Treatment of Electrographic Seizures versus Clinical Seizures in neonates: A Systematic Review and Meta-Analysis

Electrographic seizures in neonates are commonly associated with poor neurodevelopmental outcomes. However, there is conflict in evidence whether control of electrographic seizures translate into improved neurodevelopmental outcome. We aimed to evaluate whether treating all electrographic seizures compared with treating only clinical seizures leads to a better neurodevelopmental outcome at 18-24 months in neonates. We searched four electronic databases (Medline, Cochrane Library, Embase, and Web of Science) for randomized controlled trials (RCTs) published until October 31, 2022. We included RCTs comparing the treatment of electrographic seizures (± clinical seizures) with clinical seizures in neonates with or at risk of seizures. The Risk of Bias version 2 tool was used to assess the risk of bias. The random-effects meta-analysis was performed using RevMan 5.4 software. Of the 2872 unique records identified by the database search, five trials involving 474 infants were eligible for the review. There was no significant difference in the incidence of neurodevelopmental disability at 18-24 months. Infants in the electrographic seizure group had lower scores in the cognitive domain (2 trials, 186 participants, MD: -5.4; 95% CI:-10.3 to -0.4, I2-0%). There were no significant differences in scores in the motor and language domains, mortality, seizure burden, brain injury scores, antiseizure medication use, and post-neonatal epilepsy. Having limitations of small number of trials and heterogeneity, the systematic review does not identify evidence demonstrating improved neurodevelopmental outcomes or improved survival in neonates treated for electrographic seizures versus only clinical seizures. •Treating all electrographic seizures might not improve survival or neurodevelopmental outcome.•Treatment of EEG seizures compared to clinical seizures might lead to poor cognitive scores.•Treating all electrographic seizures neither reduces seizure burden nor brain injury.•Adequately designed trials using cEEG to measure the actual difference is warranted.