Neonatal Seizure Classification

The ILAE Task Force on Neonatal Seizures has created a classification for seizures in the neonate, which is intended to become the ILAE position on the classification for seizures in this age group.  As part of the approval and adoption process the League asks for its members to review and comment on the proposed classification.  These comments from our international community will then be reviewed by an independent task force, which will then amend the proposed classification to be in line with the suggestions from the community.

Read draft Neonatal Seizure Classification document here

By policy, the manuscript will be open for comments for two months, until October 15.  All comments will be placed  on the League's website as they are received and will include the name of each writer.  At the end of that time, the comments will remain public, and an independent task force will be named by the Management Committee to review the comments and to make appropriate changes.  This task force will have six months to complete the task and then submit the amended manuscript for publication.

We have been pleased and encouraged  by the extensive and thoughtful response that we received from so many of you about the previous position papers from the League, comments that led to extensive revisions.  We look forward to learning your thoughts, concerns and suggestions about the classification of neonatal seizures.

Please send your comments to Deb Flower, who will post them to this web page as they become available.

Thank you for your help in this important effort of the ILAE.

Edward Bertram, Secretary General, ILAE

Comments

12 August 2018

I have read the neonatal seizure classification. It is a clear and most welcome addition to the ILAE classifications.

I think it is really helpful to consider and give prominence to a concerning entity that is titled within the paper as 'electrographic only seizure'. 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. This to me implies that either the overarching ILAE definition of seizure needs to be updated to allow for epileptic events without clinical manifestation or the concerning electrographic only entity in neonates should be called something else.

Otherwise why shouldn't we refer to epileptiform changes without clinical correlate in the older child as electrographic only seizures.

I think figure 1 is a bit confusing particularly when trying to correlate with figure 3. I think it would be useful to have 'unknown' and 'structural' also shown in figure 1. In figure 3 structural seems to be defined as encompassing infarction and haemorrhage where in fig 1 structural seems be missing. Fig 1 the size of the ovals seem to be not proportionate to the likelihood. I think this is important as HIE may be in practice to readily considered before other other important causes of neonatal encephalopathy. Also other overlaps can occur other than those shown. I wonder whether figure 1 is best omitted as i cant imagine how it might look to correctly reflect the intention!!?

Colin Dunkley

11 August 2018

The Neonatal Seizure Classification has done an excellent job of conforming (with appropriate variations) with the overall 2017 classification of seizure types by the ILAE. This makes sense, since there was coordination and overlap of both Task Forces. 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. The EEG pattern is important for classification of some non-neonatal seizures (e.g., focal impaired awareness versus absence), but the 2017 seizure classification is mostly based on signs and symptoms.

The motor classifications of neonatal seizures include one novel word, which is “sequential.” This one word opens up the whole slippery question about whether a propagation pattern is one unified seizure or multiple “sequential” seizures. 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.

The 2017 classification classified a seizure on the basis of its first manifestation, even if not the most prominent. Exceptions were impaired awareness at any time during a seizure and the special case (not applying to neonates) of focal to bilateral tonic-clonic seizures. The neonatal classification reverses this approach and classifies by the most prominent feature. All neonatal seizures are admittedly focal, but it seems that which type of focal should be important. I am not a neonatologist, so I cannot speak to whether onset or prominence are more important for localization, etiology, prognosis and treatment. However, in adults onset is most linked to these. If a different system is used for neonatal seizures, at what age are we supposed to switch how we classify propagating seizures?

This classification system should be a major step forward for establishing clarity and consistency of terminology in this area.

Robert S. Fisher, MD, PhD, Stanford

9 August 2018

I have to congratulate all doctors involved in this great effort made in the proposed Classification of Seizures & the Epilepsies in the Neonate, since this subjetc has been forgotten long time ago and now this documente will become a great tool for clinical practice and new researches in this field. 

Sincerely,

N. Barajas, fellow pediatric neurology, UdeA, Colombia