Dwivedi D, et al. - In neonates with hypoxic ischemic encephalopathy and seizures, researchers analyzed factors correlated with failure of phenobarbital therapy. The study sample consisted of 50 term (>35 weeks) neonates with hypoxic ischemic encephalopathy and seizures treated with phenobarbital as the first-line antiepileptic. Neonates were either classified as responders (n = 30) or as nonresponders (n = 20). No significant group differences were found in demographic, clinical, and laboratory variables except nonresponders, who had higher mean seizure score and significantly more injury on MRI scan for white matter, parenchymal cortex, and watershed regions. Investigators found that neonates with moderately abnormal or severely abnormal EEG background reacted to phenobarbital poorly. According to this single-center retrospective review, one can anticipate that additional antiepileptic medication may be required in the presence of the above factors. These data also support larger studies in patients with severe injury to look forward to using alternative first-line agents.