Conditions: Neonatal Seizures
Keywords: Seizures Neonates Anticonvulsants Treatment Levetiracetam Phenobarbital
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 280
Healthy volunteers: no

Brief summary:
A new anticonvulsant, levetiracetam will be studied to treat seizures in newborn infants. Current treatments for the brain damaging complication of neonatal seizures are unsatisfactory.

Monitoring for seizure detection will be tested at five (5) US sites and one (1) international site using the internet.

Detailed description:
This project aims to improve the treatment of neonatal seizures. Current treatments are poorly effective and have significant side effects.

Levetiracetam (LEV) has great potential as a treatment for neonatal seizures but is not approved for use in children less than 2 years of age.

This study aims to obtain essential data regarding the efficacy and safety of LEV in this vulnerable and under researched population and simultaneously to develop EEG monitoring systems that facilitate seizure detection and research.

Specific aims are:

1. To determine the efficacy of intravenous LEV in terminating neonatal seizures when given as first line therapy.
2. To obtain dose escalation data by studying the additional efficacy of a further dose in non responders.
3. To obtain additional pharmacokinetic data to confirm findings from our previous pharmacokinetic study.
4. To obtain further safety data of LEV in neonates.
5. To prove the feasibility of centralized remote monitoring of continuous EEG monitoring in the Neonatal Intensive Care Unit (NICU) via the internet and test a promising automated neonatal seizure detection algorithm.

The study design is a phase 2b randomized blinded controlled study.

Arms:
arm 1: Intravenous levetiracetam 40 to 60 mg/kg loading dose. 10 mg/kg 8 hourly maintenance arm 2: Intravenous phenobarbital 20 to 40 mg/kg load. 1.5 mg/kg 8 hourly maintenance

Interventions: intervention 1: Intravenous levetiracetam intervention 2: Intravenous phenobarbital
Intervention descriptions: intervention 1: Intravenous load of levetiracetam (40 to 60 mg/kg) following identification of EEG confirmed neonatal seizure. intervention 2: Intravenous load of phenobarbital (20 to 40 mg/kg) following EEG confirmation of seizure activity load.

Protocol document:
Prot_001.pdf: 
 
 
Version: 13April2018 
 
University of California, San Diego (UCSD) and Children’s Hospital and Health Center (CHHC) 
IRB Protocol Application 
RESEARCH PLAN  
 
General Instructions: Enter a response in for all topic headings.  The form will expand as you type. 
Enter “Not Applicable” rather than leaving sections blank if the section does not apply to this project. 
Please refer to the research plan instructions located at http://irb.ucsd.edu   
Version date: 4/04 
1. PROJECT TITLE: 
Efficacy of Intravenous Levetiracetam in the Treatment of Neonatal Seizures: 
A Phase 2 Study of Levetiracetam in the Treatment of Neonatal Seizures 
 2. PRINCIPAL INVESTIGATOR:  
Richard Haas, M.D. 
 3.  FACILITIES: 
 
UCSD Medical Center Neonatal Intensive Care Unit 
Rady Children’s Hospital San Diego Neonatal Intensive Care Unit 
Sharp Mary Birch Hospital San Diego Neonatal Intensive Care Unit 
Auckland Hospital, Auckland, New Zealand Neonatal Intensive Care Unit 
Children's Hospital and Research Center Oakland Neonatal Intensive Care Unit 
 4. ESTIMATED DURATION OF THE STUDY: 
Estimated total duration of the study will be 4 years. At all sites 50 total subjects will be recruited each year 
of which 25 are estimated to qualify for treatment. The total number of treated subjects at all 5 sites will be 
100 over 4 years. Each subject will be treated with the study drug for a total of 5 days. 
 5. SPECIFIC AIMS: 
 
Specific aim 1: 
To study the preliminary efficacy of intravenous LEV as first line treatment for neonatal seizures. The primary 
endpoint will be the percentage of neonates whose seizures are terminated with LEV for 48 hours, and do not 
go on to require a second anticonvulsant agent. A secondary endpoint will be seizure cessation for 1 hour 
after treatment with LEV. 
Hypothesis: LEV has efficacy for the treatment of neonatal seizures.  
 
Specific aim 2:  
Dose escalation: To determine whether there is additional efficacy at higher doses of LEV than 40mg/kg.  
The percentage of neonates whose seizures stop following 60mg/kg LEV, having not responded to 40mg/kg 
LEV, will be calculated. 
 
Specific aim 3:  
To study the pharmacokinetics of intravenous LEV at high dosage. The hypothesis is that the 
pharmacokinetics of high dose intravenous LEV will follow predictions based upon previous lower dosage PK 
studies.  
 
Specific aim 4:  
To obtain further safety data regarding the use of high dose Levetiracetam in this population. 
 
Specific aim 5:  
5 A: To prove the feasibility of centralized remote monitoring of continuous EEG monitoring in the NICU via 
the internet, thereby developing infrastructure vital to further neonatal seizure research. 


 
 
Version: 13April2018 
Hypothesis: Remote video continuous EEG monitoring is feasible, cost effective, and will allow rapid 
treatment decisions necessary for future trials of anticonvulsant efficacy in neonates. 
 
5 B: To test the sensitivity and specificity of a promising neonatal seizure detection algorithm in comparison 
with readings of each record by 2 encephalographers skilled in neonatal EEG analysis.  
Hypothesis: A novel seizure detection algorithm will have a high sensitivity and low false positive detection 
rate, which will allow use in future clinical trials of neonatal seizure management. 
 
 
 6. BACKGROUND AND SIGNIFICANCE: 
 
There are no FDA approved treatments for neonatal seizures (seizures occurring in the first 28 days of life). 
More effective and less toxic treatments are urgently required. While appropriately holding orphan drug status, 
neonatal seizures are a common problem within the field of child neurology and cause significant morbidity. 
Current standard of care treatments Phenobarbital and phenytoin are unsatisfactory1, each agent is effective 
in less than 50% of subjects, and both have significant acute and chronic side effects. In animal studies these 
agents cause accelerated neuronal apoptosis in the neonatal brain. Better treatments could limit brain damage 
and improve neurodevelopmental outcomes in this high risk population. Levetiracetam (LEV) has great 
potential as a treatment for neonatal seizures, but is not approved for use in children less than 2 years of age. 
Given the orphan nature of neonatal seizures and the fact that LEV is out of patent, the pharmaceutical 
company that manufactures LEV will not seek market approval in this unprofitable age group. LEV has 
established efficacy and an excellent safety profile in older patients. In animal models this agent does not 
cause neuronal apoptosis and is neuroprotective. However, the efficacy of LEV has not been systematically 
studied in neonates and cannot be assumed.  Drugs that are effective in terminating seizures in adults may 
be less effective and have more toxicity in neonates. This study aims to obtain essential data regarding the 
efficacy and safety of LEV in this vulnerable and under researched population.  
 
Efforts to develop better treatments for neonatal seizures are confounded by the need in any drug trial for 
systematic continuous EEG monitoring, something that is not yet standard of care because of resource 
constraints. The proposed project would add to knowledge regarding the efficacy of LEV in neonates, while 
simultaneously addressing the need to find feasible solutions to the difficulties of providing continuous EEG 
monitoring through new technology.  
 
Should LEV prove an effective medication in this age group, clinical practice would be dramatically improved. 
We would have a safe, non-toxic treatment option for neonatal seizures with proven efficacy. 
Developing better systems for neonatal seizure detection will facilitate earlier treatment of neonatal seizures 
and enable further clinical research in this condition. 
 
Prevalence of Neonatal Seizures: 
 Measures of the incidence of neonatal seizures vary from 1/1000 live births to 3.5/1000 live births. The most 
recent US study, in Harris County Texas from 1992 to1994 concluded that the incidence was 1.8/1000 live 
births 2.The National Center for Health Statistics reported in 2009 that there were 4.3 million live births in 2007 
3. Using the survey data from Harris County, this translates to an incidence of 7740 babies in the US. 
Estimating the prevalence assuming an average 3-day duration of seizures, 63 neonates experience clinical 
seizures on any particular day in the US. The true incidence and prevalence figures are in fact likely double 
these numbers as a number of studies have noted that electrographic seizures without clinical manifestations 
account for 50% or more of neonatal seizure activity 4, 5, raising the prevalence of neonatal seizures of all 
types to 126/ day in the US.  
 
Neonatal Seizures cause Brain Injury: 
The outcome of neonatal seizures is poor which differs markedly from seizures occurring in older age groups. 
20-30% of infants with neonatal seizures die, 20-30% develop epilepsy outside the neonatal period, and 20-


 
 
Version: 13April2018 
40% develop cerebral palsy and/or mental retardation6.The most recent prospective long term follow-up of 
clinical neonatal seizures in the province of Newfoundland reported on all live newborns born between 1990 
and 1995. Data was available on 82 of 90 children. In 28 term babies only 45% were normal, 16% died, and 
32% were impaired 6. Whilst much of the mortality and morbidity in neonates with seizures can be attributed 
to the underlying condition, there is mounting evidence that seizures themselves are harmful, especially in the 
asphyxiated neonatal brain. Studies in rats show that seizures can damage the developing brain7, 8. McBride 
et al have demonstrated a strong correlation between the amount of electrographic seizure activity and 
subsequent morbidity and mortality9. Preliminary data also demonstrates an improved outcome with prompt 
and complete cessation of seizures4 and in a recent European controlled trial, treatment of subclinical seizures 
showed a trend for reduction in seizure duration which was associated with less brain injury on MRI 10. Brain 
MR spectroscopy in neonates suffering seizures secondary to perinatal asphyxia shows brain injury as a 
consequence of the seizures11.Recent evidence suggests that neonatal seizures independently contribute to 
poor outcome at 4 years of age in neonatal hypoxic-ischemic injury12. 
 
Current AEDs for Neonatal Seizures: 
 Current treatment relies on medications in use since 1914 (Phenobarbital) and 1938 (phenytoin). These 
agents are neither effective nor safe. Treatment with Phenobarbital or phenytoin produces cessation of 
neonatal seizures in less than 50% of infants treated1. Acute side effects of phenobarbital and phenytoin  
include hypotension, suppression of respiratory drive, cardiac arrhythmia and sedation. Chronic exposure to 
phenobarbital may be associated with decreased cognitive ability 13-15. 
 
Neonatal response to AEDs is different to that of adults: 
The neonatal response to AEDs is fundamentally different to that of the adult brain5, 16, 17. Neonatal seizures 
form a unique subset of pediatric seizures for a number of reasons: 
a) 
The developing neonatal brain is different to that of older children and adults. These seizures are 
occurring at a unique period of vulnerability to the developing brain. GABA is the main inhibitory 
neurotransmitter in the brain, in the developing brain however, activation of chloride-permeable GABAA-R 
receptors excite neurons instead of inhibiting them as occurs later in life. This occurs because of high 
intracellular chloride levels caused by the NKCC1 transporter 16. Drugs that act via the GABA receptor are 
therefore rendered less effective in neonates. 
In addition, there are differences in cortical versus subcortical GABAergic signalling leading to the 
phenomenon of uncoupling of clinical and electrographic seizure activity induced by Phenobarbital treatment 
which is unique to this age group 5, 17. Phenobarbital, when administered, will act at subcortical sites to 
eliminate all convulsive movements that give clinical indication of seizure activity, however electrographic 
monitoring, (if available) demonstrates ongoing cortical seizure activity. 
b) 
There is significant concern that traditional anticonvulsants may be damaging to the neonatal brain. 
Anticonvulsants can cause ‘interference with cell proliferation and migration, axonal arborization, 
synaptogenesis, synaptic plasticity, and physiological apoptotic cell death’18.In neonatal rat models traditional 
anticonvulsants- including phenobarbital and phenytoin and most of the newer agents- trigger apoptotic 
neuronal cell loss 19. Levetiracetam does not cause this effect 20. 
c) 
Drug handling in neonates is very different to older populations because of liver and renal immaturity21.  
d) 
Neonatal seizures have a different set of etiologies when compared to seizures occurring in older 
children. Fifty percent follow hypoxic ischemic injury in the perinatal period and worsen the prognosis. Other 
causes include neonatal stroke, brain developmental malformations, perinatal infections (often unique to the 
newborn), hypoglycemia, hypocalcemia, hypomagnesemia and rare inborn errors of metabolism presenting in 
the newborn period22. These etiologies predispose the neonate to severe seizures; frequently status 
epilepticus 23, and at the same time an increased susceptibility to brain injury secondary to seizure activity. 
 
 
Barriers to Detection of Neonatal Seizures: 
Because neonatal seizures are very frequently entirely subclinical it is accepted that continuous EEG 
monitoring is the only way to adequately detect neonatal seizures and the only objective means to judge the 


 
 
Version: 13April2018 
response to AED treatment 5, 24, 25Murray et al. reported in a video EEG study that only 34% of electrographic 
seizure events in encephalopathic newborns are clinically identified and only 9% were recognized by nurses 
at the bedside 26. Lawrence et al. noted that more than 90% of EEG seizures had no clinical correlate 
27.Despite this, continuous EEG monitoring is not standard of care for neonates at risk of seizures in the 
majority of NICUs in the United States and  internationally. This is due largely to the lack of available resources 
to conduct and review continuous EEG monitoring. Conventional full neonatal montage EEG requires 
specialist review.  In each hospital center there are insufficient neurologists to provide a service of real time 
review of the data 24 hours a day.  
Recent EEG data software developments now allow for remote review of full montage continuous EEG data 
securely via the internet. This opens the door to the development of a centralized system for review of continuous 
neonatal EEG data by neurologists.  
There would be great value in a reliable automated seizure detection method but such algorithms are not in 
widespread use for real time neonatal seizure detection. Automated detection of electrographic seizures in the 
newborn requires different techniques from those employed in adults and must be developed and tested 
specifically in neonates. Existing algorithms have been shown to have sensitivities of between 43 % to 63% 
and specificities between 56% to 90%, not high enough for use in a clinical environment 27, 28.  
 
 7. PROGRESS REPORT/PRELIMINARY STUDIES: 
Preliminary Validation data for Automated seizure detection algorithm 
In testing against a large dataset of 114 hours of EEG from 87 neonates, including 389 seizures from 55 
seizure-affected neonates, the August 2010 alpha version of Persyst’s neonatal seizure detector 
demonstrated an overall seizure detection sensitivity of 79%, a seizure-affected patient detection rate of 98% 
(i.e., at least one seizure correctly detected in an infant who is experiencing seizures), and a false positive rate 
of approximately 1 detection per 11 hours monitoring.  
 
Neonatal Pharmacokinetic Study: A pilot PK, safety and efficacy study of the use of LEV has recently been 
completed by Dr. Haas’ group, funded  by the Thrasher foundation. 
Study design: The trial was an add-on, open label pharmacokinetic and preliminary safety study. Between 
August 2007 and February 2009, eligible neonates admitted in 3 participating neonatal intensive care units 
were recruited to this study. The sites were the University of California San Diego Medical Center, Sharp Mary 
Birch Hospital San Diego, and Auckland City Hospital, Auckland New Zealand. The institutional review board 
at each center approved the protocol and informed consent was obtained from the parents in each case. The 
study was registered with clinical trials registry NCT00461409. 
Study entry criteria: Subjects were inpatients in the three participating neonatal intensive care units. To be 
eligible for the study subjects had to be have a corrected gestational age between 37 weeks and 44 weeks 
and weight of at least 2440 grams. Subjects had to be experiencing clinical or electrographic seizures which 
persisted after receiving a 20mg/kg loading dose of Phenobarbital in order to receive the study drug. Subjects 
were excluded from the study if they had a serum creatinine of greater than 1.2 mg/dL at the time of enrolment, 
if they were anuric, or if seizures were due to a biochemical abnormality such as hypoglycaemia or 
hypocalcemia which once rectified resulted in seizure cessation. Patients were also excluded from this study 
if death of the patient seemed imminent. 
Intervention: Patients were recruited in two ways. Patients recognized to be at high risk of developing 
neonatal seizures, for example neonates with hypoxic ischemic encephalopathy, were recruited prospectively. 
Other subjects were recruited at the time when they presented with seizure activity. Following recruitment and 
consent, patients were monitored electrographically to ascertain whether seizure activity occurred, and if so, 
if it persisted following administration of IV Phenobarbital.  
If there was ongoing definite clinical seizure activity or subclinical seizure activity detected by the continuous 
EEG monitoring 30 minutes after receiving Phenobarbital, an IV LEV loading dose was administered over 15 
minutes.  LEV maintenance dosing was given starting 12 hours after the initial infusion and continued every 
24 hours for a total of 1 week.  


 
 
Version: 13April2018 
The first cohort of babies was treated with a 20mg/kg initial load followed by 5mg/kg/day as a single daily 
dose. Following planned interim analysis of the first cohort, the dose was escalated.  The second cohort 
received 40 mg/kg as a load followed by 10mg/kg/day as a single daily dose. 
(These doses were chosen with the expectation that the dosing regimen in the second cohort would produce 
steady-state trough concentrations in the range typically seen with therapeutic doses in adults (~35-120µM or 
6-20mcg/mL).  LEV distribution is characterized by low protein binding and a volume of distribution that 
approaches total body water (0.7L/kg). Given the high total body water content in infants, it was expected that 
infant LEV volume of distribution would be slightly larger than in adults. Additionally, based on immature 
glomerular filtration in neonates and resulting renal function only 20% that of older children, LEV clearance in 
infants was expected to be between 15-45% of older population with the degree of hydrolysis present in 
neonates an important unknown variable.  
Serial determinations of LEV concentrations were performed to enable pharmacokinetic analyses. Blood 
samples were collected at 10 time points during the week of treatment to measure peak and trough serum 
concentrations of LEV and its major metabolite UCB L057. Urine was collected for the first 36 hours after LEV 
was commenced.  Serum and urine LEV and UCB L057 concentrations were measured by LC/MS/MS method 
62.  
Pharmacokinetic analysis was performed using the computer program NONMEM ver. 6.2.  A one-
compartment model was utilized and a population pharmacokinetic model was developed that included post-
natal age as a covariate on CL. Empiric Bayesian estimates of individual subjects pharmacokinetic parameters 
were generated using the priors of the population pharmacokinetic model 
During the treatment phase of the study each patient was clinically reviewed on a daily basis. Follow-up 
continued by phone review at 3 days and 6 days after intravenous administration of the study drug was 
completed. A follow-up visit was conducted 1 to 2 weeks after completion of the treatment phase of the study. 
Safety monitoring included measurement of CBC, serum creatinine and electrolytes and liver enzymes at 
baseline, between 48 hours and 72 hours of treatment and at completion of 7 days of treatment. 
Patient baseline characteristics: Eighteen patients received treatment with intravenous LEV, 6 at the first 
dosing level and 12 at the higher dose. There were 9 male and 9 female patients. The weight of subjects 
ranged between 2.5 and 4.7 kg. All subjects had a gestational age between 37 and 41 weeks. In 8 subjects 
the underlying etiology of seizures was hypoxic ischemic encephalopathy. 5 of these subjects received 
hypothermia treatment during the study period. 2 subjects were found to have ischemic stroke, 2 subjects had 
intraventricular hemorrhage.1 subject had a complex brain malformation with polymicrogyria, hypoplastic 
brainstem and cerebellar vermis with a Dandy Walker malformation. In 4 subjects the etiology of seizures was 
unknown despite investigation with brain MRI, sepsis screen, lumbar puncture and extensive metabolic 
investigations. 
 
Table 1 
Pharmacokinetic results: 
The final PK data set contained 149 
observations from the 18 subjects. Urine 
collections were completed in 18 subjects. 
Table 1 summarizes the PK parameters 
calculated and Figure 1 shows the raw 
pharmacokinetic data. 
 
 
 
 
 
 
 
 
 
Mean
SD
Median
Min
Max
Vd (L/kg)
1.01
0.13
0.98
0.81
1.24
CL Day 1 (L/h/kg)
0.042
0.016
0.039
0.023
0.085
CL Last Day (L/h/kg)
0.080
0.021
0.080
0.053
0.142
T1/2  Day 1 (h)
18.5
7.1
15.6
8.8
32.7
T1/2 Last Day (h)
9.1
2.0
9.0
5.3
12.7
Mean
SD
Median
Min
Max
Vd (L/kg)
1.01
0.13
0.98
0.81
1.24
CL Day 1 (L/h/kg)
0.042
0.016
0.039
0.023
0.085
CL Last Day (L/h/kg)
0.080
0.021
0.080
0.053
0.142
T1/2  Day 1 (h)
18.5
7.1
15.6
8.8
32.7
T1/2 Last Day (h)
9.1
2.0
9.0
5.3
12.7
Figure 1. 


 
 
Version: 13April2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse events and safety monitoring: Patients were reviewed daily to evaluate for possible adverse 
clinical events related to LEV treatment. LEV was well tolerated. Only one serious adverse event occurred in 
this study. One subject with a brain malformation and a high Phenobarbital level required intubation while on 
treatment with LEV. LEV was not thought to be causal of this event. 
There were a few mild adverse events identified that were possibly related to treatment with LEV: mild sedation 
was reported in 2 subjects. In both cases this resolved spontaneously. Feeding difficulty was documented in 
3 subjects. In all cases this difficulty was probably not due to LEV treatment and in all cases feeding difficulty 
resolved. One subject had mild apnea and bradycardia which resolved. This was probably not related to LEV 
treatment. Decreased urine output occurred in 1 subject with HIE. This resolved with treatment with frusemide. 
All blood test abnormalities were reviewed by an independent data safety monitoring board. Mild abnormalities 
in blood count and serum chemistries were seen, consistent with what would have been expected in this 
patient population of sick neonates. No serious or consistent treatment- emergent lab abnormalities were 
observed.  
A recent PK study of neonatal LEV treatment by Merhar et al. was based on 3 data point collections over 24 
hours in 18 infants ranging from day of life 1 to 32 67. These authors reported a half-life median of 8.9 hours 
(range 3.2-13.3). This finding is similar to our finding of mean t½ of 9.1 (SD 2.0) at 7 days of age [Table 1]. 
This study adds to the available safety data as no side effects other than sedation in one infant were noted. 
 
Efficacy in seizure cessation- preliminary analysis: Analysis of EEG data from this study demonstrating 
the effect of LEV on neonatal seizures is underway. As a simple measure of efficacy, 6 of the 18 subjects 
studied in this trial required no additional AEDs after LEV was commenced. 5 of the responders were amongst 


 
 
Version: 13April2018 
the 12 subjects who received the higher dose of LEV (42%). There was only 1 responder among the 6 subjects 
receiving the lower LEV dose. (An additional 3 subjects had an initial response to LEV; with temporary 
cessation of seizure activity as the loading dose was given, but later had recurrence of seizures). 
It should be remembered that this was the response rate to LEV used as a second line agent in subjects 
refractory to PB as a first line agent. As such this response rate of 42% seen in the higher dose cohort 
compares favorably with efficacy data for phenytoin and Phenobarbital when used as second line agents. 
Painter et al. found that of 4 of 17 (24%) neonates with seizures refractory to Phenobarbital responded to the 
phenytoin as the next AED, and 5 of 16 (31%) neonates with seizures refractory to phenytoin responded to 
Phenobarbital as the next AED 63. 
Two recent publications document retrospectively the response of neonatal seizures to IV LEV. Abend at al. 
reported that 23 neonates treated with LEV at a low mean initial dosage of 16 mg/kg had a>50% seizure 
reduction in 35% of infants with seizure termination in 7 of 23 (30%) 68. No respiratory or cardiovascular effects 
were detected. Khan et al. reported that 22 neonates received an LEV load of 10-50 mg/kg and 22 (86% 
achieved immediate seizure cessation at 1 hour. No serious side effects were evident; one infant became 
irritable on treatment responding to 50mg of pyridoxine 69. 
 
 
 
 8. RESEARCH DESIGN AND METHODS: (guideline length is 3-6 pages) 
 
Study Design Summary: 
This study will be a phase II preliminary efficacy, dose escalation and safety study. The study design will be a 
randomized blinded controlled treatment study. Infants recognized as having neonatal seizures or as being at 
risk of developing seizures will be recruited and started on continuous video EEG monitoring. The EEG data 
will then be reviewed continuously for electrographic seizures by study investigators, along with remote 
continuous EEG monitoring by Corticare technicians. A novel seizure detection algorithm operating in near- 
real time will be compared to the real-time continuous EEG reading.  
Once eligibility and consent are conﬁrmed, patients will be randomly assigned to the LEV or control treatment 
group in a 60:40 allocation ratio, stratiﬁed by site. 
 
Blinding will be maintained by appropriate dilution of LEV and Phenobarbital such that the same volume (ml/kg) 
loads are given to both treatment groups.  
 
Subjects randomised to receive LEV will, at the onset of electrographically confirmed seizure activity, receive 
an intravenous loading dose of LEV of 40mg/kg given over 15 minutes. If electrographic seizures are confirmed 
to persist or recur more than 15 minutes after the first infusion is complete, a further 20mg/kg load of LEV will 
be administered IV over 15 minutes. Maintenance LEV at 10 mg/kg/dose will be given IV q8 hours and 
continued for at least 5 days.  If seizures persist or recur more than 15 minutes after the second LEV infusion 
is complete, a PB loading dose of 20 mg/kg will be administered IV over 15 minutes. If seizures persist or 
recur more than 15 minutes after the first loading dose of PB is complete, a second 20mg/kg load will be 
administered IV over 15 minutes. This will result in PB being started within 1 hour of the onset of seizures if 
and when loading with LEV is ineffective.  Patients given any PB loading doses will be started on maintenance 
PB with 1.5 mg/kg/dose given IV q8 hours and continued at least until the end of the study 
 
 
 
 
 
 
 
 
 


 
 
Version: 13April2018 
 
 
 
 
 
Figure 2 details the study flow. 
 
 
 
Subjects randomized to the control group will, at the onset of electrographically confirmed seizure activity, 
receive an intravenous loading dose of PB of 20 mg/kg given over 15 minutes. If electrographic seizures are 
confirmed to persist or recur more than 15 minutes after the first infusion is complete, a further 20mg/kg load 
of PB will be administered IV over 15 minutes. Maintenance PB at 1.5 mg/kg/dose will be given IV q8 hours 
and continued for at least 5 days. If seizures persist or recur more than 15 minutes following the second PB 
infusion, a 40 mg/kg load of LEV will be administered IV over 15 minutes. If seizures persist or recur more 
than 15 minutes after the first loading dose of LEV is complete, a second 20mg/kg load of LEV will be 
administered IV over 15 minutes.   Patients given an LEV loading doses will be started on maintenance LEV 
with 10 mg/kg/dose given IV q8 hours and continued at least until the end of the study. 
 
If electrographic seizures are still apparent following treatment with both LEV and PB, or if they recur during 
the 5 days during which the study protocol is active, the patient will be considered to have failed the 
experimental treatment regime and institutional specific standard seizure management will dictate the ongoing 
HIE and at risk  neonates 
(prospective enrollment)
Suspicion of clinical 
seizures
300 subjects consented and 
continuous EEG initiated
100 subjects begin 
treatment with randomized 
study drug
IV LEV Load 40mg/kg  
(60 subjects)
IV PB Load 20mg/kg 
(40 subjects)
Additional LEV load 20 
mg/kg
IV PB Load 20 mg/kg
Additional PB load 20 
mg/kg
Defer to institutional 
protocol
Additional load PB 20 
mg/kg
IV LEV Load 40 mg/kg
Additional LEV load 20 
mg/kg
Electrographic seizures detected
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist


 
 
Version: 13April2018 
management. Without unblinding, it will be evident that all subjects will have received 40mg/kg Phenobarbital 
and 60mg/kg of LEV at this stage. 
 
 
 
 
 
Clinical monitoring and specific laboratory data will be collected at standardized times following study drug 
administration to determine the pharmacokinetics and safety of LEV on 12 subjects at the 40 mg/kg dose and 
12 at the 60 mg/kg dose (see Table 2).  The 
PK studies will be performed only at the San 
Diego and Auckland sites. Investigators will 
remain blinded to PB level. 
 
Study Inclusion and Exclusion criteria:  To 
be eligible for recruitment, subjects will be 
term infants with corrected gestational age 
between 36 and 44 weeks, and weight of at 
least 2.2 kg. Subjects will be excluded if they 
have received anticonvulsants within 24 hours 
of enrolling in the study, if serum creatinine is 
greater than 1.6 mg/dL  or if seizures are due to correctable metabolic abnormalities (i.e.hypoglycaemia, 
hypocalcemia, hyponatremia). Subjects in whom death seems imminent, as assessed by the neonatologist, 
will also be excluded from the study. 
 
Recruitment: There are 2 groups of babies from which subjects may be recruited-  
1. A prospective group, where it can be anticipated that seizures are at high risk of occurring, for example in 
neonates with HIE. Consent will be obtained prospectively and continuous EEG monitoring will commence. 
2. Acutely presenting group, neonates that present with symptoms indicative of or suggestive of seizures.  It 
is recognised that it will not be possible to recruit all patients in this acutely presenting group. Efforts to obtain 
consent can not be allowed to delay management.  However, in many cases there will be opportunity to 
ethically recruit and consent subjects without delaying care. For example, in cases where clinical seizures are 
brief and have stopped spontaneously, and in cases where there is suspicion of seizure activity but EEG 
confirmation is needed before AEDs are indicated. 
 
Table 2 
CBC 
diff 
Chem Panel, 
LFTs 
LEV level Phenobarbital 
Level 
Baseline X 
X 
X 
X 
1 hour  
 
 
X 
X 
24 hours  
 
X 
X 
48 hours X 
X 
X 
X 
0
8
16
24
32
40
48
56
64
72
Time
0
10
20
30
40
50
60
70
Levetiracetam (mcg/mL)
40mg/kg x 1
10mg/kg q8
40 & 20mg/kg
10mg/kg q8
Figure 3 Predicted blood levels 
at 40 mg/kg and 60 mg/kg 
loads with 10 mg/kg 8 hourly 
maintenance 


 
 
Version: 13April2018 
Expected enrollment:  We plan to treat 100 subjects over 4 years and based on our prior PK study experience 
we anticipate needing to recruit, consent and monitor 300 subjects to yield this number, (a conservative 
estimate). Randomization will be carried out with a six to four ratio so that 60 subjects will receive treatment 
with LEV and 40 will receive standard treatment with Phenobarbital treatment. Each site will treat 4 to 6 
subjects with seizures each year, recruiting and monitoring up to 13 infants per year in order to yield these 
numbers. Historical data from the past 3 years in each of four neonatal intensive care units indicate that we 
will be able to recruit these numbers of patients easily: Rady Children’s Hospital have treated on average 39 
term infants with seizures per year over the past 3 years, Auckland Hospital NICU have treated on average 
12 per year, Oakland Children’s Hospital have treated 6-10 per year. In our prior PK study we recruited 36 
subjects with neonatal seizures in 18 months, (18 of whom were refractory to PB and therefore received study 
drug). 
 
Data to be collected:  
 
Clinical Data:  Demographic and clinical data will be collected, including birth weight, gestational age at birth, 
postnatal age, gender, pregnancy history, family medical history, mode of delivery, Apgar scores, and cord 
blood gas if available. Etiology of seizures will be recorded. Where etiology is unknown, results of 
neuroimaging, blood, urine metabolic and CSF studies will be reviewed. A record of all medications received 
by the infant will be kept. Case report forms will be developed to facilitate data entry from all sites into the 
REDcap data management system available to us through the UCSD Clinical and Translational Institute 
(CTRI). 
 
Feasibility data: We will record the times of the following events: subject admission to NICU, contact of study 
staff by treating physicians, subject enrolment, initiation of EEG monitoring, first recognized seizure, and time 
of study drug administration. Record will be made of whether seizure is first identified by Corticare staff or by 
onsite study investigator. Record will be systematically collected from each monitored subject of any difficulties 
with functioning of the remote continuous monitoring infrastructure. All data will be referenced to date/time of 
birth so that precise age in hours can be determined for age at enrolment, timing of seizures, administration 
of study drug, and administration of other treatments given to treat seizures.  
 
Safety data: Continuous monitoring of vital signs will occur as part of routine neonatal intensive care. Vital 
signs will be recorded at baseline, and at 15 minutes after each drug infusion commences. Documentation of 
presence or absence of adverse event occurring during each treatment phase will be made.  
Blood tests of haematological indices, electrolytes, glucose, renal function and liver enzymes will be tested 
and recorded at baseline, at 24 hours and at 48 hours as part of safety and adverse events monitoring. 
 
Pharmacokinetic data: For subjects at the 3 San Diego sites serum LEV levels will be drawn at baseline, 1 
hour after starting the treatment, at 24 and 48 hours.  
 
EEG data monitoring and automated seizure detection:  Gold standard 9 channel neonatal montage 
continuous video-EEG data will be collected for 24 to 48 hours after study drug administration with the length 
of monitoring time determined by the Principal Investigator for each site. There may be infants who, after 24 
hours of remaining seizure-free, are appropriate for discontinuation of monitoring which also may enable them 
to be safely discharged home. Babies undergoing hypothermia for hypoxic ischemic encephalopathy will have 
EEG monitoring data captured for 24 hours post start of rewarming as this is a high risk time for seizures. 
Each site will use available video EEG equipment with Persyst software installed. A research dedicated 
Cadwell video EEG system is requested under this grant for each site.  Following recruitment to monitoring, 
each site will have their study investigator monitoring the EEG in real time, per the study algorithm. Corticare 
technicians will provide continuous EEG monitoring by remote access to the acquisition station. If Corticare or 
the real time onsite observer detects seizure activity the site investigator or local encephalographer will 
immediately be contacted to review the tracing. Neonatal EEG data obtained from conventional digital EEG 
machines based at the study sites will be monitored in near- real time using Persyst Insight software running 


 
 
Version: 13April2018 
on the acquisition stations via the site’s local area network or remotely via secure Internet access utilizing 
Citrix server, Microsoft Remote Desktop, or similar institutional remote access capabilities. The EEG data will 
be continuously analyzed in near- real time using Persyst MagicMarker in order to produce and display EEG 
data trend graphs. The graphical EEG trends will include Rhythmic Run Detection and Display, amplitude 
integrated EEG, FFT spectrograms, asymmetry spectrograms, and other trends useful in the rapid recognition 
of seizures. Following completion of the local study on each subject the full video EEG (totalling 5 Gigabytes 
of data/ 24 hours) will be archived on the UCSD server for analysis by the encephalographers. Data transfer 
will be achieved where possible by encrypted internet connections. Alternatively the studies will be mailed on 
memory sticks or DVDs. Archived video continuous EEG data will be available for trend analysis and seizure 
detection comparison with the duplicate formal encephalographers reading of the 48 hours of tracing. 
 
Add on Study: 
The study population of treated babies with electrographic seizures and the parallel control group at risk for 
seizures but with none detected forms an excellent cohort for a neurodevelopmental outcome study and the 
effect of seizures. This is being planned and I am asking the parents in the consent if they are interested in 
being contacted for a neurobehavioral follow-up study. 
 
Rationale for study design: 
Justification for a phase II study: The objectives of this study are to gain preliminary evidence of efficacy of 
LEV in neonates, to determine if a definitive phase III trial is warranted, and if so, to obtain sample size 
estimates for that study. In addition further safety data in this population will be aquired. 
Planning is underway for a large definitive phase III randomised controlled trial of the leading potential new 
treatments for neonatal seizures. If LEV is established as efficacious in neonates, a future study comparing it 
with other agents such as Phenobarbital alone or Phenobarbital in combination with bumetanide or topiramate 
is likely. Such a study to compare the current standard of care AED treatment with newer agents will require 
300-400 treated subjects. Long term follow-up of subjects will be necessary, since neurodevelopmental 
outcome will be the relevant primary outcome measure. 
Prior to a definitive phase III trial of any promising new treatment for neonatal seizures, efficacy in the neonatal 
age group must be proven. Prospective data on the efficacy LEV in neonatal seizures are not yet sufficient to 
justify a phase III trial. The precision of the estimated response rate to LEV obtained in this proposed study 
will be important in the design of a future comparative trial64. 
 
Justification of study design using LEV as first line treatment: 
While it is customary to study new AEDs in subjects who have failed standard treatments, this is especially 
problematic for the setting of neonatal seizures. On the one hand, by studying efficacy in only those neonates 
who have failed to respond to a first line agent, a group of refractory neonates has been selected, who may 
not respond to any AED.  On the other hand, neonatal seizures typically resolve spontaneously in a significant 
proportion of subjects. These factors make interpretation of second line efficacy data difficult, and a poor 
surrogate for first line treatment efficacy data.  
 
There is sufficient evidence of efficacy and safety to justify study of LEV as a first line agent. LEV has good 
efficacy in other populations, including in populations experiencing refractory status epilepticus. In neonates 
there are accumulating reports of its efficacy in cases where seizures are refractory to multiple other agents. 
Our preliminary analysis of efficacy when LEV is used as a second line agent suggests efficacy similar to that 
of Phenobarbital and phenytoin when used as second line agents (as described above). 
 
Our study design ensures rapid escalation to treatment with Phenobarbital in subjects who do not respond to 
LEV. Additionally, because our study will utilize real time monitoring of continuous EEG recordings leading to 
more rapid detection and treatment of electrographic seizures than is normally standard of care, our study 
subjects will receive AED treatment in a shorter time frame than is usual. 
 
Plan for Statistical Analysis  


 
 
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General considerations: The general objectives of this study are to gain preliminary evidence of efficacy of 
LEV in neonates, to determine if a phase III trial is warranted, and if so, and to obtain to obtain sample size 
estimates for that study.  In addition further safety data in this population is required. This study will allow the 
LEV and PB groups to be compared with respect to (a) preliminary evidence of efficacy, and (b) safety.  
All analyses will incorporate the intention-to-treat principle; all randomized participants will be included in the 
analysis. Analyses for all efficacy outcomes will be guided by descriptive and exploratory analyses. All results 
will be reported as point estimates (proportions or mean differences across groups, as appropriate) and 
interval estimates (95% confidence intervals) with two-sided p-values denoting statistical significance.  Since 
this is a phase II preliminary efficacy and safety study, no adjustments for multiple comparisons will be made 
and a p-value of 0.05 will be considered statistically significant. 
 
Analysis Plan for Aim 1: Evaluating efficacy in seizure cessation 
A Fisher’s exact test will be used to test the 48 hour seizure cessation rate between the two treatment groups.  
As a secondary reanalysis, multivariate logistic regression (if there are sufficient number of events), will be 
performed to study the association between cessation rates and treatment. Any baseline covariates (including 
stratification factors) that are simultaneously unbalanced between treatment groups at baseline (univariate p 
<0.10) and associated with the outcome (univariate p<0.15) will be included in the multivariable model as 
observed confounders. A similar approach will be utilized to analyze the 1-hour seizure cessation rates. 
Power Analysis for Aim 1: Power calculations were based on a 2-sided chi-square test for detecting a 
difference between two proportions, assuming a Type 1 error of 0.05. With a sample size of 60 LEV subjects 
and 40 PB subject and assuming a seizure cessation rate of 50% in the control arm, we have 80% power to 
detect a seizure cessation rate as low as 22% (an absolute difference in seizure outcome rates of 28% or 
greater) in the LEV group. 
 
Analysis Plan for Aim 2: Dose escalation analysis  
The percentage of neonates whose seizures stop following 60mg/kg LEV, having not responded to 40mg/kg 
LEV will be calculated with the corresponding 95% confidence interval. 
 
Analysis Plan for Aim 3:  Pharmacokinetic analysis 
The actual individual concentration data, collection times and dosing histories will be used to create graphs of 
plasma LEV concentration vs. time for each infant. Median plasma drug concentration vs. time curves will also 
be generated. Summary statistics (i.e., n, mean, standard deviation, median, minimum, maximum, and 
coefficient of variation) will be calculated for plasma concentrations for each time point and each dose level.  
LEV population pharmacokinetic parameters will be determined using the computer program NONMEM (ver. 
6 or later). The data will be nested with existing raw infant LEV pharmacokinetic data generated in the 
preliminary LEV study.   Assuming linear pharmacokinetics as suggested by our current pharmacokinetic data, 
studying 12 subjects at each dosage level will result in 90% confidence intervals for the pharmacokinetic 
parameters (CL, V and t1/2) of +/- 15%. The 90% confidence intervals for the exposure parameters (Cmax, 
AUC) will be approximately +/- 20%. The pharmacokinetics will be modeled recognizing the two stages of a 
nonlinear hierarchical model development. The first stage introduces the structural model (e.g. one 
compartment open model), the population parameters, individual effects and the within-patient variation.  The 
second portion of the model development recognizes that variation between patients in the pharmacokinetic 
parameters exists and will attempt to determine covariates that may identify different pharmacokinetic 
subpopulations.  A one-compartment model with first order elimination will be utilized.  Alternative structural 
models will be explored if indicated by the data.  The impact of clinical factors and demographic factors 
(including weight, sex, age, race, serum creatinine, hypothermia and dosing regimen) will be assessed as 
fixed effects in the model.  Nested models will be compared graphically and with a likelihood ratio test.  
 
Analysis Plan for Aim 4: Safety analysis  
A Fisher’s exact test will be used to compare rates of adverse events, serious adverse events and study 
discontinuation rates between the LEV and control groups.  
 


 
 
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Analysis Plan for Aim 5 A: Feasibility of remote continuous EEG monitoring system 
Feasibility will be measured by accuracy and speed of notification of electrographic seizures. We will report 
the standard metrics of sensitivity and specificity. If Corticare reports a seizure rejected by the study 
investigator, this will be recorded as a false positive. Conversely seizures recorded by the neurophysiologist 
but missed by Corticare will be false negatives, and we will determine the rate of false positives and false 
negative seizure reports by Corticare technologists. We will calculate the specificity and sensitivity of Corticare 
seizure reporting.  For speed of reporting, we will measure the time lapse between the occurrence of seizure 
and site study investigator notification and the lapse between occurrence of seizure and study drug 
administration.  Descriptive report of technical difficulties experienced with the remote centralized EEG review 
system will be made. 
Analysis plan for Aim 5 B. Analysis of performance of the automated seizure detection algorithm 
In addition to standard visual EEG review by the study’s electroencephalographers, the early detection of 
seizures will be assisted by automated seizure detection notifications generated by the computerized 
algorithm. These notifications, and images of their associated EEG tracing and graphical trends, can be 
automatically broadcast via email to specifically designated study personnel for verification of the nature of the 
detected event. The performance of the seizure detection algorithm will be assessed by comparing its output 
to the final EEG markings of two neonatal electroencephalographers. The following seizure detection algorithm 
performance parameters will be calculated: overall seizure detection sensitivity, false positive rate, and 
seizure-affected patient detection rate (the percentage of patients with seizures in whom at least one seizure 
is correctly identified). 
 
 9. HUMAN SUBJECTS: 
 
The trial will be a Phase II trial to test the efficacy, pharmacokinetic and safety of intravenous Levetiracetam 
(LEV) as first line treatment for neonatal seizures with greater than minimal risk. 
 
Human Subjects Involvement and Characteristics 
Subject characteristics: This trial will be conducted in term-age newborns with seizures who are admitted to 
the neonatal intensive care units (NICUs) at one of five participating hospitals, namely Rady Children’s 
Hospital University of California, San Diego, UCSD Medical Center, Sharp Mary Birch Hospital San Diego, 
Children’s Hospital and Research Center Oakland, and Auckland Hospital.  The subjects will have a 
corrected gestational age at birth of 36-44 weeks and a postnatal age of < 14 days. Subjects are expected to 
be critically ill newborns, reflecting the underlying etiology of the seizures as well as the physiologic effects 
of seizures per se. Approximately 50% of neonatal seizures are caused by hypoxic ischemic 
encephalopathy, (HIE). These infants have sustained global hypoxic ischemic injury with consequent renal, 
hepatic, gastrointestinal, respiratory and cardiac sequelae. Other common etiologies of neonatal seizures 
include intracranial hemorrhage, infection and developmental defects, which may also be associated with 
impaired function of other organs. Therefore seizures are frequently associated with high mortality and 
morbidity. 20-30% of infants with neonatal seizures die, 20-30% develop epilepsy outside the neonatal 
period, and 20-40% develop cerebral palsy and/or mental retardation6 
 
Rational for enrolling newborns as subjects: There are several important factors contributing to the rationale 
for involving term newborns in this research. The drug to be studied has been extensively studied in adults 
and older children and shown to be safe and effective. It cannot be assumed however that this will mean that 
the drug is safe or effective in neonates without study in this population. The neonatal response to AED’s is 
fundamentally different to that of the mature brain. Agents that have good efficacy and safety in the mature 
brain, (Phenytoin and Phenobarbital) are much less effective and have increased toxicity in the immature 
brain.  
There is an urgent need for safe and effective treatments in this neonatal population. Currently used 
treatments are poorly effective and have significant side effects, none are FDA approved. The incidence of 
seizures is higher in newborns (2-3.5 per 1000 live births) than at any later age. Neonatal seizures are often 


 
 
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refractory to treatment and lead to frequent and serious long-term consequences in survivors, such as 
significant cognitive and motor disabilities and later epilepsy.  
 
Collaborating sites and study investigators: This trial will be a collaborative effort among Pediatric Neurology, 
Epilepsy/ Neurophysiology and Neonatology at the five sites. Together the study investigators have 
extensive experience in clinical trials in newborns and expertise in the, diagnosis, monitoring and treatment 
of neonatal seizures. The investigators have recently successfully completed a pharmacokinetic study of the 
study drug in neonates. The PI will oversee all aspects of the trial and will be the site PI coordinating conduct 
of the study at Rady Children’s, UCSD Medical Center NICU and Sharp Mary Birch San Diego NICU. Gail 
Reiner DNP, FNP based at UCSD will be the study coordinator assisted by research coordinators Lilly Lee, 
B.A., Kimberly Thomas, M.S., and Mallory Boutin, MPH. Dr Mary Harbert will be a study co-investigator at 
the San Diego sites. Dr. Kuperman will be the site PI supervising conduct of the study at the Oakland 
Children’s Hospital NICU. Dr Sharpe will be the site PI supervising conduct of the study at the Auckland 
Hospital NICU. Drs. Honold and Lane neonatologists at the Rady Children’s UCSD NICU and will be the 
neonatologists contributing to coordination of the study at that site. Durand will be the primary neonatologist 
at the Oakland Children’s Hospital NICU and Dr .Battin will be the participating neonatologist at the Auckland 
Hospital site. Drs. Garey and Rasmussen will be the neonatologists at UCSD Medical Center and Sharp 
Mary Birch Hospital respectively. Drs. Wang, Nespeca and Kuperman have expertise and certification in 
neurophysiology and neonatal seizures in particular, and will be the study investigators supervising analysis 
of EEG data. In addition, at each site we have collaborating neurophysiologists: Dr. Davis at the Auckland 
site, and Dr. Kuperman at the Oakland site. Dr. Edmund Caparelli is an internationally recognized expert in 
pediatric pharmacology and will be a consultant regarding those aspects of the study.  Dr Rema Raman, 
biostatistician at University of California, San Diego has advised on study design and will continue to provide 
statistical support. Corticare Corporation will provide continuous remote EEG monitoring under HIPPA 
regulations and Persyst Corporation will assist in EEG analysis and seizure detection using their commercial 
Magic Marker software which is installed on all EEG machines in use in the study. This software with it’s 
trending capability is already in daily use at the study sites. 
 
Sources of Material 
Data that will be collected specifically for the purposes of this trial will include clinical data regarding the 
subjects’ medical history and hospital course including clinical characteristics such as weight, medications 
administered, blood pressure measurements, and fluid input/output. Most clinical data will be obtained from 
the subjects’ medical records, but there may be some data obtained by interviewing the parent(s).  
 
Much of the laboratory data that will be recorded in the database will be laboratory data obtained in 
newborns as part of standard clinical care of newborns with seizures, such as serum blood gas 
measurements, serum electrolytes, levels of AEDs administered and liver function tests. Some laboratory 
tests such as albumin and serum bicarbonate may not be collected at both time points for standard care for 
some subjects and thus will be obtained for purposes of the trial. Serum LEV levels will be collected only for 
purposes of this trial.  
 
EEG data will be read and used for clinical purposes at each site with the assistance of the remote 
centralized continuous monitoring system. For the purposes of the study itself EEG data collected at each 
site will be de-identified before analysis by the study neurophysiologists who will be blinded to the subjects’ 
group assignment or demographic information. 
 
Study staff at each site will have access to individually identifiable information about newborns enrolled at 
that site. Data will be collected by each site’s study investigators and the research coordinator and recorded 
onto case report forms (CRFs) by the research coordinator, and data from the CRFs will subsequently be 
entered into the database by the research coordinator. The CRFs and the electronic database will only have 
de-identified information to preserve confidentiality of patients’ protected health information. Files that link 
the study identification number for each subject to the subject’s personal information (such as name, medical 


 
 
Version: 13April2018 
record number, parents’ names) will be kept at each site and accessible only by the site PI and research 
coordinator. 
 
 
 
 
10. RECRUITMENT AND SCREENING: 
300 subjects will be recruited in total from the 5 NICU’s over 4 years. A higher than anticipated screening to 
treatment ratio of approximately 3:1 monitored to treated neonates has occurred in the initial 85 neonates 
recruited to this study. The originally anticipated 2:1 EEG monitoring: treatment ratio is likely lower due to 
the beneficial effects of hypothermia treatment many neonates receive as a usual standard of care. 
Hypothermia treatment may be reducing the incidence of seizures in this population.  This change in ratio 
may also be a reflection of a benefit of this study in that behavior in a few neonates which may have 
previously been clinically judged to reflect seizure activity, because of continuous EEG monitoring viewed by 
EEG technicians in this study also reviewed by a neurologist, have been correctly diagnosed as myoclonic 
jerks rather than seizures.  This has thereby prevented some neonates from receiving medication for seizure 
treatment because their behavior is not confirmed by their EEG as seizure activity.  For these reasons an 
increased number of total subjects will be needed in this study in order for 100 subjects to be treated.   
 
Inclusion Criteria:    
Term newborns admitted to the UCSD, Children’s Hospital and Research Center Oakland, Auckland 
Hospital, Rady Children’s Hospital or Sharp Mary Birch NICUs with seizures or at risk for seizures: 
 
• Term infants (gestational age greater than or equal to 36 weeks) 
• Postnatal age < 14 days. 
• Serum creatinine equal to or less than 1.6 mg/dL at time of enrollment  
• Are still experiencing either clinical or electroencephalographic seizures or are at risk for neonatal 
seizures.   
• For whom parental consent to participate in the study is obtained. 
 
Exclusion criteria: 
• Biochemical abnormality – hypoglycemia, hypocalcemia- that when treated result in seizure cessation. 
• Severe hypoxic ischemic injury likely to result in imminent death 
• Infants with a birth weight less than 2200 g would be excluded the study. This is the new 
recommended 10th percentile for 36 weeks gestation. The blood drawn at any one time will be <3 
mls/kg which remains within the NIH guidelines for pediatric blood draws. 
 
Patients of all ethnic groups will be included in the study. Based on the patient population our group treats, 
most patients will be European or Hispanic. Both male and female infants will be recruited to the study. 
 
The only significant exclusions that will be made in recruitment and enrollment will be the exclusion of 
infants who are judged by the attending neonatologist to be so critically ill that death is imminent and benefit 
from neonatal intensive care is very unlikely. No rule-based criteria, (using lab or clinical parameters) 
adequately capture the complete nature of this clinical assessment. In general any child receiving active 
treatment with head cooling will not be excluded. Mechanical ventilation and/ or the use of inotropic agents 
to support blood pressure will not be exclusion criteria.   
 
These patients will be a very sick population, reflecting the underlying etiology of the seizures as well as the 
physiologic effects of seizures per se. Approximately 50% of neonatal seizures are caused by hypoxic 
ischemic encephalopathy, (HIE). These infants have sustained global hypoxic ischemic injury with 
consequent renal, hepatic, gastrointestinal, respiratory and cardiac sequelae. Other common etiologies of 


 
 
Version: 13April2018 
neonatal seizures include intracranial hemorrhage, infection and developmental defects, which may also be 
associated with impaired function of other organs. Therefore seizures are frequently associated with high 
mortality and morbidity. In studies of term infants with neonatal seizures, it has generally been found that 
between 20 to 30% died, 20 to 30% developed post-neonatal epilepsy and between 20 and 40% developed 
cerebral palsy1,2. 
 
Commonly, it is expected that a new drug or drug formulation would be studied extensively in healthy adult 
populations prior to its use in studies in vulnerable newborns. The basic assumption underlying this common 
practice is that standard management is adequate. This is not the case in the treatment of neonatal 
seizures. Agents that have good efficacy and safety in the mature brain, (Phenytoin and Phenobarbital) are 
much less effective and have increased toxicity in the immature brain. The dire need for better treatments for 
neonatal seizures, combined with the existing data that suggest that this new agent may well be safer than 
traditional agents and that it may also have good efficacy is justification for studying the drug in this 
population.  
 
Infants admitted to the 5 participating NICU’s will be recruited in 3 separate situations: 
A. Infants with HIE identified prospectively as being at high risk for developing seizures,  
B. Infants admitted to NICU with pathologies other than HIE that also place the infant of high risk to 
develop seizures. 
C.  Infants with seizures as first indication of illness, transferred to the NICU for treatment. Initially 
etiology may not be clear but may include infection, stroke, hemorrhage, brain malformation and 
idiopathic seizures.  
 
Partial HIPAA waiver will need to be granted for the recruitment procedure, specifically the waiver of consent 
for the transfer from the clinical team to the study team of clinical information needed to determine patient 
eligibility for the study. 
 
In groups A + B it will be possible to prospectively obtain consent for participation in the trial at the time 
when the infant is admitted to the unit. Neonatal staff (Admitting neonatal fellow or resident) will identify 
eligible subjects in group A or B briefly discuss the study with patients’ families and obtain permission to 
contact study staff. Study staff will screen the patient for inclusion and exclusion criteria as listed above and 
obtain consent from parents for participation in the study in the event that seizures should occur 
 
Group C: 
 
Frequently seizures are the first indication that a neonate is unwell. These occur in the regular postnatal 
nursery. Once the infant is transferred to the NICU and stabilized cardiovascularly, and if seizures are 
ongoing and hypoglycemia and hypocalcemia have been excluded as cause for the seizure, a continuous 
EEG monitor will be placed, (this is not yet standard of care in the majority of NICU’s in the United States but 
is an option available in many centers). 
While the EEG leads are being placed intensive efforts will be made by neonatal and study staff at this stage 
to obtain parental consent for participation in the study. If consent can be obtained the patient will be 
enrolled in study and a randomized to a treatment arm during the EEG set up. If electrographic seizures are 
confirmed, IV treatment with study drug according to the protocol will commence. 
 
 
11. INFORMED CONSENT: 
 
1. The admitting resident or fellow who identifies seizures or high risk of seizures developing in the future will 
request the parents’ permission for the study staff to approach them to discuss their possible participation. 


 
 
Version: 13April2018 
It will be made clear to the parents that participation is voluntary and that their child will receive standard 
care if they do not wish to participate. Furthermore it will be made clear that the study staff is separate from 
the infant’s own primary physician and nursing group. 
 
2. If permission is granted the study staff will be contacted and will review the clinical details to ensure 
inclusion and exclusion criteria are met. 
 
3. Study staff will approach the parent with study information to obtain consent in person. 
 
Parents not available in person, (in situations for example where the infant has been transferred from a 
remote hospital), will be faxed a consent form for review and signature. Study staff will be available by phone 
to the parents, should they have any questions regarding the faxed consent.  
 
If the follow-on study question is left unanswered, the study team may use an IRB approved phone script to 
contact the family in order to complete the question. From recent review post recruitment closure, the follow-
on study question was missed in approximately 10% of the consents. A waiver of documentation will be 
used for contacting the families, and all responses will be documented in a separate study source 
document.” 
 
12. ALTERNATIVES TO STUDY PARTICIPATION:  
 
If parents do not wish to participate in the study they will not be coerced to do so and will be reassured that 
their infant will continue to receive the normal standard of care. Study staff is separate from the primary 
physicians and nurses involved in the infants’ care, which should help to free the parents from feelings of 
undue pressure to participate. 
 
 
13. POTENTIAL RISKS: 
 
The potential risks to the subjects include 1) adverse drug reaction risk secondary to LEV, 2) risks of 
blood drawing, 3) risk that LEV is a less efficacious drug and that consequently study subject will have a 
longer duration of seizures before adequate treatment is given 4) risks regarding confidentiality.  
 
Potential risks related to LEV  
LEV has been used for many years as an anticonvulsant in older children and adults and has a very 
favorable safety profile. LEV toxicity data show a very wide safety margin, with a TD50/ED50 ratio of >148 in 
rodents37 .No deaths, organ failure or other irreversible toxicity were seen after long-term oral treatment up 
to doses of 1,800 mg/kg/d in the rat, 960 mg/kg/d in the mouse and 1,200 mg/kg/d in the dog.38 Animal fetal 
toxicity data are reassuring38. Data from the UK Epilepsy and pregnancy register65 documents that no fetal 
malformations occurred in 39 pregnancies where levetiracetam was used as monotherapy. Where 
levetiracetam was used with other anticonvulsants 3 major malformations occurred in 78 pregnancies. 
 
Clinical experience with LEV use in adults and in children has found it to be well tolerated and safe29, 30, 33, 39-
42 including 3 recent reports of use at high dosage 43-45 .  In humans 2 cases of reversible thrombocytopenia 
have been reported. Tan et al have reported a case in which levetiracetam was implicated as a possible 
cause of liver failure66. No other significant hematological, hepatic or renal toxicities have been reported.  In 
children and adults the most common side effects are somnolence and behavioral side effects. Glauser et 
al50 report 23% of children treated with levetiracetam experienced somnolence, compared to 11% of placebo 
patients however this side effect rarely requires cessation of treatment. Behavioral side effects associated 
with treatment included agitation, anxiety, apathy, depersonalization, depression, emotional lability, hostility 
and hyperkinesias. A total of 37.6% of children in this study reported some behavioral side effect, compared 
with 18.6% of placebo patients. These behavioral abnormalities were significant enough to prompt 


 
 
Version: 13April2018 
discontinuation of treatment or dose reduction in 10.9% of levetiracetam treated patients compared with 
6.2% of placebo patients. 
 
In our recently completed pharmacokinetic and preliminary safety study of LEV in neonates, the drug was well 
tolerated. Only one serious adverse event occurred in this study. One subject with a brain malformation and 
a high Phenobarbital level required intubation while on treatment with LEV. LEV was not thought to be causal 
of this event. There were a few mild adverse events identified that were possibly related to treatment with LEV: 
mild sedation was reported in 2 subjects. In both cases this resolved spontaneously. Feeding difficulty was 
documented in 3 subjects. In all cases this difficulty was probably not due to LEV treatment and in all cases 
feeding difficulty resolved. One subject had mild apnea and bradycardia which resolved. This was probably 
not related to LEV treatment. Decreased urine output occurred in 1 subject with HIE. This resolved with 
treatment with frusemide. All blood test abnormalities were reviewed by an independent data safety monitoring 
board. Mild abnormalities in blood count and serum chemistries were seen, consistent with what would have 
been expected in this patient population of sick neonates. No serious or consistent treatment- emergent lab 
abnormalities were observed.  
Two recent publications of LEV use in neonates reported only sedation and irritability as side effects . 
 
It therefore appears that levetiracetam is a very safe drug with a wide therapeutic range. However, any 
adverse drug reaction is possible.  
 
Potential risks of blood drawing: blood loss and pain 
 Blood draws will be required in a subset of patients for measuring the pharmacokinetics of LEV. For some 
patients there may also be additional blood drawn for safety studies, although in most patients these laboratory 
tests would be obtained as standard care because of their underlying illness (i.e., systemic asphyxia). 
Furthermore, additional blood tests required for the study may not require additional blood draws, because 
laboratory tests such as liver function tests can be run on serum drawn for other purposes, such as serum 
electrolytes. The required volume of each blood sample for LEV levels will be 0.5 mL. Drawing a total blood 
volume of 2 ml/kg (ca. 3% of blood volume) over 24 hours is considered acceptable. For a 2.2-kg term 
newborn, this would amount to 4.4 ml of blood/ 24 hours. This protocol requires 4 samples for LEV analysis, 
over 48 hours for a total volume of 2 ml. For additional blood draws of laboratory tests which may not 
otherwise be drawn for clinical purposes, the total volume of blood will be 2-3 ml. Thus the total amount of 
blood drawn for research purposes will be ≤5 ml over 48 hours. It is unlikely that this small increase in the 
amount of blood drawn would result in significant anemia. Most blood draws will be via indwelling vessel 
catheter in place as part of  routine care.  This will render blood sampling painless and free of any risk beyond 
that usually associated with the care of a critically ill newborn.  Blood sampling towards the end of the 1-week 
treatment period may require additional venipunctures or heel stick blood draws. All efforts will be made to 
reduce infants discomfort by warming the heel adequately prior to blood draw, administering oral glucose 
during blood draw and feeding infant after blood draw. 
  
Risk of less effective drug. There is a potential risk that LEV is a less efficacious drug than standard 
treatments, placing study subjects at risk of a longer duration of seizures before effective treatment is given 
if randomized to receive LEV. This will be minimized as described in the following section.  
. 
Potential risks regarding confidentiality.  There is a potential risk for breach of confidentiality, which will be 
minimized by the procedures described in the following section. 
 
14. RISK MANAGEMENT PROCEDURES: 
Adequacy of Protections against Risk 
Recruitment and Informed Consent 
Research conducted in this project will be reviewed and approved by the appropriate Institutional Review 
Board (IRB) for each site. Only trained study investigators listed on the IRB protocol will obtain written 
informed consent using the locally approved consent form.  


 
 
Version: 13April2018 
 
Recruitment procedure:  Newborns will be recruited from the five neonatal intensive care units (NICUs) once 
the IRB protocol has been approved at all the five institutions. We will provide in-servicing to NICU staff in 
each unit and post flyers in the NICUs to alert neonatology staff to the study’s purpose, inclusion criteria, and 
the pager number needed to contact the study staff regarding potential subjects. We anticipate that we will 
recruit subjects in two groups. The first group will be subjects in whom it can be anticipated that seizures are 
at high risk of occurring, for example in neonates with hypoxic ischemic encephalopathy. These subjects will 
be identified by the neonatology staff who will then contact the investigator on call for the research study. 
The neonatologist will first mention the study to the parents and then ask whether the parents will give 
permission for the study investigators to talk with them about the study in detail. Only parents who consent 
to hearing about the research study will be approached regarding enrollment of their newborn.  
In the second acutely presenting group, neonates present with symptoms indicative of or suggestive of 
seizures without prior warning. It is recognised that it will not be possible to recruit all patients in this group. 
Efforts to obtain consent will not be allowed to delay management.  However, in many cases there will be 
opportunity to ethically recruit and consent subjects without delaying care. For example, in cases where 
clinical seizures are brief and have stopped spontaneously, and in cases where there is suspicion of seizure 
activity but EEG confirmation is needed before AEDs are indicated.  
 
Consent procedure:  The PI and other selected study investigators (neurology and neonatology attendings 
and fellows) will obtain consent. All study investigators who will be obtaining consent will receive training in 
how to determine eligibility of subjects and how to discuss the research study and consent process with 
parents of a critically ill newborn. It is anticipated that some mothers may be hospitalized at a referring 
hospital where the baby was born; in that case the consent form will be faxed to that hospital for the 
parent(s) to review. If consent is obtained in part by telephone with either or both parents, the telephone 
consent will be witnessed by one of the medical personnel at the NICU where the newborn is being enrolled. 
The child’s assent will not be obtained as only newborns will be enrolled. Parents will be reassured that 
participation in this study is completely voluntary and that a refusal to provide consent will not affect their 
child’s clinical care. Parents will be informed that they can ask questions of study staff at any time during the 
study and contact information for the study staff will be provided on the consent form. The study investigator 
who obtains consent will ask the parent(s) questions to determine whether they have understood the 
informed consent process and the requirements of the study.   
 
 
Data and Safety Monitoring Plan (DSMB) 
 
The population being studied is a very sick pediatric population. A high rate of morbidity and mortality is 
expected in this patient group. Therefore a DSMB will be used to monitor adverse events occurring during the 
trial, to try to carefully determine whether the study drug is implicated in the outcome.  
The study will be conducted in compliance with the IRBs of the participating hospitals and with FDA 
regulations, since Dr. Haas holds an IND (#109622) from the FDA for the use of LEV to treat neonatal 
seizures and an Orphan Drug Designation for the treatment of neonatal seizures with levetiracetam (#10-
3033). 
 
The FDA will appoint a Data Safety and Monitoring Board (DSMB). The DSMB will have the opportunity to 
request changes in protocol design and conduct and to design the Data Safety Monitoring Plan for the trial. 
The DSMB will define how frequently it wants to meet, and the exact nature of the information it wants to 
review, in adherence to FDA specific guidelines for DSMBs. We expect that the DSMB will request to 
monitor adverse events, patient screening, study accrual, eligibility violations, and any protocol violations. 
The DSMB will report their conclusions and recommendations to the sponsor (Dr. Haas).  
 
We have assembled a highly qualified group who have agreed to serve on our DSMB pending approval from 
the FDA. The suggested  DSMB participants include James Cloyd PhD (Univ of Michigan) Director, Center 


 
 
Version: 13April2018 
for Orphan Drug Research ,Lawrence C. Weaver Endowed Chair-Orphan Drug Development is an expert in 
the clinical pharmacology antiepileptic drugs and medications used to treat rare pediatric neurological 
disorders; Our statistician is Sonya Jain PhD Associate Professor of Biostatistics & Bioinformatics at UCSD 
in the Department of Family & Preventive Medicine; Professor Terrie Inder MD (Washington University Saint 
Louis) is a pediatric neurologist and neonatologist and an international authority on neonatal clinical trials. 
These DSMB  members were chosen because (apart from our UCSD Statistician) they are external to the 
trial sites and have experience in conducting clinical trials in newborns or drug trials in childhood epilepsy. 
The current plan for reporting adverse events is proposed: 
 
Adverse event Reporting:  Newborns seizures who will be enrolled in this study are at high risk for several 
serious medical complications and death related to the underlying etiology of their seizures. Life support is 
withdrawn in a significant minority of severely asphyxiated newborns because of the high probability of 
severe neurologic disability. It is very unlikely that LEV will result in death or any serious adverse event.  
The following adverse events not described in the investigator’s brochure for LEV will be considered 
expected adverse events in this population: 
 
Clinical or electrographic seizures 
EEG abnormalities (seizures or background abnormalities) 
Multiorgan Failure 
Abnormal lab values associated with organ failure 
Death 
Any other adverse events associated with systemic asphyxia and hypoxic-ischemic encephalopathy 
in newborns 
 
Any adverse events that are expected, not related to LEV, and not severe in nature will be recorded in the 
database, and reviewed at regular meetings of the DSMB.  The DSMB will be able to review significant 
trends of adverse events at their meetings, since the DSMB will be the only party not blinded in this trial. 
After review of the data, the DSMB will report to the sponsor regarding the risks of the study and whether the 
risks are consistent with what is described in the informed consent form.  These reports will be provided by 
the sponsor to the local IRBs for determining continuing review, and to the FDA for annual IND safety 
reports. 
 
Any adverse events that are deemed by the investigator to be unexpected, possibly related to LEV, and 
severe in nature will be reported to the sponsor within 24 hours of the event.  These unanticipated adverse 
events will also be reported by the PI to the local IRB in accordance with the local IRB policies.  The sponsor 
will be responsible for reporting the unanticipated adverse events to the DSMB chair within 24 hours of 
receiving the report, and to the FDA in an IND safety report in accordance with FDA regulations.  The DSMB 
will determine if the adverse event changes the known risk to study subjects.  If the information changes the 
known risk to subjects, the DSMB’s report regarding the change in risk will be released to all participating 
investigators by the sponsor.  The DSMB may request changes to the DSMP. 
 
Mechanisms to minimize potential risks to privacy and confidentiality of data 
 
Privacy Provisions:  The treating neonatology staff or pediatric neurologist will first approach a newborn’s 
parents to ask permission for the study investigator to discuss the study with the family. Only if and after 
parents agree to this step will a study investigator then talk with the parents and review the subject’s medical 
record. Once informed consent is obtained, the parents may need to answer a few questions about the 
maternal and family health history, but study staff will obtain most of the data from the subjects’ medical 
records.  
 
Confidentiality Provisions:  The physicians and nurses caring for each newborn will need to know that the 
newborn is enrolled in this study but will not have access to data collected only for research purposes. 


 
 
Version: 13April2018 
Medical information collected during this study will become part of the subject’s hospital record, if the 
information is determined to be pertinent to the subject’s medical care or is a usual part of the subject’s care 
(e.g., results of tests ordered by treating clinicians that are also recorded for research purposes). Medical 
records are available to other health care professionals at the hospital and may be reviewed by hospital staff 
in their course of carrying out their responsibilities. However, they are required to maintain confidentiality in 
accordance with applicable laws and hospital policies. Information contained in a medical record may not be 
given to anyone unaffiliated with the hospital in a way that could identify the subject or parent without written 
consent, except as required or permitted by law. Information collected during the study that does not 
become part of a subject’s medical record will be stored in separate research files maintained by the 
investigators. These research records will not be made available to any individuals who are not part of the 
research team except upon a parent’s request or as required by law. If a subject is withdrawn from the 
research study, information that has already been collected will become part of the research database. 
 
Only the research coordinator, neurology fellow and site PI at each NICU will have access to individually 
identifiable information about newborns enrolled at that site. Data will be collected by the study investigators 
and research coordinator and recorded onto case report forms (CRFs) by the research coordinator. The 
CRFs and the electronic database containing the research data will contain only de-identified information to 
preserve confidentiality of patients’ protected health information. Only the study identification number will 
identify the subjects on the CRFs and in the electronic database. Files that link the study identification 
number for each subject to the subject’s personal information (such as name, medical record number, 
parents’ names) will be kept at each study site and accessible only by the site PI and research coordinator. 
The research database containing the subjects' study ID numbers and research data will be stored on a 
single computer, protected with a password, and will be backed up on the network in a private folder 
accessible only to study staff.  
 
Mechanism to minimize potential risks of adverse drug reaction related to LEV  
As described above LEV is a very safe drug with a wide therapeutic range. However, any adverse drug 
reaction is possible. Careful monitoring for adverse drug reactions will be maintained throughout the 
treatment period. Neonates will be monitored continuously during the study period for heart rate, respiratory 
rate and blood pressure. Serum chemistries and CBC will be performed at baseline and after 48 hours of 
treatment with study drug.  Daily physical examinations will be performed while in-house and record made of 
the occurrence of hypotonia, sedation, poor feeding, irritability or infection. Since all subjects will be closely 
monitored by clinical, laboratory and EEG data, it is expected that adverse events can be anticipated and 
managed rapidly and effectively by the treating clinicians. 
If there are serious adverse events, these events will be reported to the IRB within 24 hours of knowledge of 
the event, and will be reported to the DSMB in the timeframe that they require.  
 
Mechanism proposed to minimize the patient’s potential risks involving blood drawing  
Blood drawing will be done by clinical staff who are trained and experienced in drawing blood from newborns. 
A clinically indicated indwelling arterial or venous catheter will be present in most study subjects, so that in 
most cases there will be no discomfort to the newborns from needle sticks for research-only blood draws. 
Sterile techniques will be used at all times to minimize the chance of infection, thereby minimizing potential 
risks related to the collection of blood samples. It is possible that in some subjects indwelling arterial or venous 
catheter access will not be maintained throughout the study period and may require additional venipunctures 
or heel stick blood draws. All efforts will be made to reduce infants discomfort by warming the heel adequately 
prior to blood draw, administering oral glucose during blood draw and feeding infant after blood draw. 
 
Mechanism proposed to minimize patients’ risk of time delay to effective AED therapy 
Our study design ensures rapid escalation to treatment with Phenobarbital in subjects who do not respond to 
LEV. Additionally, because our study will utilize real time monitoring of continuous EEG recordings leading to 
more rapid detection and treatment of electrographic seizures than is normally standard of care, our study 
subjects will receive AED treatment in a shorter time frame than is usual. LEV has good efficacy in other 


 
 
Version: 13April2018 
populations, including in populations experiencing refractory status epilepticus. In neonates there are 
accumulating reports of its efficacy in cases where seizures are refractory to multiple other agents. Our 
preliminary analysis of efficacy when LEV is used as a second line agent suggests efficacy similar to that of 
Phenobarbital and phenytoin when used as second line agents. Therefore we believe that the risk that  the 
overall risk to patients is low in this regard 
 
 
Specific Measures to reduce potential risks listed in (13) 
 
1.Measures to reduce pain from venipunctures 
 
For the first days of the study all patients will have indwelling vessel catheter in place as part of their routine 
care.  This will render blood sampling painless and free of any risk beyond that usually associated with the 
care of a critically ill newborn.  Blood sampling towards the end of the 1-week treatment period may require 
additional venipunctures or heel stick blood draws. All efforts will be made to reduce infants discomfort by 
warming the heel adequately prior to blood draw, administering oral glucose during blood draw and feeding 
infant after blood draw. 
 
2. Measures to reduce risk secondary to blood loss from venipunctures  
The total blood drawn over 2 days for the study will be 44 to 5  ml (4 x 0.5 ml specimens for levetiracetam 
levels, and at the same lab draw as the last levetiracetam level an additional 1.0 ml  for chemistry CBC and 
phenobarbital level). By excluding infants with birth weights less than 2440g we will be able to ensure that this 
is a safe percentage (≤3%) of the infants total blood volume.  
 
3. Adverse drug reaction 
 
As above levetiracetam is apparently a very safe drug with a wide therapeutic range. Adverse drug reactions 
to orally administrated levetiracetam in adults and older children have been exceedingly rare. Use of the IV 
formulation in animal studies and a PK study in adults has so far not been associated with serious adverse 
drug reactions. However, any adverse drug reaction is possible including serious anaphylactic reaction and 
death. Careful monitoring for adverse drug reactions will be maintained throughout the treatment period: 
 
Levetiracetam has been well tolerated in other age groups and found to be without significant risks.  Adverse 
events have mainly consisted of CNS effects such as somnolence, asthenia, coordination difficulty and 
behavioral symptoms. Other than 2 cases of reversible thrombocytopenia associated with levetiracetam use, 
no unexpected toxicities or serious laboratory abnormalities have been reported. 
 
Neonates will be monitored continuously during the study period for heart rate, respiratory rate and blood 
pressure. 
Serum chemistries, and CBC will be performed at baseline and at end of treatment.   
Daily physical examinations will be performed while in-house and record made of the occurrence of 
hypotonia, sedation, poor feeding, irritability or infection. 
Following the last dose of study drug, a phone review of the same symptoms will be conducted every 3 days 
and a visit and physical examination will be conducted one week after the last dose of study drug. A home 
visit or clinic visit can be conducted if the subject is discharged. 
 
 
4. Mechanism proposed to minimize patients’ risk of time delay to effective AED therapy 
 
Our study design ensures rapid escalation to treatment with Phenobarbital in subjects who do not respond to 
LEV. Additionally, because our study will utilize real time monitoring of continuous EEG recordings leading to 
more rapid detection and treatment of electrographic seizures than is normally standard of care, our study 


 
 
Version: 13April2018 
subjects will receive AED treatment in a shorter time frame than is usual. LEV has good efficacy in other 
populations, including in populations experiencing refractory status epilepticus. In neonates there are 
accumulating reports of its efficacy in cases where seizures are refractory to multiple other agents. Our 
preliminary analysis of efficacy when LEV is used as a second line agent suggests efficacy similar to that of 
Phenobarbital and phenytoin when used as second line agents. Therefore we believe that the 
overall risk to patients is lower than the usual clinical care risk when using our treatment protocol. The 
continuous EEG monitoring that will be used for the study will mean that these determinations of the efficacy of 
medications will be possible sooner than is possible with routine management.  
 
 
5. Measures to safeguard confidentiality of data. 
 
Personal identifiers such as name, date of birth and medical record number will be eliminated from each 
case as it is entered in the database. A single copy of the list linking medical record number to study number 
will be kept locked and will be available only to study investigators. Data will be entered on single secure 
database, accessible only by study investigators. The code will be destroyed at the end of the study. 
 
15. POTENTIAL BENEFITS: 
The main benefit of the study will be to society and future neonates with seizures, in the knowledge that will be 
gained from the study.  If LEV efficacy, safety and pharmacokinetics can be established in neonates this will 
be of great benefit to all neonates with seizures. Developing better infrastructures to increase the feasibility of 
continuous monitoring and the early detection of neonatal seizures will also significantly improve the 
management of this condition. 
 
Several potential benefits to enrollment in this study compare favorably with the low risks associated with 
participation in the study. One principal benefit of this study is that early and more intensive “real time” EEG 
monitoring will likely lead to more rapid diagnosis and treatment of neonatal seizures than in the current 
standard of care. Subjects enrolled in both treatment and control groups will have the potential benefit of this 
early EEG monitoring.  
 
Although there are potential risks associated with administration of LEV, the overall risk of adverse events 
are low. All subjects will be carefully monitored with respect to clinical, laboratory and EEG data in a more 
systematic fashion than is typical in the care of such newborns, thus any adverse event will be recognized 
quickly. Our study design ensures rapid escalation to standard treatment with Phenobarbital in subjects who 
do not respond to LEV. Additionally, because our study will utilize real time monitoring of continuous EEG 
recordings leading to more rapid detection and treatment of electrographic seizures than is normally 
standard of care, it is likely our study subjects will receive AED treatment in a shorter time frame than is 
usual. 
 
Benefits to the individual participant: 
 
Potential Benefits of the Proposed Research to Human Subjects and Others 
There may be no benefit to the individual participant. A potential benefit of this study is that earlier placement 
of EEG leads and greater than routine monitoring of the prolonged EEG recording, clinical and laboratory 
data will improve the overall management of the subjects’ seizures and other clinical conditions, compared 
with standard management of these patients. In particular, there will likely be more rapid diagnosis and 
management of seizures than in the standard care of newborns with seizures, because of the early, 
continuous EEG monitoring analyzed in near-real time. This relates in part to the lack of availability of rapid 
placement of EEG electrodes and less vigilant or less frequent/prolonged monitoring of EEG data for 
recurrent seizures in the standard clinical care of newborns. EEG monitors cannot usually be placed rapidly 
because of the lack of availabile EEG technologists to place EEG leads on an urgent basis, especially at 
night or on weekends. In standard practice, continuous EEG monitoring is often not started until seizures are 


 
 
Version: 13April2018 
clearly shown to be refractory, which may not be recognized when most or all of the seizures are 
electrographic only (subclinical). EEG monitoring for clinical purposes is often intermittent rather than 
continuous and prolonged over two days. 
 
Another potential benefit of the study to the participant is that LEV may be a more effective antiepileptic 
medication than the standard treatments. It is also a potential benefit to the participant that LEV may be a safer 
drug associated with fewer side effects than the standard treatments. 
 
Benefits to society: 
Importance of the Knowledge to be gained 
There are no FDA approved treatments for neonatal seizures. More effective and less toxic treatments are 
urgently required. Neonatal seizures are a common problem and cause significant morbidity. Current standard 
of care treatments Phenobarbital and phenytoin are unsatisfactory1, each agent is effective in less than 50% 
of subjects, and both have significant acute and chronic side effects. In animal studies these agents cause 
accelerated neuronal apoptosis in the neonatal brain. Better treatments could limit brain damage and improve 
neurodevelopmental outcomes in this high risk population. LEV has great potential as a treatment for neonatal, 
hhowever; the efficacy of LEV has not been systematically studied in neonates and cannot be assumed.  Drugs 
that are effective in terminating seizures in adults may be less effective and have more toxicity in neonates.  
 
Efforts to develop better treatments for neonatal seizures are confounded by the need in any drug trial for 
systematic continuous EEG monitoring, something that is not yet standard of care because of resource 
constraints. The proposed project would address the need to find feasible solutions to the difficulties of 
providing continuous EEG monitoring through new technology.  
 
Should LEV prove an effective medication in this age group, clinical practice would be dramatically improved. 
We would have a safe, non-toxic treatment option for neonatal seizures with proven efficacy. 
 
Developing better systems for neonatal seizure detection will facilitate earlier treatment of neonatal seizures 
and enable further clinical research in this condition. 
 
If levetiracetam efficacy, pharmacokinetics and safety can be established in neonates with seizures this will be 
of great benefit to all neonates with seizures. 
 
This study will be registered in ClinicalTrials.gov. website as required by the FDA. 
 
16. RISK/BENEFIT RATIO: 
No drug study in neonates is without risk, however IV levetiracetam appears to be a very safe drug. There is a 
dire need for better anti-epileptic agents for neonates and there are substantial risks associated with the use of 
standard therapies. The potential benefit to all neonates with seizures outweighs the risks that would be 
involved in this study. There is considerable potential that the risk/benefit ratio is favorable in the study 
subjects themselves. 
 
17. EXPENSE TO SUBJECT: 
 
None. 
Cost of levetiracetam, all blood and urine specimens drawn for the purposes of the study and EEG monitoring 
for the purposes of the study will be paid for by the study. 
 
18. COMPENSATION FOR PARTICIPATION: 
 
None. 
 


 
 
Version: 13April2018 
19. PRIVILEGES/CERTIFICATIONS/LICENSES AND ROLES OF THE RESEARCH TEAM: 
Auckland (National Women’s) Hospital  
Cynthia Sharpe, MB ChB, Pediatric Neurologist, Principal Investigator 
Suzanne Davis, MD, Neurology and Pediatrics, Co-Investigator 
 
UCSD Co-Investigators and Research Staff 
Richard Haas, MB B Chir, Pediatric Neurology, Principle Investigator 
Gail Reiner, DNP, FNP-C, Neurosciences, Co-Investigator 
Sonya Wang, MD, Neurosciences and Pediatrics, Co-Investigator  
Krishelle Marc-Aurele, MD, Pediatrics, Co-Investigator 
Jae Kim, MD, Pediatrics, Co-Investigator 
Renee Bridge, BSN, RN, Neonatology, Research Nurse 
Kimberly Thomas, MS, Neonatology, Research Coordinator 
Mallory Boutin, MPH, Neonatology, Research Coordinator 
Lilly Lee, BA, Neurosciences, Research Assistant 
 
RCHSD Co-Investigators and Research Staff 
Jeff Gold, MD, PhD, Neurology and Pediatrics, Principal Investigator 
Brian Lane, MD, Neonatology, Principal Investigator 
Jose Honold, MD, Neonatology, Co-Investigator 
Eileen Cowan, MD, Neonatology, Co-Investigator  
Mark Speziale, MD, Neonatology, Co-Investigator 
Amy Kimball, MD, Neonatology, Co-Investigator 
Denise Suttner, MD, Neonatology, Co-Investigator 
Crystal Le, MD, Neonatology, Co-Investigator 
Marva Evans, MD, Neonatology, Co-Investigator 
Ellen Knodel, RCP, Neonatology, Research Coordinator 
 
Sharp Mary Birch Hospital Co-Investigators and Research Staff 
Maynard Rasmussen, MD, Director of Neonatology, Principal Investigator 
Paul Wozniak, MD, Neonatology, Co-Investigator 
Nancy Wight, kMD, Neonatology, Co-Investigator 
Jack Anderson, MD, Neonatology, Co-Investigator 
Allison Graham, MD, Neonatology, Co-Investigator 
Anup Katheria, MD, Neonatology, Co-Investigator 
Zahra Ghorishi, MD, Neonatology, Co-Investigator 
Mandhir Suri, MD, Neonatology, Co-Investigator 
Jeevarathi Gnanaratnem, MD, Neonatology, Co-Investigator 
David Kaegi, MD, Neonatology, Co-Investigator 
Graham Bernstein, MD, Neonatology, Co-Investigator 
Donna Garey, MD, Neonatology, Co-Investigator 
Deborah Petruzzelli, BSN, Research Nurse 
Kathy Arnell, BSN, Research Nurse 
Sarah Jane Steen, RN, Research Nurse 
 
Children’s Hospital Oakland 
Rachel Kuperman, MD, Director of Epilepsy Program, Principal Investigator 
Priscilla Joe, MD, Neurology and Pediatrics, Co-Investigator 
Marisa Gardner, MD, Neonatology, Co-Investigator 
Sharon Jubrias, PhD, Research Coordinator 
 
Children’s Hospital of Orange County 
Mary Zupanc, MD, Neurology, Principal Investigator 
Andrew Mower, MD, Neurology, Co-Investigator 
Daniel Shrey, MD, Neonatology, Co-Investigator 
Maija Steen, MD, Neonatology, Co-Investigator 
Lily Tran, MD, Neonatology , Co-Investigator 
Dorian Chan, BSN, RN, CCC, Research Nurse and Coordinator 
Rebeca Quintana, CRA, Research Coordinator 
 
Pharmacologist 
Edmund Capparelli, PharmD, Clinical Professor and Director of Pediatric Pharmacology Research Unit 


 
 
Version: 13April2018 
 
Other Research Staff Member 
Mary Jo Harbert, MD, Consulting Pediatric Neurologist, UCSD, RCHSD, Sharp Mary Birch 
Jason Sauberan, PharmD, Pharmaceutical Sciences, UCSD 
Rema Raman, PhD, Neurosciences, Principal Statistician UCSD 
David Michelson, MD, Neurology, Loma Linda University 
 
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Faul S, Boylan G, Connolly S, Marnane L, Lightbody G. An evaluation of automated neonatal seizure 
detection methods. Clin Neurophysiol 2005;116(7):1533-41. PMID: 15897008 
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De Smedt T, Raedt R, Vonck K, Boon P. Levetiracetam: part II, the clinical profile of a novel 
anticonvulsant drug. CNS Drug Rev 2007;13(1):57-78. PMID: 17461890 
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Silverstein FS, Ferriero DM. Off-label use of antiepileptic drugs for the treatment of neonatal seizures. 
Pediatr Neurol 2008;39(2):77-9. PMID: 18639748 
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De Smedt T, Raedt R, Vonck K, Boon P. Levetiracetam: the profile of a novel anticonvulsant drug-part 
I: preclinical data. CNS Drug Rev 2007;13(1):43-56. PMID: 17461889 
32. 
Kim J, Kondratyev A, Gale K. Antiepileptic drug-induced neuronal cell death in the immature brain: 
effects of carbamazepine, topiramate, and levetiracetam as monotherapy versus polytherapy. J 
Pharmacol Exp Ther 2007;323(1):165-73. PMID: 17636003 
33. 
Glauser TA, Mitchell WG, Weinstock A, et al. Pharmacokinetics of levetiracetam in infants and young 
children with epilepsy. Epilepsia 2007;48(6):1117-22. PMID: 17442002 
34. 
Chhun S, Jullien V, Rey E, Dulac O, Chiron C, Pons G. Population pharmacokinetics of levetiracetam 
and dosing recommendation in children with epilepsy. Epilepsia 2009;50(5):1150-7. PMID: 19175400 
35. 
Pellock JM, Glauser TA, Bebin EM, et al. Pharmacokinetic study of levetiracetam in children. Epilepsia 
2001;42(12):1574-9. PMID: 11879369 
36. 
Fountain NB, Conry JA, Rodriguez-Leyva I, et al. Prospective assessment of levetiracetam 
pharmacokinetics during dose escalation in 4- to 12-year-old children with partial-onset seizures on 
concomitant carbamazepine or valproate. Epilepsy Res 2007;74(1):60-9. PMID: 17270398 
37. 
Klitgaard H, Matagne A, Gobert J, Wulfert E. Evidence for a unique profile of levetiracetam in rodent 
models of seizures and epilepsy. Eur J Pharmacol 1998;353(2-3):191-206. PMID: 9726649 
38. 
Genton P, Van Vleymen B. Piracetam and levetiracetam: close structural similarities but different 
pharmacological and clinical profiles. Epileptic Disord 2000;2(2):99-105. PMID: 10954241 
39. 
Krief P, Li K, Maytal J. Efficacy of levetiracetam in children with epilepsy younger than 2 years of age. 
J Child Neurol 2008;23(5):582-4. PMID: 18448575 
40. 
Shoemaker MT, Rotenberg JS. Levetiracetam for the treatment of neonatal seizures. J Child Neurol 
2007;22(1):95-8. PMID: 17608315 
41. 
Sharpe C, Haas RH. Levetiracetam in the Treatment of Neonatal Seizures. J Pediatr Neurol 2009;7:79-
83.**** 
42. 
Wheless JW, Clarke D, Hovinga CA, et al. Rapid infusion of a loading dose of intravenous levetiracetam 
with minimal dilution: a safety study. J Child Neurol 2009;24(8):946-51. PMID: 19264738 
43. 
Ramantani G, Ikonomidou C, Walter B, Rating D, Dinger J. Levetiracetam: Safety and efficacy in 
neonatal seizures. Eur J Paediatr Neurol. PMID: 21094062 
44. 
Obeid M, Pong AW. Efficacy and tolerability of high oral doses of Levetiracetam in children with 
epilepsy. Epilepsy Res;91(1):101-5. PMID: 20663645 
45. 
Depositario-Cabacar DT, Peters JM, Pong AW, et al. High-dose intravenous levetiracetam for acute 
seizure exacerbation in children with intractable epilepsy. Epilepsia;51(7):1319-22. PMID: 20163437 


 
 
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46. 
Privitera M. Efficacy of levetiracetam: a review of three pivotal clinical trials. Epilepsia 2001;42 Suppl 
4:31-5. PMID: 11564123 
47. 
Brodie MJ, Perucca E, Ryvlin P, Ben-Menachem E, Meencke HJ. Comparison of levetiracetam and 
controlled-release carbamazepine in newly diagnosed epilepsy. Neurology 2007;68(6):402-8. PMID: 
17283312 
48. 
Noachtar S, Andermann E, Meyvisch P, Andermann F, Gough WB, Schiemann-Delgado J. 
Levetiracetam for the treatment of idiopathic generalized epilepsy with myoclonic seizures. Neurology 
2008;70(8):607-16. PMID: 18285535 
49. 
Berkovic SF, Knowlton RC, Leroy RF, Schiemann J, Falter U. Placebo-controlled study of levetiracetam 
in idiopathic generalized epilepsy. Neurology 2007;69(18):1751-60. PMID: 17625106 
50. 
Glauser TA, Ayala R, Elterman RD, et al. Double-blind placebo-controlled trial of adjunctive 
levetiracetam in pediatric partial seizures. Neurology 2006;66(11):1654-60. PMID: 16641323 
51. 
Vigevano F. Levetiracetam in pediatrics. J Child Neurol 2005;20(2):87-93. PMID: 15794171 
52. 
Opp J, Tuxhorn I, May T, et al. Levetiracetam in children with refractory epilepsy: a multicenter open 
label study in Germany. Seizure 2005;14(7):476-84. PMID: 16182573 
53. 
Grosso S, Cordelli DM, Franzoni E, et al. Efficacy and safety of levetiracetam in infants and young 
children with refractory epilepsy. Seizure 2007;16(4):345-50. PMID: 17368928 
54. 
Striano P, Coppola A, Pezzella M, et al. An open-label trial of levetiracetam in severe myoclonic 
epilepsy of infancy. Neurology 2007;69(3):250-4. PMID: 17636062 
55. 
Belcastro V, Costa C, Striano P. Levetiracetam-associated hyponatremia. Seizure 2008;17(4):389-90. 
PMID: 18584781 
56. 
Verrotti A, Coppola G, Manco R, et al. Levetiracetam monotherapy for children and adolescents with 
benign rolandic seizures. Seizure 2007;16(3):271-5. PMID: 17204435 
57. 
Pina-Garza JE, Nordli DR, Jr., Rating D, Yang H, Schiemann-Delgado J, Duncan B. Adjunctive 
levetiracetam in infants and young children with refractory partial-onset seizures. Epilepsia 
2009;50(5):1141-9. PMID: 19243423 
58. 
Furwentsches A, Bussmann C, Ramantani G, et al. Levetiracetam in the treatment of neonatal seizures: 
a pilot study. Seizure;19(3):185-9. PMID: 20133173 
59. 
Wilson SB, Scheuer ML, Emerson RG, Gabor AJ. Seizure detection: evaluation of the Reveal algorithm. 
Clin Neurophysiol 2004;115(10):2280-91. PMID: 15351370 
60. 
Wilson SB. A neural network method for automatic and incremental learning applied to patient-
dependent seizure detection. Clin Neurophysiol 2005;116(8):1785-95. PMID: 16005680 
61. 
Wilson SB. Algorithm architectures for patient dependent seizure detection. Clin Neurophysiol 
2006;117(6):1204-16. PMID: 16600676 
62. 
Mendu DR, Soldin SJ. Simultaneous determination of levetiracetam and its acid metabolite (ucb L057) 
in serum/plasma by liquid chromatography tandem mass spectrometry. Clin Biochem;43(4-5):485-9. 
PMID: 19941845 
63. 
Painter MJ, Scher MS, Stein AD, et al. Phenobarbital compared with phenytoin for the treatment of 
neonatal seizures. N Engl J Med 1999;341(7):485-9. PMID: 10441604 
64. 
Friedman LM, Furberg CD, DeMets DL: Fundamentals of Clinical Trials. 3rd ed. New York, 1998, 
Springer-Verlag. ISBN 0-387-98586-7 SPIN 10953785 
65. 
Hunt S, Craig J, Russell A, et al. Levetiracetam in pregnancy: preliminary experience from the UK 
Epilepsy and Pregnancy Register. Neurology 2006;67(10):1876-9. PMID: 17130430 
66. 
Tan TC, de Boer BW, Mitchell A, et al. Levetiracetam as a possible cause of fulminant liver failure. 
Neurology 2008;71(9):685-6. PMID: 18725594 
67.      Merhar SL, Schilber KR, Sherwin CM et al. Pharmacokinetics of Levetiracetam in Neonates with 
seizures. J  Pediatr 2011;159:152-4. PMID: 21592494 
68.     Abend NS, Guitierrez-Colina AM, Monk HM, Dlugos DJ, Clancy RR. Levetiracetam for Treatment of 
Neonatal Seizures. J Child Neurol  2011;26:465-70. PMID: 21233461 
69.      Khan O, Chang E, Cipriani C et al. Use of Intravenous Levetiracetam for Management of Acute           
Seizures in Neonates. Pediatr Neurol 2011;44:265-269. PMID: 21397167 
 


 
 
Version: 13April2018 
 
 
21. INDUSTRY-SPONSORED OR COLLABORATING STUDIES: 
 
Not applicable. 
 
22. OTHER FUNDING SUPPORT FOR THIS STUDY: 
 
FDA Orphan Products Development Grant  
Application FD-R-4147-01 Richard Haas MD Principal Investigator 
 
 
23. BIOLOGICAL MATERIALS TRANSFER AGREEMENT 
 
A materials transfer agreement is on file with UCSD. 
 
24. INVESTIGATIONAL DRUG FACT SHEET: 
 
See Attached – Package Insert for Keppra 
 
25. IMPACT ON STAFF:  
Neonatal residents, fellows and attendings will be asked to identify patients at risk, briefly discuss the study 
with patients families and request permission to notify study staff. 
Respiratory technicians and nurses or EEG technicians together with study investigators will be required to 
apply continuous EEG monitors, depending on the procedures in place at each study site.  
If blood collection is to be done via indwelling catheters, the infant’s primary nurse will be required to draw 
these labs. 
Nursing staff will be asked to administer the IV medication. 
Investigational pharmacy will prepare all doses of medication. 
Study staff will conduct all other duties, including the labeling and sending of specimens for collection. 
The procedures to be done by non-study staff require minimal additional time and are not expected to 
adversely impact the staff. 
 
26. CONFLICT OF INTEREST (COI) 
None 
 
27. SUPPLEMENTAL INSTRUCTIONS FOR CANCER-RELATED STUDIES 
 
NA 
28. PROCEDURES FOR SURROGATE CONSENT AND/OR DECISIONAL CAPACITY ASSESSMENT 
NA 
 
29. HIPAA AND CONFIDENTIALITY 
Application for partial waiver of HIPAA authorization is requested for the recruitment process in order to 
allow communication between clinicians and investigators. Specifically the waiver of consent for the transfer 
from the clinical team to the study team of clinical information needed to determine patient eligibility for the 
study is required. This was granted in our currently active IRB levetiracetam protocol. 
 
Protected health information will be entered into the database with the consent of the subject’s parents. 
In addition to the pharmacokinetic, seizure cessation and safety data for each patient, data entered will include 
demographic data and clinical baseline data, such as gestational age, mode of delivery, postnatal age at 
presentation, presumed etiology but personal identifiers such as name, date of birth and medical record 


 
 
Version: 13April2018 
number will be eliminated from each case as it is entered in the database Personally identifiable data will not 
be publicly disclosed. Single copy of list linking medical record number to study number will be kept locked 
and available only to study investigators. Data will be entered on single secure database, accessible only by 
study investigators. 
 
Study records will not be released without separate consent, except as required by law. 
Code linking medical record to study number in the database will be destroyed once the study is published. 
 
 
 
2 
L. Prediction of outcome based on clinical seizure type in newborn infants. J; 140(6): 707-12.  
 
 
 
 
 
                                                        

SAP_000.pdf: 
CONFIDENTIAL DOCUMENT 
Statistical Analysis Plan (SAP) 
VERSION 2 
Efficacy of Intravenous Levetiracetam in Neonatal Seizures 
(NEOLEV2) 
September 14, 2018 
Principal Investigator: 
Richard Haas, MD 
Lead Biostatistician:  
Rema Raman, PhD 
Author: 
Karin Ernstrom, MS 


NEOLEV2 SAP VERSION 2 
2 
CONFIDENTIALITY STATEMENT: This report from the USC Alzheimer’s Therapeutic Research Institute (ATRI) is for the sole use of the intended recipient(s)  and contains 
confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
 
Contents 
1 Introduction 
3 
2 Abbreviations 
3 
3 Study Design/Summary 
3 
3.1 Overview 
3 
3.2 Specific Aims 
4 
3.3 Study Population 
4 
3.4 Power and Sample Size Determination 
5 
3.5 Treatment Allocation 
5 
4 Study Outcome Variables 
5 
4.1 Primary Outcome 
5 
4.2 Key Secondary Outcome 
5 
4.3 Other Secondary Outcomes 
6 
4.4 Safety Outcomes 
6 
5 Sequence of Planned Analysis 
6 
5.1 Interim Analysis 
6 
5.2 Final Analyses and Reporting 
6 
6 Statistical Methods 
6 
6.1 Analysis Populations 
6 
6.2 Multiple Comparisons and Multiplicity 
6 
6.3 Covariates 
6 
6.4 Data Management and Analysis Software 
7 
7 Statistical Analysis 
7 
7.1 Study Flow 
7 
7.2 Patient characteristics and baseline variables 
7 
7.3 Analysis of Primary and Key Secondary Outcomes 
7 
7.4 Analysis of Remaining Secondary Outcomes 
8 
7.5 Analysis of Safety Outcomes 
8 
7.6 Pharmacokinetic Analysis 
8 
8 Appendix 
9 
8.1 Study Flow Chart 
9 
8.2 Approval 
10 
 


NEOLEV2 SAP VERSION 2 
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CONFIDENTIALITY STATEMENT: This report from the USC Alzheimer’s Therapeutic Research Institute (ATRI) is for the sole use of the intended recipient(s)  and contains 
confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
 
1 Introduction 
This document is the second version of the Statistical Analysis Plan (SAP) describing the planned analyses and reporting for 
the NEOLEV2 trial. The SAP was updated due to a change in primary outcome from seizure termination at 48 hours after 
treatment to seizure termination at 24 hours after treatment. This change was approved by the FDA on September 4, 2018. 
 
The planned analyses identified in this SAP, will be included in future manuscripts. Exploratory analyses not necessarily 
identified in this SAP may be performed to support planned analyses. Any post-hoc or unplanned analyses not specified in 
this SAP will be clearly identified as such in the manuscripts for publication. 
 
The following documents were reviewed when preparing this SAP: 
 
• NEOLEV2 Clinical Research Plan (111361 NEOLEV2 Research Plan Clean 20180413.docx) 
 
• ATRI Statistical Analysis Plan SOP 
 
Readers of this SAP should read the Clinical Research Plan for details on the conduct of this study and the operational aspects 
of clinical assessments and timing for completing a patient in this study. 
 
2 Abbreviations 
 
ABBREVIATION 
DEFINITION 
 
AE 
Adverse Event 
ATRI 
Alzheimer’s Therapeutic Research Institute 
CRF 
Case Report Form 
DSMC 
Data and Safety Monitoring Committee 
LEV 
Levetiracetam 
PB 
Phenobarbital 
PK 
Pharmacokinetic 
PP 
Per-Protocol 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SOP 
Standard Operating Procedure 
 
3 Study Design/Summary 
3.1 Overview 
This section is from the NEOLEV2 Clinical Research Plan (111361 NEOLEV2 Research Plan Clean 20180413.docx). 
 
This study will be a phase II preliminary efficacy, dose escalation and safety study. The study design will be a randomized 
blinded controlled treatment study. Infants recognized as having neonatal seizures or as being at risk of developing seizures 
will be recruited and started on continuous video EEG monitoring. The EEG data will then be reviewed continuously for 
electrographic seizures by study investigators, along with remote continuous EEG monitoring by Corticare technicians. A 
novel seizure detection algorithm operating in near-real time will be compared to the real-time continuous EEG reading. 
Once eligibility and consent are confirmed, patients will be randomly assigned to the LEV or control treatment group in a 60:40 
allocation ratio, stratified by site. 
 
Blinding will be maintained by appropriate dilution of LEV and Phenobarbital such that the same volume (ml/kg) loads are given 
to both treatment groups. 
 
Subjects randomized to receive LEV will, at the onset of electrographically confirmed seizure activity, receive an intravenous 
loading dose of LEV of 40mg/kg given over 15 minutes. If electrographic seizures are confirmed to persist or recur more than 


NEOLEV2 SAP VERSION 2 
4 
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confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
15 minutes after the first infusion is complete, a further 20mg/kg load of LEV will be administered IV over 15 minutes. 
Maintenance LEV at 10 mg/kg/dose will be given IV q8 hours and continued for at least 5 days. If seizures persist or recur 
more than 15 minutes after the second LEV infusion is complete, a PB loading dose of 20 mg/kg will be administered IV over 
15 minutes. If seizures persist or recur more than 15 minutes after the first loading dose of PB is complete, a second 20mg/kg 
load will be administered IV over 15 minutes. This will result in PB being started within 1 hour of the onset of seizures if and 
when loading with LEV is ineffective. Patients given any PB loading doses will be started on maintenance PB with 1.5 
mg/kg/dose given IV q8 hours and continued at least until the end of the study. Subjects randomized to the control group will, 
at the onset of electrographically confirmed seizure activity, receive an intravenous loading dose of PB of 20 mg/kg given over 
15 minutes. If electrographic seizures are confirmed to persist or recur more than 15 minutes after the first infusion is 
complete, a further 20mg/kg load of PB will be administered IV over 15 minutes. Maintenance PB at 1.5 mg/kg/dose will be 
given IV q8 hours and continued for at least 5 days. If seizures persist or recur more than 15 minutes following the second 
PB infusion, a 40 mg/kg load of LEV will be administered IV over 15 minutes. If seizures persist or recur more than 15 minutes 
after the first loading dose of LEV is complete, a second 20mg/kg load of LEV will be administered IV over 15 minutes. 
Patients given an LEV loading doses will be started on maintenance LEV with 10 mg/kg/dose given IV q8 hours and continued 
at least until the end of the study. 
 
If electrographic seizures are still apparent following treatment with both LEV and PB, or if they recur during the 5 days during 
which the study protocol is active, the patient will be considered to have failed the experimental treatment regime and 
institutional specific standard seizure management will dictate the ongoing management. Without unblinding, it will be evident 
that all subjects will have received 40mg/kg Phenobarbital and 60mg/kg of LEV at this stage. 
 
For study flow, see appendix. 
 
3.2 Specific Aims 
This section is from the NEOLEV2 Clinical Research Plan (111361 NEOLEV2 Research Plan Clean 20180413.docx) 
 
Aim 1: To study the preliminary efficacy of intravenous LEV as first line treatment for neonatal seizures. The primary endpoint 
will be the percentage of neonates whose seizures are terminated with LEV for 48 hours, and do not go on to require 
a second anticonvulsant agent. A secondary endpoint will be seizure cessation for 1 hour after treatment with LEV. 
Aim 2: Dose escalation: To determine whether there is additional efficacy at higher doses of LEV than 40mg/kg. The 
percentage of neonates whose seizures stop following 60mg/kg LEV, having not responded to 40mg/kg LEV, will be 
calculated. 
Aim 3: To study the pharmacokinetics of intravenous LEV at high dosage. The hypothesis is that the pharmacokinetics of 
high dose intravenous LEV will follow predictions based upon previous lower dosage PK studies. 
Aim 4: To obtain further safety data regarding the use of high dose Levetiracetam in this population. 
Aim 5: 5A: To prove the feasibility of centralized remote monitoring of continuous EEG monitoring in the NICU via the 
internet, thereby developing infrastructure vital to further neonatal seizure research. 
5B: To test the sensitivity and specificity of a promising neonatal seizure detection algorithm in comparison with 
readings of each record by 2 electroencephalographers skilled in neonatal EEG analysis. 
ANALYSIS OF AIMS 5A AND 5B WILL NOT BE A PART OF THE PRIMARY ANALYSIS DUE TO MONITORING CHANGES 
IN THE STUDY. 
 
3.3 Study Population 
Inclusion Criteria: 
Term newborns admitted to the UCSD, Children’s Hospital and Research Center Oakland, Auckland Hospital, Rady Children’s 
Hospital, Loma Linda University Medical Center or Sharp Mary Birch NICUs with seizures or at risk for seizures: 
• Term infants (gestational age greater than or equal to 36 weeks and less than or equal to 44 weeks). 
• Postnatal age < 14 days. 


NEOLEV2 SAP VERSION 2 
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confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
• Serum creatinine equal to or less than 1.6 mg/dL at time of enrollment. 
• Are still experiencing either clinical or electroencephalographic seizures or are at risk for neonatal seizures. 
• For whom parental consent to participate in the study is obtained. 
Exclusion criteria: 
• Biochemical abnormality - hypoglycemia, hypocalcemia - that when treated result in seizure cessation. 
• Severe hypoxic ischemic injury likely to result in imminent death. 
• Infants with a birth weight less than 2200 g would be excluded the study. This is the new recommended 10th percentile 
for 36 weeks’ gestation. The blood drawn at any one time will be <3 mls/kg which remains within the NIH guidelines for 
pediatric blood draws. 
Patients of all ethnic groups will be included in the study. Based on the patient population our group treats, most patients will 
be European or Hispanic. Both male and female infants will be recruited to the study. 
 
The only significant exclusions that will be made in recruitment and enrollment will be the exclusion of infants who are judged by 
the attending neonatologist to be so critically ill that death is imminent and benefit from neonatal intensive care is very unlikely. 
No rule-based criteria, (using lab or clinical parameters) adequately capture the complete nature of this clinical assessment. 
In general any child receiving active treatment with head cooling will not be excluded. Mechanical ventilation and/ or the use 
of inotropic agents to support blood pressure will not be exclusion criteria. 
 
3.4 Power and Sample Size Determination 
Power calculations were based on a 2-sided chi-square test for detecting a difference between two proportions, assuming a 
Type 1 error of 0.05. With a sample size of 60 LEV subjects and 40 PB subject and assuming a seizure cessation rate of 50% 
in the control arm, we have 80% power to detect a seizure cessation rate as low as 22% (an absolute difference in seizure 
outcome rates of 28% or greater) in the LEV group. 
 
3.5 Treatment Allocation 
The two interventions are as follows: 
 
• Group 1 (active): Levetiracetam treatment 
 
• Group 2 (control): Standard treatment with Phenobarbital 
 
3.6 Modification of Primary Aim 
Aim 1 was changed from seizure termination at 48 hours after treatment to seizure termination at 24 hours after treatment. This 
change was approved by the FDA on September 4, 2018 (see appendix for e-mail confirmation). The updated aim 1 reads as 
follows: 
Aim 1: To study the preliminary efficacy of intravenous LEV as first line treatment for neonatal seizures. The primary endpoint 
will be the percentage of neonates whose seizures are terminated with LEV for 24 hours, and do not go on to require 
a second anticonvulsant agent. A secondary endpoint will be seizure cessation for 48 hours and 1 hour after treatment 
with LEV. 
 
4 Study Outcome Variables 
4.1 Primary Outcome 
• Seizure termination at 24 hours after treatment. 
 
4.2 Key Secondary Outcome 


NEOLEV2 SAP VERSION 2 
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confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
• Seizure termination at 48 hours after treatment. 
 
4.3 Other Secondary Outcomes 
 
• Seizure termination at 1 hour after treatment. 
• Dose escalation - Seizure termination at 24 hours following 60mg/kg LEV, having not responded to 40mg/kg. 
• Length of seizure freedom. 
• Phenobarbital dose 
 
4.4 Safety Outcomes 
• Rate of Adverse Events (AEs) 
 
• Rate of Serious Adverse Events (SAE) 
 
• Discontinuation Rate 
 
• Laboratory data 
 
• PK analysis of LEV 
5 Sequence of Planned Analysis 
5.1 Interim Analysis 
AEs and SAEs are being monitored on a regular basis by a Data and Safety Monitoring Committee (DSMC). No interim futility 
or efficacy analyses are planned. 
 
5.2 Final Analyses and Reporting 
All final planned analyses identified in the research plan and in this SAP will be performed only after the last patient has 
completed assessments scheduled for the length of the study period and the database has been cleaned and locked. Any post- 
hoc exploratory analyses performed to provide support for planned analyses but not identified in this SAP will be documented 
and clearly identified as unplanned analysis in the manuscript. 
6 Statistical Methods 
6.1 Analysis Populations 
• Intent-To-Treat [ITT] population: All randomized participants. 
 
• Per-Protocol (PP) population: Excluding babies not following the protocol. 
 
• Subset Populations: Hypoxic-Ischemic Encephalopathy (HIE); Cooled/not cooled 
 
6.2 Multiple Comparisons and Multiplicity 
Tests of group differences (active LEV compared to the control PB group) for the primary outcome will be conducted at a two- 
sided alpha level of 0.05. Similarly, other secondary outcomes will also be conducted using a two-sided alpha level of 0.05. No 
adjustment for multiple comparisons will be used in this study; however, all results will be reported using point estimates with 
the corresponding 95% confidence intervals. 
 
6.3 Covariates 
Covariate adjustment will be specified for each analysis in their respective sections in this SAP, as applicable. 


NEOLEV2 SAP VERSION 2 
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confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
 
6.4 Data Management and Analysis Software 
All analyses will be performed using R statistical software (http://www.r-project.org). The R version used will be specified in the 
analysis reports and will be reported in all manuscripts. 
7 Statistical Analysis 
7.1 Study Flow 
A CONSORT style flow diagram will illustrate patient progression through the trial from enrollment to completion of the final 
primary outcome assessment. Number (percentage) will be included for neonates enrolled, randomized, study discontinued 
(with reasons), analyzed, excluded from analysis (with reasons). The diagram will be separated by treatment groups starting 
from randomization. 
 
7.2 Patient characteristics and baseline variables 
Baseline demographics and clinical characteristics will be summarized by frequencies and percentages for categorical 
variables, continuous variables will be summarized by mean and standard deviation as well as quartiles. Group comparisons 
will be performed using Wilcoxon-rank sum test for continuous variables. Fisher’s Exact test will be used for categorical data. 
The following baseline demographic and clinical characteristics will be presented: 
• Demographics 
 
– Gender 
– Race 
– Ethnicity 
– Family Medical History of Seizures or Neurological Abnormality 
– Pregnancy (Normal/Abnormal) 
– Delivery Situation 
– Mode of Delivery 
– Did Mother Have Anesthesia? 
– Delivery Presentation 
– Birth Weight 
– Head Circumference at Birth 
– Gestational Age at Birth 
 
• Clinical 
– Cord PH 
– APGAR Scores at 1, 5 and 10 min 
– Seizures etiology  
 
7.3 Analysis of Primary and Key Secondary Outcomes 
Primary Hypothesis 
Hypothesis: Treatment with LEV improves the rate of seizure termination at 24 hours in neonates compared with standard PB 
treatment. 
 
Analysis Plan: A Fisher’s exact test will be used to test the 24 hours seizure termination rate between the two treatment groups. 
As a secondary analysis, multivariate logistic regression (if there are sufficient number of events), will be performed to study 
the association between termination rates and treatment. Pre-specified covariates, including seizure etiology (HIE vs Other) 


NEOLEV2 SAP VERSION 2 
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confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
and hypothermia treatment (yes, no), will be included in the multivariable model as observed confounders. 
 
Key Secondary Hypothesis 
Hypothesis: Treatment with LEV improves the rate of seizure cessation at 48 hours in neonates compared with standard PB 
treatment. 
 
Analysis Plan:  A similar approach as used for the primary outcome will be utilized to analyze the 48 hours seizure 
cessation rates. 
 
7.4 Analysis of Remaining Secondary Outcomes 
• 
Hypothesis 1: Treatment with LEV improves the rate of seizure cessation at 1 hour in neonates compared with standard 
PB treatment. 
 
 
Analysis Plan: A similar approach as used for the primary outcome will be utilized to analyze the 1-hour seizure cessation 
rates. 
• 
Hypothesis 2: Length of seizure freedom will be longer in the LEV group than in the PB group. 
 
Analysis Plan: Actual length of seizure freedom will be summarized by mean and standard deviation as well as quartiles. 
Comparison between randomization groups will be performed using Wilcoxon-rank sum test. 
• 
Hypothesis 3: Additional LEV treatment in neonates who didn’t respond to 40mg/kg LEV will be effective (additional 
seizure terminations). 
 
 
Analysis Plan: The percentage of neonates whose seizures stop following 60mg/kg LEV, having not responded to 40mg/kg 
LEV will be calculated with the corresponding 95% confidence interval. 
• 
Hypothesis 4:  LEV treatment will result in a lower dose of phenobarbital being needed as compared to the PB treatment 
alone.  
 
Analysis Plan: Phenobarbital dose will be summarized by mean and standard deviation as well as quartiles. Comparison 
between randomization groups will be performed using Wilcoxon-rank sum test. 
 
7.5 Analysis of Safety Outcomes 
Adverse Event and Serious Adverse Events will be tabulated by randomization group and by drugs received, 
respectively. Details including seriousness, intensity, causality, withdrawal due to event and outcome will be summarized by 
frequencies and percentages by randomization group and by drugs received. Fisher’s exact tests will be used to compare rates 
of adverse events, serious adverse events, study discontinuation and deaths between randomization group and by drugs 
received, respectively. 
 
Findings will be tabulated by randomization group overall and for findings marked as AE and SAE, respectively. 
 
Safety Labs (using DAIDS guidelines) will be presented with shift tables (hour 48 vs baseline) by randomization group and by 
drugs received, respectively. 
 
7.6 Pharmacokinetic Analysis 
These analyses will be performed by Dr. Edmund Capparelli at UC San Diego. The below analysis plan is a preliminary 
plan as stated in the study research plan, a more detailed analysis plan will be provided by Dr. Capparelli at the time 
of analysis. 
The actual individual concentration data, collection times and dosing histories will be used to create graphs of plasma LEV 
concentration vs. time for each infant. Median plasma drug concentration vs. time curves will also be generated. Summary 
statistics (i.e., n, mean, standard deviation, median, minimum, maximum, and coefficient of variation) will be calculated for 


NEOLEV2 SAP VERSION 2 
9 
CONFIDENTIALITY STATEMENT: This report from the USC Alzheimer’s Therapeutic Research Institute (ATRI) is for the sole use of the intended recipient(s)  and contains 
confidential and privileged information. Any unauthorized review, use, disclosure, copying or distribution is strictly prohibited. 
 
 
plasma concentrations for each time point and each dose level. LEV population pharmacokinetic parameters will be determined 
using the computer program NONMEM (ver. 6 or later). The data will be nested with existing raw infant LEV pharmacokinetic 
data generated in the preliminary LEV study. Assuming linear pharmacokinetics as suggested by our current pharmacokinetic 
data, studying 12 subjects at each dosage level will result in 90% confidence intervals for the pharmacokinetic parameters (CL, 
V and t1/2) of +/- 15%. The 90% confidence intervals for the exposure parameters (Cmax, AUC) will be approximately +/- 20%. 
The pharmacokinetics will be modeled recognizing the two stages of a nonlinear hierarchical model development. The first stage 
introduces the structural model (e.g. one compartment open model), the population parameters, individual effects and the within-
patient variation. The second portion of the model development recognizes that variation between patients in the 
pharmacokinetic parameters exists and will attempt to determine covariates that may identify different pharmacokinetic 
subpopulations. A one-compartment model with first order elimination will be utilized. Alternative structural models will be 
explored if indicated by the data. The impact of clinical factors and demographic factors (including weight, sex, age, race, serum 
creatinine, hypothermia and dosing regimen) will be assessed as fixed effects in the model. Nested models will be compared 
graphically and with a likelihood ratio test. 
8 Appendix 
 
8.1 Study Flow Chart 
     
 
HIE and at risk  neonates 
(prospective enrollment)
Suspicion of clinical 
seizures
200 subjects consented and 
continuous EEG initiated
100 subjects begin 
treatment with randomized 
study drug
IV LEV Load 40mg/kg  
(60 subjects)
IV PB Load 20mg/kg 
(40 subjects)
Additional LEV load 20 
mg/kg
IV PB Load 20 mg/kg
Additional PB load 20 
mg/kg
Defer to institutional 
protocol
Additional load PB 20 
mg/kg
IV LEV Load 40 mg/kg
Additional LEV load 20 
mg/kg
Electrographic seizures detected
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist
If seizures persist


9/14/2018