NORMAL NEONATES

Documentation

• Head circumference

• PMA - Post Menstrual Age

• Respiratory status (spontaneous, assisted)

• When baby was last fed

• Body temp

• Temp management protocol

• Sedation/neuroactive meds

• details of questionable events/ spells

Age Terminology: Preterm

up to 37 weeks PMA

Age Terminology: Term

37-44 weeks PMA

Age Terminology: Post Term

44-48 weeks PMA

ACNS neonatal guideline

2 finger width of space between head wrap and scalp

No collodion

Never use needles on neonates except in CVEEG

Electrode Placement guidelines

ACNS states full 10-10 system placement can be used, if not measured use ESTIMATED 10-20

Minimum of 12 channels + 2 polygraphic channels (ex : EKG, EOG, EMG, Respirations)

electrode placement

Cz must be included for positive “rolandic” sharp waves and extremely focal seizures

FZ, CZ, PZ is useful in visualizing rolandic sharp waves

multiple montages can be helpful

extra parameter electrodes

EKG (required by ACNS)

EOG (suggested by ACNS) Eye leads 0.5cm (5mm) below slightly lateral to outer canthus LOC, 0.5cm (5mm) above and slightly lateral to outer canthus ROC

EMG (suggested by ACNS Chin movement 2-3cm apart on chin

Respirations (suggested by ACNS)

We do not expect to see state changes until at least…

32 weeks PMA and clear reactivity closer to full term

State changes in the neonate

ACNS guidelines 16- state changes are present if the clinical condition lasts 1 minute. that is 6 pages of 10 sec of EEG

Neonate state changes identified by:

Wake, Quiet Sleep, Active Sleep, and Indeterminate sleep

Wake and sleep defined by ACNS in neonates

eyes opened for at least 60 seconds. eyes closed for 60 seconds

Active sleep

eyes closed

persistent EMG

movement

(looks like the baby is about to wake up)

• This is a premature version of REM)

Quiet sleep

Eyes closed

Low EMG

Rare movements

• This is a premature version of slow wave sleep

When its possible to define wakefulness

32 weeks PMA, EEG differentiation of wakefulness is appreciated at 41weeks PMA

Wake <32weeks

No wake features on EEG

Wake 32-34 weeks

Wake EEG increasing continuity

Sleep EEG <29 weeks PMA

No differentiation on EEG mainly quiet sleep

Sleep EEG 29-31 weeks PMA

Developing active sleep

Sleep EEG 32-34 weeks PMA

Increasing continuity for active sleep

discontinuity correlates with quiet sleep

Sleep EEG 34-37 weeks PMA

discontinuity in quiet sleep is replaced by trace alternant

Sleep EEG 38-40 weeks PMA

trace alternant gradually becoming slow wave sleep

Sleep EEG 41-44 weeks PMA

Slow wave sleep replaces trace alternant

Active sleep becomes activite moyenne

Trace discontinu

• intermittent, irregular, mixed bursts of theta-delta with sharp & fast activity interrupted by periods of suppression

IBI <30 seconds under 29 weeks

• 0.3-1 hz delta burst, sometimes mixed with theta activity of 4-5hz frequency

Trace alternant

has a shorter IBI and higher voltage

35-37 weeks PMA

22-27 weeks PMA

• Trace discontinu ( IBI usually 30 seconds, Synchronous bursts of delta to beta activity lasting 1 to several seconds)

• Asymmetry between hemispheres

• No wake/Sleep on EEG, No reactivity

27-29 weeks PMA

• Trace discontinu (IBI usually <30 seconds, bursts longer but morphology is similar to 22-27 weeks)

• Asymmetry between hemispheres

• Bursts are often synchronous

• May see Delta Brush activity

• No wake/sleep on EEG

Delta Brush

• spindle like fast activity, brushes, rapid bursts & ripples of prematurity

• High amplitude delta activity with superimposed fast activity

• maximal central, temporal or occipital areas

• Appear 27 weeks PMA, abundant 31-34 weeks PMA, disappear by 44 weeks PMA

29-31 weeks PMA

• Trace discontinu IBI shorter, bursts are longer

• delta brushes more prominent

• discontinuity decreasing overall

• No differentiation between wake/sleep

• New transition develops: Temporal theta bursts/temporal sharp transients. temporal sawtooth waves & Monomorphic occipital delta

Temporal Theta Bursts

• Brief bursts of rhythmic, sharply contoured theta activity

• 4-7hz

• 150-200uV

• 29-32 weeks PMA

• Synonyms: Temporal sharp transients, Temporal sawtooth waves

Monomorphic Occipital Delta

• medium to high amplitude delta activity in the occipital region

• 1-4hz

• 150-200uV

• 29-32 weeks PMA

32-34 weeks PMA

• Differentiation between wake, active & quiet sleep begins

• Delta Brushes more abundant, spindle portion slower & more dominant

• Trace discontinu decreases in discontinuity

• New feature: Multifocal sharp transients ( appear during ALL stages)

32-34 weeks PMA awake-clinically eyes open

• Trace alternant »»» Continuous

• Low amptiude 15-60uV

• Mixed theta-delta activity

• Superimposed low voltage alpha & beta activity

• Multifocal sharps

• Delta brushes seen more with awake

32-34 weeks PMA Active sleep-clinically low EMG, frequent movements

• background activity resembles low voltage, continuous EEG or active sleep

• Delta brushes

• Multifocal sharp transients

• Only distinction between active sleep & wakefulness is eyes open

32-34 weeks PMA Quiet sleep (Non REM)-Clinically, persistent EMG, Low movements

• discontinuity, trace discontinu

• Rare delta brushes

• Fewer multifocal sharp transients

Activite’ Moyenne

• Average amplitude(low to medium voltage)

• Average frequency (delta and theta with superimposed beta) activity with little fluctuating in amplitude

Encoches Frontales

• frontal sharp transients of high amplitude in the neonate

• Occur unilaterally or bilaterally

• Asynchronously

• Transition from active to quiet sleep

• Appear about 35-36 weeks PMA

• Sharper at 36-37 weeks PMA

• Persist until 44 weeks PMA

34-37 weeks PMA

• Quiet sleep - Trace discontinu changed to Trace alternant as infant approaches 37 weeks PMA

• Delta brushes more frequent quiet sleep

• Bursts should be completely synchronous by 37 weeks PMA

• New features: Encoches frontales appear between active and quiet sleep, Activite Moyenne is present during wake and active

Trace alternant

• bursts of theta and delta activity lasting 2-5 seconds, 50-100uV voltage

• IBI of lower amplitude mixed frequency activity in the beta and alpha range lasting a second to 30 seconds depending on age

38-40 weeks PMA (full term)

• Trace alternant and delta brushes decrease in occurrence

• Trace alternant transitions to CSWS

• New features: CSWS

40-44 weeks PMA ( full term)

• increasing continuity

• Increasing activite moyenne

• Delta brush disappears by 44 weeks PMA

• CSWS replaces trace alternant

• New features: Lambda in occipital regions during wake

44-48 weeks PMA (full term)

• CSWS is dominant in quiet sleep

• Delta brushes are gone

• Trace alternant is gone

• Entire EEG is continuous & synchronous

• Activite moyenne present

• New features: PDR starts to develop, V waves develop