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Objective We aimed to determine the incidence and risk factors for electrographic seizures (ES) in neonates and children requiring extracorporeal membrane oxygenation (ECMO) support. Design Prospective quality improvement project. Setting Quaternary care pediatric institution. Patients Consistent with American Clinical Neurophysiology Society EEG monitoring recommendations, neonates and children requiring ECMO support underwent clinically indicated EEG monitoring. Interventions We performed a two-year quality improvement study from July 2013 – June 2015 evaluating ES incidence and risk factors. Main Results 99 of 112 patients (88%) requiring ECMO support underwent EEG monitoring. ES occurred in 18 patients (18%), of which 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively EEG-only seizures. ES were more common in patients with low cardiac output syndrome (p=0.03). Patients with ES were more likely to die prior to discharge (72% vs 30%, p=0.01) and have unfavorable outcomes (54% vs 17%, p=0.004) than those without ES. Conclusions ES occurred in 18% of neonates and children requiring ECMO support, often constituted electrographic status epilepticus, and were often EEG-only thereby requiring EEG monitoring for identification. Low cardiac output syndrome was associated with an increased risk for ES. ES were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether ES identification and management improves outcomes.

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