The cessation of clinical seizures must be followed by an EEG looking for clinically silent electroencephalographic seizures because clinically silent seizures produce significant oxygenation changes in the brain. If electroencephalographic seizures are present, our current approach is to maintain phenobarbital and phosphenytoin levels in a high therapeutic range and to use lorazepan intermittently to stop the long electroencephalographic seizures. In a published report phenobarbital did not stop seizures in 57% of neonates, phenytoin did not stop seizures in 55% of neonates, and when used simultaneously, they did not stop seizures in 40% of neonates. Eighty percent reduction in seizure frequency was not achieved in about 25% of neonates despite the combination of phenobarbital and phenytoin.
We discontinue antiepileptic drugs in neonates with proven or suspected hypoxic-ischemic encephalopathy, acute cerebrovascular accidents, or correctable metabolic disorders after 48 hours without clinical and electroencephalographic seizures. If more than one antiepileptic drug is being used, the one that was used first is stopped initially. If seizures recur, antiepileptic drugs are restarted and used for at least one month before attemping to stop medication again. All neonates with abnormal brain development and seizures are usually treated for about 1 month.