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Neuroimaging of the preterm infant is a common assessment performed in the NICU. Timely and focused studies can be used for diagnostic, therapeutic, and prognostic information. However, significant variability exists among neonatal units as to which modalities are used and when imaging studies are obtained. Appropriate timing and selection of neuroimaging studies can help identify neonates with brain injury who may require therapeutic intervention or who may be at risk for neurodevelopmental impairment. This clinical report reviews the different modalities of imaging broadly available to the clinician. Evidence-based indications for each modality, optimal timing of examinations, and prognostic value are discussed., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background: Approximately 10% of US newborns require a NICU. We evaluated whether the NICU acoustic environment affects neonatal sleep and whether exposure to the mother's voice can modulate that impact., Methods: In a level IV NICU with single-infant rooms, 47 neonates underwent 12-hour polysomnography. Their mothers were recorded reading children's books. Continuous maternal voice playback was randomized to either the first or second 6 hours of the polysomnogram. Regression models were used to examine sleep-wake stages, entropy, EEG power, and the probability of awakening in response to ambient noise during and without voice playback., Results: After epochs with elevated noise, the probability was higher with (versus without) maternal voice exposure of neonates staying asleep ( P = .009). However, the 20 neonates born at ≥35 weeks' gestation, in contrast to those born at 33 to 34 weeks, showed an age-related increase in percent time awake ( R 2 = 0.52; P < .001), a decrease in overall sleep ( R 2 = 0.52; P < .001), a reduction in rapid eye movement sleep bouts per hour ( R 2 = 0.35; P = .003), and an increase in sleep-wake entropy ( R 2 = 0.52; P < .001) all confined solely to the 6 hours of maternal voice exposure. These associations remained significant ( P = .02 to P < .001) after adjustment for neurologic examination scores and ambient noise., Conclusions: Hospitalized newborns born at ≥35 weeks' gestation but not at 33 to 34 weeks' gestation show increasing wakefulness in response to their mother's voice. However, exposure to the mother's voice during sleep may also help protect newborns from awakening after bursts of loud hospital noise., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objectives: We assessed the adherence to neuroimaging guidelines and the diagnostically relevant yield of neuroimaging in newly presenting early life epilepsy (ELE)., Methods: There were 775 children with a new diagnosis of epilepsy (<3 years old at onset) who were recruited through the ELE study at 17 US pediatric epilepsy centers (2012-2015) and managed prospectively for 1 year. The data were analyzed to assess the proportion of children who underwent neuroimaging, the type of neuroimaging, and abnormalities., Results: Of 725 children (93.5%) with neuroimaging, 714 had an MRI (87% with seizure protocols) and 11 had computed tomography or ultrasound only. Etiologically relevant abnormalities were present in 290 individuals (40%) and included: an acquired injury in 97 (13.4%), malformations of cortical development in 56 (7.7%), and other diffuse disorders of brain development in 51 (7.0%). Neuroimaging was abnormal in 160 of 262 (61%) children with abnormal development at diagnosis versus 113 of 463 (24%) children with typical development. Neuroimaging abnormalities were most common in association with focal seizure semiology (40%), spasms (47%), or unclear semiology (42%). In children without spasms or focal semiology with typical development, 29 of 185 (16%) had imaging abnormalities. Pathogenic genetic variants were identified in 53 of 121 (44%) children with abnormal neuroimaging in whom genetic testing was performed., Conclusions: Structural abnormalities occur commonly in ELE, and adherence to neuroimaging guidelines is high at US pediatric epilepsy centers. These data support the universal adoption of imaging guidelines because the yield is substantially high, even in the lowest risk group., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Wirrell has received a consulting fee from Biomarin; Dr Knupp has served as a consultant for Zogenix and has an additional grant funded by the Pediatric Epilepsy Research Foundation; Dr Sullivan has served as an expert witness in various cases that involve seizures in children in which he was not subpoenaed. Subjects who were enrolled in this study by Dr Sullivan were seen as part of routine clinical care; Dr Patel discloses consulting with Greenwich Biosciences, UCB Pharma, Supernus, and LivaNova. He has pending or active grants with the Pediatric Epilepsy Research Foundation, Upsher-Smith, Greenwich Biosciences, and LivaNova; Dr Loddenkemper discloses board membership service on the council (and as president) of the American Clinical Neurophysiology Society and the American Board of Clinical Neurophysiology. He serves as committee chair at the American Epilepsy Society (Special Interest Group and Investigator Workshop committees) and as founder and consortium principal investigator of the pediatric Status Epilepticus Research Group. He received grant support from federal epilepsy-related groups as well as from pharmaceutical companies, including research support from the National Institutes of Health, the Patient-Centered Outcomes Research Institute, the Epilepsy Research Fund, the American Epilepsy Society, the Epilepsy Foundation of America, the Epilepsy Therapy Project, the Pediatric Epilepsy Research Foundation, and Citizens United for Research in Epilepsy, and he received research grants from Lundbeck, Eisai, Upsher-Smith, Mallinckrodt, Sage, and Pfizer. Dr Loddenkemper is part of pending patent applications to detect and predict seizures and to diagnose epilepsy; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Febrile infection-related epilepsy syndrome (FIRES) is a newly recognized epileptic encephalopathy in which previously healthy school-aged children present with prolonged treatment-resistant status epilepticus (SE). Survivors are typically left with pharmacoresistant epilepsy and severe cognitive impairment. Various treatment regimens have been reported, all with limited success. The ketogenic diet (KD) is an alternative treatment of epilepsy and may be an appropriate choice for children with refractory SE. We report 2 previously healthy children who presented with FIRES and were placed on the KD during the acute phase of their illness. Both children experienced resolution of SE and were maintained on the KD, along with other anticonvulsant medications, for several months. Both were able to return to school, with some academic accommodations. These cases highlight the potential value of the KD as a preferred treatment in FIRES, not only in the acute setting but also for long-term management. Early KD treatment might optimize both seizure control and cognitive outcome after FIRES., (Copyright © 2014 by the American Academy of Pediatrics.)

Low-molecular-weight heparins, such as enoxaparin, are often used to treat thrombosis in infants. We present 4 infants with diffuse brain injury who developed cerebral venous sinus thrombosis or deep vein thrombosis and were treated with enoxaparin. These infants subsequently developed subdural hemorrhages, and enoxaparin was stopped. In 3 cases, the subdural hemorrhages were found on routine surveillance brain MRI, and in 1 case imaging was urgently obtained because of focal seizures. Two patients needed urgent neurosurgical intervention, and all subdural hemorrhages improved or resolved on follow-up imaging. Each infant developed severe neurologic deficits, probably from the coexisting diffuse brain injury rather than from the subdural hemorrhages themselves. The risk of intracranial hemorrhage from enoxaparin may be accentuated in patients with diffuse brain injury, and careful consideration should be given before treatment in this population., (Copyright © 2014 by the American Academy of Pediatrics.)

Background: Conventional electroencephalography remains the gold standard for the diagnosis and quantification of neonatal seizures. However, amplitude-integrated electroencephalography (aEEG) is being introduced to neonatal intensive care as an adjunct for neonatal seizure detection., Objectives: This study's purpose was to determine the sensitivity of neonatal seizure detection in a single electroencephalogram channel (C3-->C4), used to simulate the raw signal from which aEEG is derived. We also aimed to determine the sensitivity of seizure detection by neonatologists by using aEEG and to establish those neonatal seizure characteristics that are associated with their correct detection by aEEG., Methods: Conventional electroencephalograms with neonatal seizures were reviewed for electroencephalogram background and neonatal seizure characteristics (site of onset, duration, and peak-to-peak amplitude). The presence, duration, and peak-to-peak amplitude of each seizure were simultaneously noted in a single electroencephalogram channel (C3-->C4). aEEGs generated from this channel were reviewed for background and seizures by 6 neonatologists with varying aEEG interpretation expertise., Results: A total of 851 neonatal seizures from 125 conventional electroencephalograms were analyzed. The patients' conceptional ages were 34 to 50 weeks. Because 94% of the conventional electroencephalograms had > or = 1 neonatal seizure visible in C3-->C4, and 78% of all neonatal seizures appeared in the C3-->C4 channel, the theoretical sensitivity of seizure detection in a single electroencephalogram channel was high. However, seizures were briefer and lower in amplitude in C3-->C4 compared with conventional electroencephalography. Neonatologists identified seizures in 22% to 57% of the 125 records of neonatal seizure. They detected 12% to 38% of the 851 individual seizures. Multivariate analysis revealed that the appearance of seizures in C3-->C4, neonatal seizure duration, seizure amplitude, seizure count per hour, and neonatologists' experience with aEEG interpretation all correlated with neonatal seizure detection., Conclusions: Even among physicians who have extensive experience, many neonatal seizures are difficult to detect on an aEEG, especially when they are infrequent, brief, or of low amplitude.

Background: Little is known about the clinical features and spectrum of diagnoses in children with "stroke mimics," those with acute neurologic deficits but without cerebrovascular diseases., Objectives: Our goal was to describe patients with stroke mimics and to determine if clinical features predict benign diagnoses., Methods: Our stroke consult team registered a prospective consecutive cohort of 143 patients with acute presentations suspicious for cerebrovascular disease from November 2003 to November 2004. Cases in which stroke was ruled out (stroke mimics) were reviewed for clinical features and diagnostic test results and were classified "benign" if there was no structural brain lesion and there was an expectation of complete recovery., Results: Of the 143 cases evaluated for suspected stroke, 30 (21%) had stroke mimics. Presenting signs included seizure (n = 11), headache (n = 9), mental status change (n = 6), focal weakness (n = 14), and focal sensory change (n = 7). Eleven patients had "benign" diagnoses (3 migraine, 3 psychogenic diagnoses, 3 musculoskeletal abnormalities, 1 delirium, and 1 episodic vital sign changes). Nineteen patients had "not-benign" diagnoses (3 reversible posterior leukoencephalopathy syndrome, 3 neonatal seizures, 2 vascular anomalies, 2 inflammatory disease, 2 intracranial infection, 2 epilepsy, 2 metabolic stroke, 1 tumor, 1 drug toxicity, and 1 idiopathic intracranial hypertension). Except for the presence of seizures, there were no significant differences in presentation or risk factors between benign and not-benign cases., Conclusions: Many disorders mimic childhood stroke. History and clinical presentation often do not distinguish the one third of patients with benign disorders from the two thirds with more serious problems, necessitating timely comprehensive investigations, especially brain MRI.