How to read a pediatric EEG

How to Read a Pediatric EEG

John Giang, MD

Why it matters

Having a systematic approach to reading pediatric/neonatal EEGs stops you from anchoring on the first spike and forces the questions that decide the report: is the study adequate, is the background normal for age, and only then, is anything epileptiform. The order is the same from preterm neonate to adolescent; only the age norms change.

Key points

1. Study quality. Confirm age (PMA in neonates), indication, medications and clinical state. Check settings: 30 mm/s, 7 µV/mm, 1–70 Hz; neonates 15 mm/s with reduced montage plus EOG, chin EMG, respiration, ECG. Mark artifacts first: blinks frontal, eye movements phase-reverse at F7/F8, muscle frontotemporal, electrode pop has no field.
2. Background, symmetry, state, reactivity. Describe continuity, PDR and its eye-opening reactivity, AP gradient, symmetry, synchrony and organization. Judge against age appropriate PDR; neonates by IBI limits for PMA, synchrony by 38 wk, reactivity after 30 wk. Name each state captured and confirm its age-appropriate markers (vertex waves, spindles, K-complexes; quiet vs active sleep in neonates).
3. Epileptiform activity and seizures. A true discharge stands out from the background, has a field, and phase-reverses on bipolar montage; confirm end-of-chain (Fp, O) discharges on a referential montage. Localize, note state and frequency, and exclude sharp mimics (vertex waves, hypnagogic hypersynchrony, POSTS, breach, neonatal frontal sharp transients). For seizures: onset, evolution, duration, clinical correlate, burden; in neonates ≥10 s, otherwise a brief rhythmic discharge.
4. Concise impression. Normal or abnormal for age; abnormalities in order of importance (seizures, discharges, background); one line of clinical correlation; states recorded and limitations.