Developing clinical trials for the diagnosis and treatment of neonatal seizures

Seizures, a common clinical manifestation of neurological dysfunction in the neonate, occur in 1-4 per 1000 live births and are associated with very poor outcomes. However, the role of seizures as merely associative or contributory to poor outcomes remains unclear. Clinical and laboratory studies have demonstrated a deleterious effect of seizures on the developing brain. There is a lack of consensus among the neonatal and neurologic community about how to monitor and treat patients at risk for seizures. Currently used antiepileptic drugs lack efficacy and may potentially cause apoptosis in the developing brain. Continuous conventional electroencephalography with video is the gold standard for detection and monitoring of electrographic seizures but may not be practical in a study design or 24 h widespread clinical use. New drugs such as bumetanide, levetiracetam, and topiramate hold promise as new therapies, but safety, pharmacokinetic, and efficacy data remain limited. In this article, current challenges in designing seizure trials are discussed including potential options to accurately assess the seizure burden, possible antiepileptic drug choices, and potential outcome measures. Ongoing trials in the field of neonatal seizures are also discussed including two separate drug trials and a multicenter trial evaluating the impact of subclinical seizure treatment using limited channel amplitude-integrated electroencephalography.