Amplitude integrated electroencephalography for neonatal seizure detection: an alternative opinion to the 2025 Cochrane review

Amplitude-integrated electroencephalography (aEEG) is widely used in neonatal intensive care units for bedside neuromonitoring, seizure detection, prognostication, and guidance of therapeutic hypothermia. A recent Cochrane systematic review comparing aEEG with conventional video-electroencephalography (cEEG) questioned the value of aEEG for neonatal seizure detection. However, careful interpretation of these findings is warranted. This commentary highlights key methodological limitations of the review, including the inclusion of studies without raw EEG display, heterogeneity in electrode configurations, inconsistent reporting of interpreter expertise, and variable seizure definitions. These factors likely bias pooled estimates toward underestimating the performance of modern aEEG systems when used according to contemporary standards. We emphasize that aEEG should not be evaluated as a substitute for cEEG, but as a complementary bedside modality. Beyond seizure detection, aEEG provides clinically meaningful information through background assessment, early prognostication in hypoxic–ischemic encephalopathy, and longitudinal trend monitoring, particularly in settings where cEEG is unavailable. We conclude that dismissing aEEG technology based on methodologically limited comparisons risks undervaluing an important and pragmatic neuromonitoring tool. Future research and guidelines should prioritize optimized application, standardized protocols, training, and integration with emerging analytic approaches, including artificial intelligence, to support equitable neonatal neurocritical care worldwide.