We must recognize not only the motor but also the electographic only- seizures , non- motor presentation and some particular types seizures in this age group that can give clues to the etiologies. Since many neonates with BIRDS also have seizures, a longer recording might reveal that those with poor outcomes actually have BIRDS and seizures. Until there is enough evidence, it seems more prudent to retain the definition of a seizure as a minimum 10 seconds of evolving activity and BIRDS/BRDs as less than 10 seconds of evolving activity. We can have : Focal (motor/non motor), generalised and electrographic as three major groups to begin with. As seizures in neonates are often electrographic only with no clinical feature, therefore three separate groups of classification like clinical, electroclinical and electrographic groups need to be included. Additionally, 2017 ILAE classification manual emphasizes the onset of seizures, in the example given which was as follows: “Sequential seizure manifestations: A seizure begins with tingling in the right arm of a 75-year-old man (Fisher RS, Cross JH, D'Souza C, et al. So should there be an entity of ' clinical seizures/ suspected seizures even if no electrographic abnormalities are seen during the seizures. Neonate with seizures. Trouvé à l'intérieur – Page 439... variable Niveaux liquide-liquide fréquents dus à une hémorragie interne Définition • Tumeur bénigne hépatique du nourrisson due à une prolifération mésenchymateuse primitive IMAGERIE Caractéristiques • générales Clés du diagnostic ... By policy, the manuscript will be open for comments for two months, until October 15. According to Cambridge dictionary, sequential means, consecutive, successive. How did the authors determine whether a seizure with more than one clinical seizure type could be classified as having a predominant clinical seizure type rather than a sequential seizure? “The 10-seconds rule” lacks biological evidence, but its appropriateness has been recognized until now. This explains the reason why the brainstem release phenomenon remains in a subcortical area and usually does not spread through the cortex. All neonatal seizures are admittedly focal, but it seems that which type of focal should be important. The gold standard of classification is EEG, and there is no doubt that it is a justified means according to the nature of the neonatal seizures, but as you know there are many countries with limited health resources to afford modern digital video-EEG monitoring facilities for their nurseries and neonatal units. from Loddenkemper et al 2005: “2. Trouvé à l'intérieur – Page 68La définition, les caractéristiques ou les facteurs de risque, les facteurs favorisants permettent de préciser le diagnostic infirmier et s'intègrent dans une « démarche diagnostique». Vingt-six nouveaux diagnostics infirmiers et 14 ... In epilepsies in older children and adults, determination of site of seizure onset is important. The duration has to be sufficient to determine the ictal epileptic discharges are focal / focal secondary generalized or generalized. This classification system should be a major step forward for establishing clarity and consistency of terminology in this area. There are three steps to the acid-base interpretation, A respiratory acidosis or alkalosis is the diagnosis when the pH is abnormal because of a change in the pco2 (respiratory component). Clinical ,Electroclinical and Electrographic classification needs more elaboration: Epilepsy syndromes sould be under a separate heading although it may genetically determined Syndromes presenting in the neonatal period include: self-limited (benign) familial neonatal epilepsy, early myoclonic encephalopathy (EME), and early infantile epileptic encephalopathy (Ohtahara syndrome). The heel of the infant is arterialized by using a warm- wet cloth (45 C) on the site for 5 to 7 minutes, 1. I appreciate the presentation of this classification. 3. How does one decide what is the dominant feature – a significant desaturation with apnoea or a motor phenomenon (positive or negative) or the feature that persists for the longest duration? Could it be modified based on cheaper devices such as aEEG? I believe that this new classification on neonatal seizures is a great effort to unify the diagnostic criteria, and thus to better understand the pathophysiology and the evolutionary course. Rosa Alvarado Merino, pediatric neurologist. Overall I think the classification is great and will be helpful for clinicians. This was noted across all etiologies except genetic. I think the team had done a tremendous job so far. If one comes to practise neurology in resource limited country the first questions crossing the mind is that how to recognize the subtle forms and bizarre features of NS; Is it epileptic or symptomatic one; Is it easy to manage or intractable as we see often. 2013;15:9–18. Figure 3 – again I think you need to add back in focal seizures and focal epilepsy as mentioned above I would suggest something like the following: Clinical Seizure without EEG documentation or normal EEG, Clinical seizures with Electrographic documentation. The authors have done a terrific work which provides many clarifications on the topic. Background EEG is important because, in my experience, paroxysmal discharges such as BIRDs or electrographic-only seizures are more easily picked up in the severely encephalopathic infant since they stand out from suppressed or discontinuous EEG; in the healthier, perhaps more active infant, brief or every focal discharges may be “hidden” to algorithms or to the eye. The neonatal seizure classification proposed emphasizes the role of EEG in the diagnosis of seizures in the neonate, this is essential, as electrographic only seizures as well as electroclinical seizures are important to recognise, identify and quantify in the neonate. 2. Nonspecific vaginitis: diagnostic criteria and micro-bial and epidemiologic associations. First of all, heartiest congratulations to the whole team for taking up this clinically relevant task and proposing a simple, yet concise classification in concordance with ILAE 2017 classification of seizures and epilepsy. The neonatal classification reverses this approach and classifies by the most prominent feature. Trouvé à l'intérieur... l'X fragile Rang A B A B A B B B Rubrique Intitulé Descriptif Définition Connaître les règles de bases du conseil ... Connaître les situations à risque de mucoviscidose fœtale Diagnostic positif Dépistage néonatal généralisé de la ... Only few suggestions I would like to make which I think could be included in the draft, Thanks and regards,Professor Sheffali Gulati. - The fact that arbitrarily 10 seconds have been chosen as the minimum duration to define a seizure must be reviewed, taking into account that not only spasms, but also focal seizures, may have a shorter duration, although they are clearly epileptic in nature. Some of the most common seizure types are not highlighted in Table 4. Ventilation is the most important life function and should be evaluated first by looking at PaCO2, a. Oxygenation is the second critical life function and is evaluated by looking at the PaO2 and FIO2, By looking at the PaO2 (along with the PaCo2 and FIO2) each of these causes can be easily identified and treated, It is more important to keep the FIO2 low than to turn down the level of PEEP or CPAP. Seizures in the neonate could originate in neocortical, thalamocortical, limbic, and? Should they be defined as neonatal seizures? Whether frequent BRDs without clinical seizures constituting more than 50% be treated as status is another dilemma. Thank you for your help in this important effort of the ILAE. Localization within the brain should be specified when this is appropriate”. Thank you very much for the excellent work. My suggestion is that the issue of classification of the clinical manifestations of neonatal seizures, be discussed further and perhaps modified. Overall I think it is very good. "However, the choice of 10 seconds duration was explicitly arbitrary:" This is not completely true: van Rooij et al* are citing:“a sudden, repetitive, evolving and stereotyped ictal pattern with a clear beginning, middle and ending and a minimum duration of 5–10 seconds" *van Rooij LG, van den Broek MP, Rademaker CM, de Vries LS. Trouvé à l'intérieur – Page 1009... pieds, bouche, 203t médullaire, 737 métabolique diagnostic du, 367e maladie cardiovasculaire et, 367 néphrotique, faciès du, ... 513-519 membres supérieurs, 511-513 Systole définition de la, 344 bruits surajoutés dans la, 390e, 408t ... I commend the authors for this work, which reflects their hard work and commitment to use available evidence to create a categorization of neonatal seizures that harmonizes with the greater ILAE terminology, yet reflects the unique features seen in neonates. Sequential and predominant are more difficult terms to use in practice. Was inter-rater agreement tested? The seizure classification according to the predominant clinical sign manifestation, as this is more likely to have clinical implication for etiology than seizure onset zone. The duration of abnormality found in EEG, is it only if we found the discharge more than 10 s, what if it less than 10 s but occur repeatedly? 1. Trouvé à l'intérieurLes surdités légères et unilatérales, dont le diagnostic est devenu précoce grâce au dépistage néonatal, sont des surdités à part entière. Il faut les prendre en charge tôt et de manière adaptée ; à défaut de prise en charge précoce, ... As rightly pointed out by the authors, this scheme will be difficult to use in developing countries without access to continuous EEG. Thank you for the great effort of The Task Force . This classification must also be able to be consulted by neonatologists. Definition of severe hyperbilirubinaemia. Hyperventilation is indicated for patients with a cute elevations in ICP (closed head injury, trauma, and surgery) decrease cerebral blood flow and ICP. h�b```b``�a`a`�_� Ā B@1V �8� ��յtB��2O. En France, la prévalence d'une surdité sévère à profonde pré-linguale est estimée à 1 naissance pour 1000. It can be expected that the diagnosis and treatment of neonatal seizures will be advanced by the wide application of this new classification of neonatal seizures. I think this material will be very important to support all the neuropediatrics who work with the neonatal population. To subscribe, please click on the button below. These questions are presented in the usual clinical practice. Also other overlaps can occur other than those shown. The following division into motor and non- motor seizures and finally by the seizure type is difficult due to lack of verbal and limited non- verbal communication. No doubt, there is a need for a Neonatal Seizures Classification like this. It is desirable to show clearly how to determine “predominant” seizure manifestations using several representative scenarios. Although it is clear that most of the seizures remain focal. Trouvé à l'intérieur – Page 96Le dépistage et la prise en charge précoces des anomalies congénitales Selon la définition de l'O.M.S . , " le dépistage ... Le dépistage systématique néonatal des affections métaboliques permet de son côté d'arriver à un diagnostic ... From the clinical point of view, the classification seems simple and very applicable in different contexts, in addition to emphasizing the role of the EEG in the diagnosis. In contrast, a large majority of neonatal seizures are not caused by epilepsies as a chronic disorder. I thank them for making video EEG as the gold standard for the diagnosis of neonatal seizure. What is suggested where EEG may not be available with the neonatologists in peripheral centers in LMIC and those centers which have amplitude integrated EEG monitoring? Diagnostic accuracy of S100B urinary testing at birth in full-term asphyxiated newborns Evaluation of urinary S100B protein level and lactate/creatinine ratio for early diagnosis and prognostic prediction. Perhaps the biggest differences are minimization of subjective symptoms (not reportable in neonates), lack of generalized seizures in neonates and increased emphasis on the EEG pattern. Found one typo page 16 line 55 should be Bedside maneuvers not Beside maneuvers. As part of the approval and adoption process the League asks for its members to review and comment on the proposed classification. epileptic syndromes genetically determined, hypoxic ischemic encephalopathy(HIE) Commonest, vascular event like intraventricular hemorrhage, metabolic encephalopathy(trasient errors) and enzymopathies, West`s syndrome is classical example of electroclinical diagnosis which perhaps merges with LGS in later age group, Transient metabolic errors ,sepsis or in HIE(early stage) where only clinical manifestation may be recorded in video with nonspecific EEG changes, Clinically silent or sub-clinical seizures where only EEG changes are seen, The 1998 semiological seizure classification proposed the term "hypomotor" for seizures with predominant motor arrest, when consciousness cannot be assessed (as is obviously the case here). Your recommendations may increase the availability of video EEG in our country. This does create some confusion by referring to this entity as a seizure given that the current ILAE definition of seizure referred to implies a clinical manifestation. I thank the ILAE Task Force on Neonatal Seizure for their hard work on this challenging topic. According to Mizrahi and Kellaway (1987) this proposed classification states the importance of the EEG in the diagnosis of seizures in neonates. On the other hand, electrographic only seizures would be better if they appeared in a different column than non-motor seizures. Thank you for your tremendous work, I totally agree with the proposal adjusting neonatal seizure classification. Well done work, which takes account of the etiology, clinical manifestation, EEG, epileptogenesis etc. Did the authors also note the initial clinical seizure type or was only the predominant seizure type noted? This is for the benefit of those dealing with neonates and neonatal seizures in the developing world. - The novel seizure type “sequential” has to be discussed. For example, the Neonatologist may view apnea as "dominant" manifestation, while Neurologist may see 'focal tonic' as "dominant" manifestation. Neonatal seizures are defined as a paroxysmal electroclinical phenomenon characterized by the. %%EOF
In particular, as already underlined in the draft, the clear distinction between: Seizure in the neonatal period with acute brain damage and therefore Symptomatic Epilepsy due to symptomatic neonatal seizures, Versus, Seizures without acute brain damage, so, Neonatal Seizures / Genetic Epilepsy since first onset and consequently Epilepsy from the beginning: Syndromes, Cortical Malformations, EIEE, and so on, is the most evident evolutionary concept that has come to delineate in recent years. The outcomes combined neonates with BIRDS and clinical seizures and BIRDS without clinical seizures so it is not clear how many neonates with BIRDS and no clinical seizures had an abnormal outcome. The next is less a critique of the document than an acknowledgement of the difficulty in neonatal EEG. It seems to me that it might be convenient to consider adding to the classification the seizures with clinical manifestation only, especially when they appear in neonates with interictal paroxysmal activity in the EEG and there is a symptomatic etiology known. At first, there may be substantial inter-observer variability determining the predominant manifestation within a single seizure. Semiology: abdominal aura -> automotor seizure ->right versive seizure -> generalized (now bilateral) tonic-clonic seizure”). Only reference 11 states that the majority of preterm infants have electrographic only seizures, and it is not noted how many infants had received a seizure medication prior to eeg recording. In this direction, the description of semiology would be one of the most important aspects. Congratulations to the Authors, Patricia Navas Sánchez, Clinical Neurophysiologist. I am not sure there is enough evidence to say that a BIRD is equivalent to a seizure and therefore should be treated with seizure medication. There are also a few statements that I found confusing: Thank you again for all your work on this! If so, a description of the process and how often it was used will be helpful to readers. Pediatrics 1984; 73:11-3. ABG are an important part of assessing the infant or child in respiratory distress, 1. The 2017 classification classified a seizure on the basis of its first manifestation, even if not the most prominent. Thirdly, I totally agree that “electrographic only seizures”, without clinical signs, have to be included in the classification system: therefore neonatal epileptic seizures may be 1) electro-clinical or 2) electrical only seizures. Sincere regards,Dr Priyanka Madaan, Dr Jitendra Kumar Sahu. I have the following comments: Thank you for giving me the opportunity to comment on the proposal. I have one question though: In the introduction of the proposal (P6; line 6) BIRDS are defined as “Brief Rhythmic Ictal Discharges”, whereas in the discussion (p15; line20-21) they are defined as “Brief Rhythmic Interictal Discharges”. 1. We hope that vigorous researches will be performed toward future revision. Do the authors think it is possible that the low number of seizures with predominant behavioral arrest is due to a referral bias? Doing away with seizure onset (focal, generalized) from the proposed classification, is debatable. I agree fully with the electrographic only term. As a matter of fact, literature data showed that the cortical layers are not still completely developed in preterm neonates until 40 weeks post-menstrual age. You have proposed a very nice flowchart in Fig 2 which seems to be pretty simple but very practical, but there is a dead-end after “non-seizure episodes, without EEG correlate”! Dr. Vivianne van Kranen-Mastenbroek, Clinical Neurophysiologist. This is not an easy issue in any age group, but the 2017 classification defined the seizure type by how it started, and not by its propagation – which is infinitely variable. By not looking at the initial manifestation of the electroclinical seizure, the evolution of the semiology, the electroclinical patterns at onset and propagation, the opportunity to learn more about the neonatal brain circuits involved in seizure generation may be lost. We strongly agree with the brave statement that neonatal seizures are exclusively of focal onset. Well written paper and agree with their recommendations. As a non-expert in neonatal seizures I have the impression that his is a very clear and rational way to classify seizures at this age range. I think it would be interesting to have some examples of what is an electroencephalografic seizure and what is not. I thank the ILAE Task Force on Neonatal Seizure for their hard work on this challenging topic and for give us the opportunity to review this important document. I agree to the rest comments, that there is a tremendous effort done by the task force for this issue. If EEG is available, it can help in a better classification, but there is still work to be able to define events without EEG correlate, especially when the diagnosis defins therapeutic behaviors, considering environments where EEG availability in neonatal units is scarce.
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