dangerous side effects of anticonvulsant medications.
Identify treatment for pain associated
with minor procedures.
Identify a treatment for pain associated
with major procedures.
Considerations in neonatal neurology.
Asphyxia defined as inadequate delivery of oxygen
to meet metabolic needs, is the number one cause
of death in neonates in Rwanda.
Risk factors for asphyxia are related to the fetus, mother,
and placenta.
While prenatal asphyxia is very rare and is not preventable,
asphyxia during labor or immediately after labor
is more common and is very preventable.
Prevention strategies include active management of labor,
detection of fetal distress, prompt management,
and immediate resuscitation with the goal
of breathing within one minute.
The goals of this module include harm reduction
and how to optimize outcomes of babies
who suffer from asphyxia to ensure
happy, healthy childhoods.
Hypoxic ischemic encephalopathy, or HIE,
is caused by inadequate pre-, intra-,
and/or post-partum oxygen delivery and blood flow.
Signs and symptoms include delayed first breath,
need for neonatal resuscitation, low Apgar
scores, less than five at five minutes.
Absence of cry at five minutes of life.
An abnormal neurologic exam, abnormal tone, and seizures.
The severity of HIE should be assessed by Sarnat stage.
Stage 3 is the most severe with the worst prognosis,
while stage 1 to 2 have minimal to moderately
adverse long-term outcomes.
There are three main principles for treatment of HIE.
Avoid hyperthermia, provide supportive care,
and monitor for, and treat seizures.
To avoid hyperthermia, avoid bundling, and warmer,
and incubator in order to keep the newborn's temperature
under 37.5 degrees Celsius, which
will help decrease ongoing brain damage
after initial perinatal injury.
Allowing newborns to get cool is only
meant for babies with asphyxia and concern for HIE,
and should be avoided in all other cases.
When providing supportive care, start supplemental oxygen
if the newborn is experiencing respiratory distress
or has an oxygen saturation below 90%.
NPO if respiratory distress or seizures or Sarnat stage 3.
Give IV fluid with dextrose 10% at 60 mLs per kg per day
to avoid cerebral edema.
Monitor and then normalize the newborn's glucose
and electrolytes.
Neonatal seizures should be quickly diagnosed
and aggressively managed.
Clinicians should take frequent vital signs
and monitor the newborn closely.
Neonatal seizures can be subtle compared
to those in older patients, so it
is important to be familiar with the criteria for diagnosis.
Those include the non-extinguishable twitching,
rhythmic lip or jaw movement, staring or eye twitching,
extension of extremities, clenching of fists,
and changes in vital signs including apnea.
Seizures should be controlled within 30 minutes
of presentation using combination of the three
main treatment drugs: phenobarbital, phenytoin,
and diazepam.
The loading dose of phenobarbital
is 20 milligrams per kg as an IV slow push with subsequent doses
of 10 milligrams per kg after 20 to 30 minutes,
if the seizures continue.
No more than 40 milligram per kg of phenobarbital
should be given in one day.
Phenytoin, preferably fosphenytoin,
is a second agent to be used if seizures
persist after the second or third dose of phenobarbital.
The loading dose is 15 milligrams per kg
by IV, with subsequent doses of 5 milligrams
per kg after 20 to 30 minutes if seizures continue.
IV tubing containing glucose must
be flushed with normal saline before and after use.
Diazepam can be used as a second agent
if phenytoin is not available.
Give 0.1 milligram per kg over three to five minutes
as a first dose, and then repeat this dose
after at least 15 minutes if seizures continue or recur.
If seizures recur after acute treatment,
start maintenance therapy 24 hours
after the first loading dose of phenobarbital is given.
The maintenance dose of phenobarbital
is five milligrams per kg per day
given IV or per os every 24 hours.
In the unlikely event that the second agent
is needed for maintenance therapy,
give phenytoin at five milligrams per kg per dose IV
every 24 hours.
After three days of maintenance dosing without seizures,
it is time to try discontinuation of therapy
to determine whether or not the infant will
require long-term outpatient anticonvulsant therapy.
If the infant is on second agent,
discontinue this agent first and monitor for 48 hours.
If seizures recur, re-bolus with another loading
dose and restart maintenance.
If seizures do not recur, discontinue phenobarbital
and monitor the newborn for another 48 hours.
If seizures recur here, re-bolus with a loading
dose of phenobarbital and restart maintenance.
if seizures don't recur, discharge the infant home
off of anticonvulsant therapy.
Anticonvulsants can cause apnea, especially when
administered at high doses and in combination.
Infants on anticonvulsants should therefore
be monitored closely.
In the case of apnea, be prepared
to provide bag-mask ventilation while awaiting the return
of respiratory drive.
An infant who has required an anticonvulsant
must be observed for at least 48 hours after the last dose
to ensure that seizures don't recur.
When considering discharging patient requiring
long-term outpatient anticonvulsant therapy,
the drugs the patient is on needs to be considered.
Phenobarbital should be changed to per os
and the patient can be discharged.
Phenytoin, however, can't be changed to per os,
so a patient on phenytoin can't be discharged to home.
A rendezvous should be scheduled for all patients with HIE
after discharge home, with the frequency determined
based on the severity of HIE and seizures.
The first appointment should be within two to four weeks.
Newborns with a devastating neurologic prognosis
from congenital or acquired conditions
require special consideration.
The severity of the expected outcome
must be explained to the family honestly and clearly.
And it is your responsibility to communicate and support them
compassionately.
Like all patients, newborns experience
pain, though it can be more difficult to appreciate,
especially if they are preterm.
Repeated painful procedures have been
proven to cause adverse long-term neurological effects.
Minor procedures such as a blood draw, IV placement,
and the lumbar puncture all cause pain for newborns.
To control pain for minor procedures,
give newborns sugar water with one teaspoon of sugar
in 20 mL of clean water, as well as
breastfeeding, comfort measures, holding, and swaddling.
For major procedures such as intubation, chest tube
insertion, newborns should be given morphine at 0.02
to 0.05 milligram per kg IV.
This dose may be repeated once, with a maximum of 0.1 milligram
per kg per four hours.
Morphine should be administered slowly
to avoid the respiratory depression.
To review this material, we will go over
a case study about a newborn patient Francois.
Case studies.
He was just admitted to the neonatal ward
and was born full term.
He required the chest compressions at delivery.
And his Apgar score was 1 at one minute and 4 at five minutes.
What is your neurological concern?
What is your goal temperature for Francois?
Francois is at risk for hypoxic ischemic brain injury.
A goal temperature is at the low end
of normal range, below 37.5 degrees Celsius,
as HIE can be exacerbated in the setting of hyperthermia.
Six hours later, Francois has a generalized tonic-clonic
seizure.
You give him 20 milligrams per kg of phenobarbital.
The seizures continued, so you give another 10 milligrams
per kg 20 minutes later.
Which side effects of phenobarbital
are you most concerned about?
Francois is at risk for apnea due to both the seizure
and the anticonvulsant.
He should be monitored closely, and they
should be prepared to provide bag-mask ventilation,
if needed.
You decide to start Francois on maintenance phenobarbital
because he has recurrent seizures.
When would you discontinue the phenobarbital?
You should discontinue the phenobarbital after three days
without seizures.
If the seizures recur, phenobarbital
should be restarted, and Francois
should be discharged to home on phenobarbital.
If the seizures do not recur, the infant
should be observed in the hospital for two days
to ensure that there are no seizures
as the phenobarbital level becomes subtherapeutic.
Next, you decide to do a lumbar puncture
to assist for possible meningitis
as etiology of seizures.
Is this a major or minor procedure?
What treatment could you give to control pain?
This is a minor procedure, so you could give sugar
water or breastfeeding, comfort measures, holding,
or swaddling.
Summary.
Now that you have finished this chapter,
you should be able to identify appropriate temperature
for newborns with hypoxic ischemic encephalopathy, HIE;
explain the diagnosis and management
procedures for seizures; identify dangerous side
effects of anticonvulsant medications;
identify treatment for pain associated
with minor procedures; and identify treatment
for pain associated with major procedures.
Consider these key points on neonatal neurology.
The three main principles for treatment of HIE
are avoiding hyperthermia, providing supportive care,
and monitoring for and treating seizures.
Seizures in a newborn should be quickly diagnosed
and aggressively treated.
The first line treatment is phenobarbital.
A major side effect of anticonvulsants is apnea.
Newborns on anticonvulsants should
be monitored closely and provided bag-mask ventilation,
as needed.
Newborns experiencing pain for major or minor procedures
should be treated according to the recommended pain management
treatment.
Thank you so much for your attention.
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