Implementing a Digital Neurocritical Care Unit for Neonates in Brazil: A 4-Year Experience

Abstract

Objective

This study aimed to describe neuromonitoring findings and short-term outcomes after the implementation of a digital health strategy comprising continuous, real-time, tele-based video-aEEG/EEG monitoring in a publicly funded NICU in Brazil.

Study Design

Prospective, observational cohort study conducted between July 2017 and June 2021, analyzing neuromonitoring data of high-risk newborns and correlating it with clinical and imaging outcomes.

Results

A total of 116 newborns, with a median gestational age of 37 weeks (interquartile range [IQR]: 32^2/7–39^2/7) and a median birth weight of 2,800 g (IQR: 1,472–3,305), were enrolled with more than 8,000 hours of monitoring. The main indication was suspected seizure (n = 49, 42.2%). A total of 43 (37.1%) neonates presented pathological background activity, and sleep–wake cycle (SWC) was absent in 68 (58.6%). Seizures were identified in 36 (31.0%) neonates, predominantly within the first 12 hours of life (n = 14, 38.9%), electrographic-only (n = 29, 80.6%), and repetitive (n = 24, 66.7%). A total of 47 (40.5%) neonates received antiseizure medications, with phenobarbital being the most frequently used (46; 97.9%). Only one patient (2.1%) was discharged receiving antiseizure medication. Cranial ultrasound (cUS) was performed in 94 (81.0%) infants, with abnormal findings in 34 (36.2%) infants. Pathological background activity, absence of SWC, and seizures were significantly associated with severe abnormalities on cUS, and increased risk of death before discharge.

Conclusion

The implementation of a digital health strategy incorporating real-time and continuous video-aEEG/EEG monitoring demonstrated potential to improve diagnostic accuracy for electrographic seizures, optimize antiseizure medication stewardship, and inform early neuroprotective interventions.

Key Points

• Brain monitoring improves seizure diagnosis.

• aEEG/EEG supported antiseizure medication discontinuation.

• Abnormal aEEG/EEG findings are associated with poor outcomes.

• Remote aEEG/EEG monitoring is feasible in LMIC.

Keywords

neonatal intensive care units - electroencephalography - telehealth

Contributors' Statement

S.S.A., D.M.K.L., T.S.S., P.G.R., J.Q.T., T.M.L.d.O.U.B., C.G.M., A.C.P.B.F., F.B.P.S., M.M., G.F.T.V., and M.J.M.: concept and design; S.S.A., D.M.K.L., P.G.R., J.Q.T., T.M.L.d.O.U.B., C.G.M., A.C.P.B.F., and F.B.P.S.: data collection and analysis; G.F.T.V., and M.J.M.: study supervision. All the authors drafted and revised the manuscript.

Publication History

Received: 20 August 2025

Accepted: 23 November 2025

Article published online:
04 December 2025

• References

• 1 Tamir TT. Neonatal mortality rate and determinants among births of mothers at extreme ages of reproductive life in low and middle income countries. Sci Rep 2024; 14 (01) 12596
• 2 Molloy EJ, El-Dib M, Juul SE. et al; Newborn Brain Society Guidelines and Publications Committee. Neuroprotective therapies in the NICU in term infants: present and future. Pediatr Res 2023; 93 (07) 1819-1827
• 3 Yawno T, Hunt R. Recent Developments in Neonatal Seizure Interventions. In: Current Treatments for Epilepsy [Working Title]. IntechOpen; 2025.
• 4 Ramantani G, Schmitt B, Plecko B. et al. Neonatal seizures—are we there yet?. Neuropediatrics 2019; 50 (05) 280-293
• 5 Kim EH, Shin J, Lee BK. Neonatal seizures: diagnostic updates based on new definition and classification. Clin Exp Pediatr 2022; 65 (08) 387-397
• 6 Kim SY, Kang HM, Im SA, Youn YA. The impact of clinical seizures and adverse brain MRI patterns in neonates with hypoxic-ischemic encephalopathy and abnormal neurodevelopment. Clinics (Sao Paulo) 2025; 80: 100533
• 7 Murray DM, Boylan GB, Ali I, Ryan CA, Murphy BP, Connolly S. Defining the gap between electrographic seizure burden, clinical expression and staff recognition of neonatal seizures. Arch Dis Child Fetal Neonatal Ed 2008; 93 (03) F187-F191
• 8 Pressler RM, Abend NS, Auvin S. et al. Treatment of seizures in the neonate: guidelines and consensus-based recommendations—special report from the ILAE Task Force on Neonatal Seizures. Epilepsia 2023; 64 (10) 2550-2570
• 9 Cabral IE, Moraes JRMMD. Family caregivers articulating the social network of a child with special health care needs [in Portuguese]. Rev Bras Enferm 2015; 68 (06) 1078-1085
• 10 Ministério do Desenvolvimento Social e Combate à Fome, Secretaria Nacional da Assistência social. Boletim BPC – Benefício Da Prestação Continuada. 2015 . Available at: https://www.mds.gov.br/webarquivos/arquivo/assistencia_social/boletim_BPC_2015.pdf
• 11 Prust ML, Mbonde A, Rubinos C. et al. Providing neurocritical care in resource-limited settings: challenges and opportunities. Neurocrit Care 2022; 37 (02) 583-592
• 12 Variane GFT, Camargo JPV, Rodrigues DP, Magalhães M, Mimica MJ. Current status and future directions of neuromonitoring with emerging technologies in neonatal care. Front Pediatr 2022; 9: 755144
• 13 Ryan MAJ, Malhotra A. Electrographic monitoring for seizure detection in the neonatal unit: current status and future direction. Pediatr Res 2024; 96 (04) 896-904
• 14 De Vries LS, Hellström-Westas L, Vanhatalo S. An Atlas of Amplitude-integrated EEGs in the Newborn. 3rd ed.. CRC Press; 2025
• 15 Leandro DMK, Variane GFT, Dahlen A. et al. Therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy: reducing variability in practice through a collaborative telemedicine initiative. Am J Perinatol 2024; 41 (16) 2263-2270
• 16 Variane GFT, Leandro DMK, de Azevedo SS, Teixeira JQ, Mimica MJ. Remote neonatal neurocritical care: from the bedside to the cloud. Semin Perinatol 2025; 152124
• 17 Kohli-Lynch M, Tann CJ, Ellis ME. Early intervention for children at high risk of developmental disability in low- and middle-income countries: a narrative review. Int J Environ Res Public Health 2019; 16 (22) 4449
• 18 Hellström-Westas L, Rosén I, De Vries LS, Greisen G. Amplitude-integrated EEG classification and interpretation in preterm and term infants. Neoreviews 2006; 7 (02) e76-e87
• 19 Mastrangelo M, Fiocchi I, Fontana P, Gorgone G, Lista G, Belcastro V. Acute neonatal encephalopathy and seizures recurrence: a combined aEEG/EEG study. Seizure 2013; 22 (09) 703-707
• 20 Clancy RR, Legido A, Lewis D. Occult neonatal seizures. Epilepsia 1988; 29 (03) 256-261
• 21 Pressler RM, Cilio MR, Mizrahi EM. et al. The ILAE classification of seizures and the epilepsies: modification for seizures in the neonate. Position paper by the ILAE Task Force on Neonatal Seizures. Epilepsia 2021; 62 (03) 615-628
• 22 Trinka E, Cock H, Hesdorffer D. et al. A definition and classification of status epilepticus—report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia 2015; 56 (10) 1515-1523
• 23 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
• 24 Kage A, Santana YC, Malcolm IL. et al. Continuous video recording with simultaneous amplitude-integrated EEG monitoring to improve seizure recognition in newborns. Front Pediatr 2025; 13: 1585606
• 25 Abend NS, Wusthoff CJ, Goldberg EM, Dlugos DJ. Electrographic seizures and status epilepticus in critically ill children and neonates with encephalopathy. Lancet Neurol 2013; 12 (12) 1170-1179
• 26 Glass HC, Numis AL, Comstock BA. et al. Association of EEG background and neurodevelopmental outcome in neonates with hypoxic-ischemic encephalopathy receiving hypothermia. Neurology 2023; 101 (22) e2223-e2233
• 27 Kumar Krishnegowda V, Bandiya P, Bandyopadhyay T, Balasubramanian H, Trevisanuto D, Ramaswamy VV. Electroencephalography in preterm infants for predicting neurodevelopmental outcomes: a systematic review and diagnostic test accuracy meta-analysis. Pediatr Neurol 2025; 166: 65-80
• 28 Variane GFT, Magalhães M, Gasperine R. et al. Early amplitude-integrated electroencephalography for monitoring neonates at high risk for brain injury. J Pediatr (Rio J) 2017; 93 (05) 460-466
• 29 Yuan X, Kang W, Song J. et al. Prognostic value of amplitude-integrated EEG in neonates with high risk of neurological sequelae. Ann Clin Transl Neurol 2020; 7 (02) 210-218
• 30 Glass HC, Soul JS, Chang T. et al. Safety of early discontinuation of antiseizure medication after acute symptomatic neonatal seizures. JAMA Neurol 2021; 78 (07) 817-825
• 31 Guillet R, Kwon JM. Prophylactic phenobarbital administration after resolution of neonatal seizures: survey of current practice. Pediatrics 2008; 122 (04) 731-735
• 32 Falsaperla R, Saporito MAN, Scalia B. Treatment of neonatal seizures: from guidelines to precision therapy. Mol Cell Pediatr 2025; 12 (01) 8
• 33 Spenard S, Ivan Salazar Cerda C, Çizmeci MN. Neonatal seizures in low- and middle-income countries: a review of the literature and recommendations for the management. Turk Arch Pediatr 2024; 59 (01) 13-22
• 34 Sandoval Karamian AG, Wusthoff CJ. Current and future uses of continuous EEG in the NICU. Front Pediatr 2021; 9: 768670
• 35 van Wezel-Meijler G, Steggerda SJ, Leijser LM. Cranial ultrasonography in neonates: role and limitations. Semin Perinatol 2010; 34 (01) 28-38