Neonatal seizures are challenging to diagnose due to subtle clinical presentations and require video-EEG for confirmatory diagnosis. However, video-EEG is not always available, so clinicians must sometimes decide to treat neonatal seizures prior to diagnostic confirmation. The extent of this gap in clinical care is not previously described. This retrospective study examined anti-seizure medication (ASM) use in 115 infants who underwent video-EEG at Mount Sinai. Of 46 infants treated with ASMs, 59% received loading doses before EEG. Among these, 89% showed epileptiform activity and 52% (14/27) had seizures on EEG. Mortality among treated infants was high (30%). These findings highlight the significant reliance on clinical judgment without EEG when treating neonatal seizures. Our data support future work to develop scalable, accessible tools to improve timely and accurate treatment of neonatal seizures.

The authors have declared no competing interest.

Friedman Brain Institute Fascitelli Scholar Junior Faculty Grant to Felix Richter. Thrasher Research Fund Early Career Award to Felix Richter.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The institutional review board at the Icahn School of Medicine at Mount Sinai (IORG0000124). Ethical approval was given. Our retrospective data collection approach was approved by the institutional review board at the Icahn School of Medicine at Mount Sinai and informed consent was obtained in accordance with our protocol.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All data produced in the present study are available upon reasonable request to the authors.