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EEG of Newborn
and Infants
Ki Joong Kim MD PhD
Pediatric Neurology
Seoul National University Children’s Hospital
Seoul, Korea

Maturation of EEG

• Maturation of EEG patterns parallels brain development
• Anatomical and physiological development of brain
• Development of age-specific waking and sleep patterns
• Most dramatic EEG changes occur between premature
age and 1st 3 months of life
• EEG patterns during 1st 6 months closely correlate with
conceptual age (CA)

Neonatal EEG

• Function of actual age of brain
• CA = gestational age + legal (chronological) age
• A number of age-specific normal EEG features for only
several weeks at a time
• Different clinical implication when seen at later ages
• Persistence or reappearance of patterns with immature
features (dysmaturity) means cerebral dysfunction
• More mature EEG pattern than expected is usually due
to underestimated CA

Neonatal montage

F7

Fp1

Fp2

Fp3

Fp4

F3

CH3

CH1

T3

CH9

T5
CH4

C3

CH10

P3
CH2

O1

F4

Fz

F8

CH5

Cz

Pz

CH11

C4

CH7

CH12

P4
CH6

O2

T4

T6
CH8

Developmental EEG Characteristics of premature and term baby
Continuity of
Background Activity

Synchrony of
Background Activity

Awake

Quiet
sleep

Active
sleep

Awake

Quiet
sleep

Active
sleep

EEG
Difference
between
Arousal and
Sleep

27-28

-

D

D

-

++++

++++

No

29-30

D

D

D

0

0

0

No

1. Temporal theta bursts
2. Beta-delta complexes in central region
3. Occipital very slow activity

No

1. Beta-delta complexes in TO region
2. Rhythmic 1.5Hz activity in frontal leads in
transitional sleep
3. Temporal alpha bursts replace 4-5 Hz bursts

No

1. Frontal sharp transients
2. Extremely high voltage beta activity during
beta-delta complexes
3. Temporal alpha bursts disappear

CA
(wk)

31-33

34-35

D

C

D

D

C

C

+

+++

+

+

++

+++

Appearance and Disappearance of
Specific Waveforms and Patterns

36-37

C

D

C

++++

++

++++

Yes

1. Continuous bioccipital delta activity with
superimposed 12-15Hz activity during active
sleep
2. Central beta-delta complexes disappear

38-40

C

C

C

++++

+++

++++

Yes

1. Occipital beta-delta complexes decrease and
disappear by 39wk
2. Trace alternant pattern (NREM sleep)

Mizrahi EM et al Atlas of Neonatal EEG 2004

EEG change in newborn
Less than 29 wks

Tracé discontinu (continuously discontinuous and bilaterally synchronous)
Delta brush emerge at 26 weeks

29-31 weeks

Greater periods of continuous activity, suppression periods les than 30 sec
Frequent delta brushes, temporal theta burst pattern

32-34 weeks

EEG reactivity to stimulation established
Periods of diffuse attenuation less than 15 sec
Abundant multifocal sharp transients and delta brushes

34-37 weeks

Delta brushes appear less often and multifocal sharp transients less frequent
Frontal sharp transients appear
Tracé discontinu pattern is replaced by tracé alternant

After 38 weeks

Low voltage irregular (LVI) in waking and active sleep
Mixed voltage (MV) pattern in waking, transitional and active sleep
High voltage slow (HVS) in quiet sleep
Tracé alternant (TA) in quiet sleep
Fisch BJ EEG Primer 1999

EEG of Premature ( GA 24-27 Weeks)
Continuity

Discontinuous, long flat stretches

Interhemispheric synchrony

Short bursts in synchrony

Differentiation of waking and sleeping

Undifferentiated

Posterior basic alpha rhythm

None

Slow activity (awake)

Very slow high voltage bursts

Temporal theta burst

Present and increasing

Occipital theta

Prominent

Fast activity (awake)

Very little beta activity

Low voltage

Long flat stretches

Tracé alternant

None

Spindles

None

Vertex waves and K complexes

None

Positive occipital sharp transients

None

Slow and fast activity in sleep

Slow activity of high voltage, little slow activity

REM sleep

Undifferentiated

(tracé discontinu)

Niedermeyer E Electroencephalography 1999

M / GA 26 wk

Tracé discontinu

M / GA 27 wk

Tracé discontinu

EEG of Premature (28-31 Weeks)
Continuity

Discontinuous

Interhemispheric synchrony

Mostly asynchronous

Differentiation of waking and sleeping

Undifferentiated

Posterior basic alpha rhythm

None

Slow activity (awake)

Very slow activity predominant

Temporal theta burst

Prominent (temporal sawtooth waves)

Occipital theta

Decreasing

Fast activity (awake)

Frequent ripples or brushes around 16/sec (delta brushes)

Low voltage

Flat stretches, mainly asynchronous

Tracé alternant

None

Spindles

None (but ripples present)

Vertex waves and K complexes

None

Positive occipital sharp transients

None

Slow and fast activity in sleep

Much slow activity, more irregular, little fast activity

REM sleep

Undifferentiated

(tracé discontinu)

Niedermeyer E Electroencephalography 1999

M / GA 28 wk

Tracé discontinu

F / GA 29 wk

Temporal theta

F / GA 29 wk

Delta brush

M / GA 30 wk

Ripples including delta brush

M / GA 31 wk

Ripples

EEG of Premature (32-35 Weeks)
Continuity

Continuous in waking and REM, discontinuous in NREM

Interhemispheric synchrony

Partly synchronous, especially in occipital leads

Differentiation of waking and sleeping

Waking distinguished from sleep early in the period

Posterior basic alpha rhythm

None

Slow activity (awake)

Slow (delta) with occipital maximum

Temporal theta burst

Decreasing and disappearing

Occipital theta

Decreasing

Fast activity (awake)

Frequent ripples or brushes (16-20/sec)

Low voltage

Low voltage records suspect of serious cerebral pathology

Tracé alternant

Present in NREM (quite) sleep

Spindles

None (but ripples present)

Vertex waves and K complexes

None

Positive occipital sharp transients

None

Slow and fast activity in sleep

Irregular slow activity of occipital predominance

REM sleep

Continuous slow activity
Niedermeyer E Electroencephalography 1999

M / GA 32 wk

Discontinuity

M / GA 32 wk

Asymmetry and asynchrony

M / GA 32 wk

Continuity

F / GA 33 wk

Continuity

F / GA 33 wk

Asynchrony

M / GA 34 wk

Status change

F / GA 34 wk

Ripples and frontal sharp transient

F / GA 35 wk

Continuity

F / GA 35 wk

Trace alternant

EEG of Full-term Newborn (36-41 Weeks)
Continuity

Continuous except for tracé alternant in NREM (quiet) sleep

Interhemispheric synchrony

Minor asynchronies still present

Differentiation of waking and sleeping

Good

Posterior basic alpha rhythm

None

Slow activity (awake)

Slow (delta) mostly of moderate voltage

Temporal theta burst

Disappearing or absent

Occipital theta

Absent

Fast activity (awake)

Decreasing ripples, sparse fast activity

Low voltage

Very low voltage records due to serious cerebral pathology

Tracé alternant

Present in NREM (quite) sleep

Spindles

None (but scanty ripples)

Vertex waves and K complexes

None

Positive occipital sharp transients

None

Slow and fast activity in sleep

Much delta and theta activity, continuous in REM sleep

REM sleep

Continuous slow activity
Niedermeyer E Electroencephalography 1999

M / GA 36 wk

F / GA 37 wk

M / GA 38 wk

Tracé alternant

F / GA 39 wk

Frontal sharp transient

F / GA 40 wk

M / GA 40 wk

Anterior dysrhythmia

M / GA 42 wk

Appearance and disappearance of developmental EEG landmarks

Trace Alternant

Frontal Sharp Transients
Occipital
Dominant
Alpha Rhythm

Temporal
Alpha Bursts

Vertex Transients

Temporal Theta Bursts

Beta Delta Complex

26

28

30

32

34

36

Sleep Spindles

38

40

42

44

46

48

50

52

54

Conceptual Age (weeks)
Mizrahi EM et al Atlas of Neonatal EEG 2004

F / GA 38 wk

Excessive suppression in HIE

F / GA 38 wk

Rhythmic epileptiform activity in HIE

F / GA 38 wk

Rhythmic epileptiform activity in HIE

F / GA 41 wk

Focal spike discharges

F / GA 40 wk

FST vs. epileptiform spike

F / GA 40 wk

Repetitive spike discharges

F / GA 40 wk

Neonatal seizures

F / GA 40 wk

Neonatal seizures

F / GA 40 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

M / GA 33 wk

Neonatal seizures

Early Infantile Epileptic Encephalopathy
with Suppression-bursts (EIEE)

• Pseudoperiodical suppression-bursts pattern
• High amplitude bursts alternating with and nearly flat
suppression phases
• Bursts of irregular 150-350 µV high voltage slow waves
mixed with spikes for 1-3 seconds
• Suppression phase for 3-4 seconds
• Burst-burst interval 5-10 seconds
• Appearance regardless of waking and sleep states

F / 1 mo

Burst suppression in EIEE

F / 1 mo

Burst suppression in EIEE


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