Understanding care gaps from restricted video electroencephalography (EEG) availability is critical for improving NICU seizure management, where delays impact neurodevelopment.

By Katrina Thornber


New research suggests electroencephalography (EEG) may be arriving too late for many infants, as a study has found that anti-seizure medicines are often started before electroencephalography confirmation, highlighting both strong clinical judgement and urgent diagnostic gaps, according to data published in JAMA Network Open.

Seizures are among the most common neurological emergencies in infancy, and are frequently difficult to recognise because clinical signs can resemble normal infant movement. Video electroencephalography is the diagnostic reference standard, yet its cost, specialist staffing requirements and limited availability restrict its use in many neonatal and pediatric intensive care units.

Delays in electroencephalography can have serious consequences, as untreated seizures may cause brain injury, while unnecessary exposure to anti-seizure medicines can affect neurodevelopment and increase the risk of drug toxicity. Understanding how often clinicians rely on clinical judgement alone before electroencephalography confirmation is therefore essential for improving safety, resource planning and diagnostic strategy within neonatal and pediatric services. 

Researchers retrospectively reviewed clinical records for 115 infants under one year of age who underwent video electroencephalography between February 2021 and December 2022. The median age was 6 days and 53.9% were female. Of these infants, 46 or 40% received loading doses of at least one anti-seizure medicine. Among them, 27 or 59% were treated before electroencephalography, while 19 or 41% were treated only after monitoring began.

Within the group treated before electroencephalography, 24 or 89% later showed epileptiform activity and 14 or 52% were confirmed to have seizures on monitoring. Thirteen infants or 48% did not demonstrate electrographic seizures, indicating the upper boundary of potential overtreatment.

These findings suggest that bedside clinical assessment has a relatively low false positive rate, particularly in high-risk contexts such as intraventricular hemorrhage and hypoxic ischemic encephalopathy. 

The results reinforce the value of experienced clinical judgement in urgent neonatal care, while also underlining the need to improve access to timely electroencephalography. Scalable solutions such as portable EEG systems, algorithm supported interpretation and computer assisted video analysis could extend diagnostic capacity to units without specialist services. For clinicians, the study supports cautious early treatment when electroencephalography is delayed, and highlights the importance of investment in accessible monitoring tools to refine diagnosis, reduce unnecessary medication exposure and improve long term neurological outcomes. 


Reference 

Beller N et al. Anti-seizure medication use before electroencephalography in infants. JAMA Netw Open. 2025;8(12):e2551124. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2843148

This article was originally published by EMJ and was made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.