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Mariani E, Scelsa B, Pogliani L, Introvini P, Lista G. Prognostic value of electroencephalograms in asphyxiated newborns treated with hypothermia. Pediatr Neurol 2008; 39:317-24. [PMID: 18940554 DOI: 10.1016/j.pediatrneurol.2008.07.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 07/23/2008] [Accepted: 07/28/2008] [Indexed: 11/16/2022]
Abstract
Previous studies described how early electroencephalogram patterns in neonatal hypoxic-ischemic encephalopathy seem to correlate with the severity of the clinical picture and provide prognostic information. This study evaluated whether electroencephalograms of newborns with severe perinatal hypoxic-ischemic encephalopathy, treated with hypothermia, provide information on clinical outcomes. Twenty-three newborns treated with hypothermia underwent electroencephalogram monitoring within 48 hours of age, and were enrolled in a follow-up with sequential electroencephalogram and neurologic controls (at ages 1 week, 1 month, 3-6 months, and 1 year). An inactive electroencephalogram pattern in the first 48 hours of age was associated with death or major neurologic sequelae. At age 1 week, a low-voltage, continuous pattern indicated a worse prognostic value when compared with other patterns. The persistence of electroencephalogram abnormalities at age 1 month was associated with a higher risk of neurologic sequelae. Background electroencephalogram abnormalities, detected in the first days of life after hypoxic-ischemic encephalopathy, can provide prognostic information, even in patients treated with hypothermia. After 1 month of age, the information on clinical outcomes provided by electroencephalograms usually decreases because of the natural trend toward electroencephalogram normalization.
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Affiliation(s)
- Emilio Mariani
- Unit of Clinical Neurophysiology, Instituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
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102
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Lindsay NM, Healy GN, Colditz PB, Lingwood BE. Use of the Ages and Stages Questionnaire to predict outcome after hypoxic-ischaemic encephalopathy in the neonate. J Paediatr Child Health 2008; 44:590-5. [PMID: 19012632 DOI: 10.1111/j.1440-1754.2008.01388.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Infants who suffer hypoxic-ischaemic encephalopathy (HIE) at birth are at increased risk of developmental disability. In this at-risk population, reliable, inexpensive and early identification of those children who are likely to require formal developmental assessment and intervention is needed. AIM To evaluate the ability of the Ages and Stages Questionnaire (ASQ) to detect developmentally delayed children in an Australian population of infants who suffered HIE at birth. METHODS Fifty-five children who survived HIE were followed until 12-14 months of age. Test characteristics were calculated to examine the ability of the ASQ to appropriately identify developmentally delayed infants against this study's 'gold standard': the Bayley Scales of Infant Development II. RESULTS Comparing the ASQ with the Bayley Scales of Infant Development II, the questionnaire had the following test characteristics: sensitivity 92%, specificity 95%, positive predictive value 92%, negative predictive value 95% when used to detect severe developmental delay; and sensitivity 67%, specificity 93%, positive predictive value 92%, negative predictive value 68% when used to detect both severe and mild developmental delay. However, the ASQ used at standard cut-offs failed to detect any of the children with mild delay. CONCLUSIONS The ASQ is extremely effective for the detection of severe developmental delay in children who have suffered HIE at birth. Its capacity to identify those with milder delay is limited. The ability of the test to detect only those with severe developmental delay means that the ASQ is of little value as a screening tool in this population.
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Affiliation(s)
- Natalie M Lindsay
- Perinatal Research Centre, The University of Queensland, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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103
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Shankaran S, Pappas A, Laptook AR, McDonald SA, Ehrenkranz RA, Tyson JE, Walsh M, Goldberg RN, Higgins RD, Das A, Network NICHDNR. Outcomes of safety and effectiveness in a multicenter randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy. Pediatrics 2008; 122:e791-8. [PMID: 18829776 PMCID: PMC2819143 DOI: 10.1542/peds.2008-0456] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Whole-body hypothermia reduced the frequency of death or moderate/severe disabilities in neonates with hypoxic-ischemic encephalopathy in a randomized, controlled multicenter trial. OBJECTIVE Our goal was to evaluate outcomes of safety and effectiveness of hypothermia in infants up to 18 to 22 months of age. DESIGN/METHODS A priori outcomes were evaluated between hypothermia (n = 102) and control (n = 106) groups. RESULTS Encephalopathy attributable to causes other than hypoxia-ischemia at birth was not noted. Inotropic support (hypothermia, 59% of infants; control, 56% of infants) was similar during the 72-hour study intervention period in both groups. Need for blood transfusions (hypothermia, 24%; control, 24%), platelet transfusions (hypothermia, 20%; control, 12%), and volume expanders (hypothermia, 54%; control, 49%) was similar in the 2 groups. Among infants with persistent pulmonary hypertension (hypothermia, 25%; control, 22%), nitric-oxide use (hypothermia, 68%; control, 57%) and placement on extracorporeal membrane oxygenation (hypothermia, 4%; control, 9%) was similar between the 2 groups. Non-central nervous system organ dysfunctions occurred with similar frequency in the hypothermia (74%) and control (73%) groups. Rehospitalization occurred among 27% of the infants in the hypothermia group and 42% of infants in the control group. At 18 months, the hypothermia group had 24 deaths, 19 severe disabilities, and 2 moderate disabilities, whereas the control group had 38 deaths, 25 severe disabilities, and 1 moderate disability. Growth parameters were similar between survivors. No adverse outcomes were noted among infants receiving hypothermia with transient reduction of temperature below a target of 33.5 degrees C at initiation of cooling. There was a trend in reduction of frequency of all outcomes in the hypothermia group compared with the control group in both moderate and severe encephalopathy categories. CONCLUSIONS Although not powered to test these secondary outcomes, whole-body hypothermia in infants with encephalopathy was safe and was associated with a consistent trend for decreasing frequency of each of the components of disability.
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Affiliation(s)
- Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, USA.
| | - Athina Pappas
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Abbott R. Laptook
- Department of Pediatrics, Women and Infant's Hospital of Rhode Island, Providence, Rhode Island
| | - Scott A. McDonald
- Department of Statistics and Epidemiology, RTI International, Research Triangle Park, North Carolina
| | - Richard A. Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas
| | - Michelle Walsh
- Department of Pediatrics, Case Western University, Cleveland, Ohio
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland
| | - Abhik Das
- Department of Statistics and Epidemiology, RTI International, Research Triangle Park, North Carolina
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104
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Oh W, Perritt R, Shankaran S, Merritts M, Donovan EF, Ehrenkranz RA, O'Shea TM, Tyson JE, Laptook AR, Das A, Higgins RD. Association between urinary lactate to creatinine ratio and neurodevelopmental outcome in term infants with hypoxic-ischemic encephalopathy. J Pediatr 2008; 153:375-8. [PMID: 18534246 PMCID: PMC2953792 DOI: 10.1016/j.jpeds.2008.03.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 01/29/2008] [Accepted: 03/17/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the association between urinary lactate to creatinine ratio (ULCR) and neurodevelopmental outcome in term infants with hypoxic ischemic encephalopathy and examine the effect of hypothermia on the change in ULCR. STUDY DESIGN Spot urine samples were collected in 58 term infants (28 hypothermia, 30 control subjects) with hypoxic ischemic encephalopathy. Urinary lactate and creatinine were measured by using (1)H nuclear magnetic resonance spectroscopy and expressed as ULCR. Survivors were examined at 18 months of age. RESULTS The ULCR was significantly higher in infants who died or had moderate/severe neurodevelopmental disability. Logistic regression analysis controlling for hypothermia and severity of encephalopathy confirmed the association (adjusted odds ratio, 5.52; 95% CI, 1.36, 22.42; P < .02). Considerable overlap in ULCR was observed between infants with normal/mild disability and those who died or survived with moderate/severe disability. ULCR fell significantly between 6 and 24 hours and 48 and 72 hours of age for all infants. The magnitude of decline did not differ between hypothermia and control groups. CONCLUSIONS High ULCR is associated with death or moderate/severe neurodevelopmental disability. Significant overlap in values between the normal/mild and moderate/severe disability groups limits predictive value of this measure. Whole-body hypothermia did not affect the decline in ULCR.
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Affiliation(s)
- William Oh
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
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105
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Azzopardi D, Brocklehurst P, Edwards D, Halliday H, Levene M, Thoresen M, Whitelaw A. The TOBY Study. Whole body hypothermia for the treatment of perinatal asphyxial encephalopathy: a randomised controlled trial. BMC Pediatr 2008; 8:17. [PMID: 18447921 PMCID: PMC2409316 DOI: 10.1186/1471-2431-8-17] [Citation(s) in RCA: 253] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/30/2008] [Indexed: 11/10/2022] Open
Abstract
Background A hypoxic-ischaemic insult occurring around the time of birth may result in an encephalopathic state characterised by the need for resuscitation at birth, neurological depression, seizures and electroencephalographic abnormalities. There is an increasing risk of death or neurodevelopmental abnormalities with more severe encephalopathy. Current management consists of maintaining physiological parameters within the normal range and treating seizures with anticonvulsants. Studies in adult and newborn animals have shown that a reduction of body temperature of 3–4°C after cerebral insults is associated with improved histological and behavioural outcome. Pilot studies in infants with encephalopathy of head cooling combined with mild whole body hypothermia and of moderate whole body cooling to 33.5°C have been reported. No complications were noted but the group sizes were too small to evaluate benefit. Methods/Design TOBY is a multi-centre, prospective, randomised study of term infants after perinatal asphyxia comparing those allocated to "intensive care plus total body cooling for 72 hours" with those allocated to "intensive care without cooling". Full-term infants will be randomised within 6 hours of birth to either a control group with the rectal temperature kept at 37 +/- 0.2°C or to whole body cooling, with rectal temperature kept at 33–34°C for 72 hours. Term infants showing signs of moderate or severe encephalopathy +/- seizures have their eligibility confirmed by cerebral function monitoring. Outcomes will be assessed at 18 months of age using neurological and neurodevelopmental testing methods. Sample size At least 236 infants would be needed to demonstrate a 30% reduction in the relative risk of mortality or serious disability at 18 months. Recruitment was ahead of target by seven months and approvals were obtained allowing recruitment to continue to the end of the planned recruitment phase. 325 infants were recruited. Primary outcome Combined rate of mortality and severe neurodevelopmental impairment in survivors at 18 months of age. Neurodevelopmental impairment will be defined as any of: • Bayley mental developmental scale score less than 70 • Gross Motor Function Classification System Levels III – V • Bilateral cortical visual impairments Trial Registration Current Controlled Trials ISRCTN89547571
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Affiliation(s)
- Dennis Azzopardi
- Division of Clinical Sciences, Faculty of Medicine, Imperial College London, UK.
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106
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Lingwood BE, Healy GN, Sullivan SM, Pow DV, Colditz PB. MAP2 provides reliable early assessment of neural injury in the newborn piglet model of birth asphyxia. J Neurosci Methods 2008; 171:140-6. [PMID: 18400305 DOI: 10.1016/j.jneumeth.2008.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Revised: 02/25/2008] [Accepted: 02/25/2008] [Indexed: 10/22/2022]
Abstract
Reduction in microtubule-associated-protein-2 (MAP2) immunoreactivity is a sensitive and quantifiable early marker of neural injury in rats. This study assessed the reliability of MAP2 as an early marker of neural injury following hypoxia/ischaemia in neonatal piglets, and compared the effects of perfusion and immersion fixation on MAP2 immunoreactivity. Hypoxia was induced in newborn piglets (n=23) by reducing the FiO2 to 4% for 0, 25, 35 or 50 min. Six hours after the end of hypoxia piglets were killed, and the brain removed and immunolabelled for MAP2. Significant reductions in MAP2 immunoreactivity were seen in cortex, hippocampus, basal ganglia and thalamus. Reductions correlated with duration of hypoxia, pH at the end of hypoxia, cerebral function monitor amplitude and cerebral impedance 6h after hypoxia, and with early histological evidence of ischaemic changes. Regions with reduced immunoreactivity correlated with areas where damage is present in later histological examination in this model. Immersion fixation with postmortem delays up to 30 min did not affect MAP2 immunoreactivity compared to perfusion-fixed tissue. Results indicate that MAP2 immunoreactivity 6h after hypoxia/ischaemia is a reliable marker of neural injury in the neonatal piglet.
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Affiliation(s)
- Barbara E Lingwood
- Perinatal Research Centre, University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia.
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107
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Sarkar S, Barks JD, Donn SM. Should amplitude-integrated electroencephalography be used to identify infants suitable for hypothermic neuroprotection? J Perinatol 2008; 28:117-22. [PMID: 18004390 DOI: 10.1038/sj.jp.7211882] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Amplitude-integrated electroencephalography (aEEG) has been used adjunctively to identify infants suitable for hypothermic neuroprotection following severe intrapartum asphyxia. To determine whether an early aEEG predicts short-term adverse outcome in infants with significant hypoxic-ischemic encephalopathy (HIE) evaluated for hypothermic neuroprotection. STUDY DESIGN The aEEG recordings were obtained within 6 h of birth in infants >or=36 weeks' gestational age during evaluation for possible selective head or whole-body cooling. Recordings were subsequently re-evaluated for both background pattern and voltage abnormalities by a certified reader masked to clinical history and brain-oriented interventions. All infants with moderate or severe HIE evaluated for hypothermic neuroprotection also underwent magnetic resonance imaging (MRI) of the brain at a median postnatal age of 7 days. The predictive value using the aEEG for determining short-term dichotomous outcomes, defined as early death related to HIE, or a characteristic pattern of abnormalities consistent with hypoxic-ischemic injury on the MRI brain scans was assessed. RESULT Fifty-four infants with moderate or severe HIE were evaluated with aEEG for hypothermic neuroprotection; 34 infants received selective head cooling, 12 infants underwent total body cooling and 8 infants were not cooled. Outcome data, available for 46 of the 54 infants, revealed a poor correlation between the early aEEG and short-term adverse outcomes, with a sensitivity of 54.8% and negative predictive value (NPV) of only 44%. CONCLUSION Because of the poor NPV of an early aEEG for a short-term adverse outcome, its use as an 'additional selection criterion' for hypothermic neuroprotection may not be appropriate.
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Affiliation(s)
- S Sarkar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI 48109, USA.
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108
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Abstract
This chapter will report to the frequency of neonatal hypoxic-ischemic encephalopathy. The pathophysiology and the childhood outcome of encephalopathy due to hypoxia-ischemia will be examined. The limitations of current therapy for this condition and new therapies will be evaluated. Hypothermia seems to offer the most promise as a therapy for neuroprotection in hypoxic-ischemic encephalopathy. The evidence-based trials of hypothermia will be reviewed along with recommendations regarding clinical applications for this therapy and need for long-term follow-up of children receiving this therapy.
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Affiliation(s)
- Seetha Shankaran
- Wayne State University, Children's Hospital of Michigan, Detroit, MI 48201, USA.
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109
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West T, Atzeva M, Holtzman DM. Pomegranate polyphenols and resveratrol protect the neonatal brain against hypoxic-ischemic injury. Dev Neurosci 2007; 29:363-72. [PMID: 17762204 PMCID: PMC3066259 DOI: 10.1159/000105477] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 11/22/2006] [Indexed: 12/18/2022] Open
Abstract
A previous study from our lab has shown that the polyphenol-rich pomegranate juice can protect the neonatal mouse brain against hypoxic-ischemic (H-I) injury when given to mothers in their drinking water. To test the hypothesis that this protection is due to the polyphenols in the juice, we studied the effects of the pomegranate polyphenol extract in the same neonatal H-I model. To further explore the role of a specific polyphenol in neonatal H-I we investigated the effects of resveratrol. The neuroprotective effects of resveratrol have been demonstrated in adult models of stroke, but had not previously been examined in neonates. We show that pomegranate polyphenols and resveratrol reduce caspase-3 activation following neonatal H-I. Resveratrol reduced caspase-3 activation when given before the injury but not when given 3 h after the injury. In addition to preventing caspase-3 activation, resveratrol also reduced calpain activation. Finally, we show that resveratrol can protect against tissue loss measured at 7 days after the injury. These and other recent findings suggest that polyphenols should be further investigated as a potential treatment to decrease brain injury due to neonatal H-I.
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Affiliation(s)
- Tim West
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
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110
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Schulzke SM, Rao S, Patole SK. A systematic review of cooling for neuroprotection in neonates with hypoxic ischemic encephalopathy - are we there yet? BMC Pediatr 2007; 7:30. [PMID: 17784966 PMCID: PMC2031882 DOI: 10.1186/1471-2431-7-30] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 09/05/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this study was to systematically review randomized trials assessing therapeutic hypothermia as a treatment for term neonates with hypoxic ischemic encephalopathy. METHODS The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL databases, reference lists of identified studies, and proceedings of the Pediatric Academic Societies were searched in July 2006. Randomized trials assessing the effect of therapeutic hypothermia by either selective head cooling or whole body cooling in term neonates were eligible for inclusion in the meta-analysis. The primary outcome was death or neurodevelopmental disability at >or= 18 months. RESULTS Five trials involving 552 neonates were included in the analysis. Cooling techniques and the definition and severity of neurodevelopmental disability differed between studies. Overall, there is evidence of a significant effect of therapeutic hypothermia on the primary composite outcome of death or disability (RR: 0.78, 95% CI: 0.66, 0.92, NNT: 8, 95% CI: 5, 20) as well as on the single outcomes of mortality (RR: 0.75, 95% CI: 0.59, 0.96) and neurodevelopmental disability at 18 to 22 months (RR: 0.72, 95% CI: 0.53, 0.98). Adverse effects include benign sinus bradycardia (RR: 7.42, 95% CI: 2.52, 21.87) and thrombocytopenia (RR: 1.47, 95% CI: 1.07, 2.03, NNH: 8) without deleterious consequences. CONCLUSION In general, therapeutic hypothermia seems to have a beneficial effect on the outcome of term neonates with moderate to severe hypoxic ischemic encephalopathy. Despite the methodological differences between trials, wide confidence intervals, and the lack of follow-up data beyond the second year of life, the consistency of the results is encouraging. Further research is necessary to minimize the uncertainty regarding efficacy and safety of any specific technique of cooling for any specific population.
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Affiliation(s)
- Sven M Schulzke
- Department of Neonatal Paediatrics, Women's and Children's Health Service, Perth, Australia
- University of Western Australia, Perth, Australia
| | - Shripada Rao
- Department of Neonatal Paediatrics, Women's and Children's Health Service, Perth, Australia
| | - Sanjay K Patole
- Department of Neonatal Paediatrics, Women's and Children's Health Service, Perth, Australia
- University of Western Australia, Perth, Australia
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111
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References. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007. [DOI: 10.1016/s1701-2163(16)32622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Handel M, Swaab H, de Vries LS, Jongmans MJ. Long-term cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: a review. Eur J Pediatr 2007; 166:645-54. [PMID: 17426984 PMCID: PMC1914268 DOI: 10.1007/s00431-007-0437-8] [Citation(s) in RCA: 227] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 02/01/2007] [Indexed: 01/02/2023]
Abstract
UNLABELLED Neonatal encephalopathy (NE) following perinatal asphyxia (PA) is considered an important cause of later neurodevelopmental impairment in infants born at term. This review discusses long-term consequences for general cognitive functioning, educational achievement, neuropsychological functioning and behavior. In all areas reviewed, the outcome of children with mild NE is consistently positive and the outcome of children with severe NE consistently negative. However, children with moderate NE form a more heterogeneous group with respect to outcome. On average, intelligence scores are below those of children with mild NE and age-matched peers, but within the normal range. With respect to educational achievement, difficulties have been found in the domains reading, spelling and arithmetic/mathematics. So far, studies of neuropsychological functioning have yielded ambiguous results in children with moderate NE. A few studies suggest elevated rates of hyperactivity in children with moderate NE and autism in children with moderate and severe NE. CONCLUSION Behavioral monitoring is required for all children with NE. In addition, systematic, detailed neuropsychological examination is needed especially for children with moderate NE.
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Affiliation(s)
- Mariëlle van Handel
- Department of Neonatology, University Medical Center Utrecht (Wilhelmina Children's Hospital), Heidelberglaan 1, 3584 CS Utrecht, P.O. Box 85500, 3500 GA, Utrecht, The Netherlands.
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113
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Bhat MA, Shah ZA, Makhdoomi MS, Mufti MH. Theophylline for renal function in term neonates with perinatal asphyxia: a randomized, placebo-controlled trial. J Pediatr 2006; 149:180-4. [PMID: 16887430 DOI: 10.1016/j.jpeds.2006.03.053] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 02/26/2006] [Accepted: 03/31/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To study whether prophylactic theophylline can reduce the incidence and/or severity of renal failure in term infants with perinatal asphyxia. STUDY DESIGN Term neonates with severe perinatal asphyxia were randomized to receive a single dose of either theophylline (study group, n = 40) or placebo (control group, n = 30) during the first hour of life. Daily weight, output/input ratio, 24-hour fluid intake, and urine volumes were recorded during the first 5 days of life. Those infants with asphyxial renal failure were followed up for 1 year. RESULTS The incidence of severe renal dysfunction was increased in the control group. Creatinine clearance was higher and excretion of beta 2 microglobulin (beta2M) was lower in the theophylline group. Conversely, the glomerular filtration rate was lower in the control group. In infants with renal failure, serum creatinine and creatinine clearance returned to normal in the neonatal period, and the increased beta2M excretion normalized by age 6 weeks. CONCLUSIONS A single dose of theophylline within the first hour of birth in term neonates with perinatal asphyxia results in a significant decrease in serum creatinine level and urinary excretion of beta2M, along with an increase in creatinine clearance.
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Affiliation(s)
- Mushtaq A Bhat
- Department of Pediatrics, Shere-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, Kashmir, India.
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114
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Jatana M, Singh I, Singh AK, Jenkins D. Combination of systemic hypothermia and N-acetylcysteine attenuates hypoxic-ischemic brain injury in neonatal rats. Pediatr Res 2006; 59:684-9. [PMID: 16627882 DOI: 10.1203/01.pdr.0000215045.91122.44] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Hypoxic ischemic (HI) injury in neonates may have devastating, long-term consequences. Recently completed clinical trials in HI neonates indicate that hypothermia within 6 h of birth results in modest improvement in the combined outcome of death or severe disability. The aim of this study was to investigate the effects of combining hypothermia and N-acetylcysteine (NAC) on brain injury, neonatal reflexes and myelination after neonatal HI. Seven-day-old rats were subjected to right common carotid artery ligation and hypoxia (8% oxygen) for 2 h. Systemic hypothermia (30 + 0.5 degrees C) was induced immediately after the period of HI and was maintained for 2 h. NAC (50 mg/kg) was administered by intraperitoneal injection daily until sacrifice. Brain infarct volumes were significantly reduced at 48 h post-HI in the hypothermia plus NAC group (21.5 +/- 3.84 mm3) compared with vehicle (240.85 +/- 4.08 mm3). Neonatal reflexes were also significantly improved by combination therapy at days 1 and 7. There was a significant loss of right hemispheric brain volume in the untreated group at 2 and 4 wk after HI insult. Brain volumes were preserved in hypothermia plus NAC group and were not significantly different when compared with the sham group. Similarly, increased myelin expression was seen in brain sections from hypothermia plus NAC group, when stained for Luxol Fast Blue (LFB), Myelin Basic Protein (MBP) and Proteolipid protein (PLP). These results indicate that hypothermia plus NAC combination therapy improves infarct volume, myelin expression and functional outcomes after focal HI injury.
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Affiliation(s)
- Manu Jatana
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA
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115
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Shankaran S, Laptook AR, Ehrenkranz RA, Tyson JE, McDonald SA, Donovan EF, Fanaroff AA, Poole WK, Wright LL, Higgins RD, Finer NN, Carlo WA, Duara S, Oh W, Cotten CM, Stevenson DK, Stoll BJ, Lemons JA, Guillet R, Jobe AH. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005; 353:1574-84. [PMID: 16221780 DOI: 10.1056/nejmcps050929] [Citation(s) in RCA: 1961] [Impact Index Per Article: 103.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hypothermia is protective against brain injury after asphyxiation in animal models. However, the safety and effectiveness of hypothermia in term infants with encephalopathy is uncertain. METHODS We conducted a randomized trial of hypothermia in infants with a gestational age of at least 36 weeks who were admitted to the hospital at or before six hours of age with either severe acidosis or perinatal complications and resuscitation at birth and who had moderate or severe encephalopathy. Infants were randomly assigned to usual care (control group) or whole-body cooling to an esophageal temperature of 33.5 degrees C for 72 hours, followed by slow rewarming (hypothermia group). Neurodevelopmental outcome was assessed at 18 to 22 months of age. The primary outcome was a combined end point of death or moderate or severe disability. RESULTS Of 239 eligible infants, 102 were assigned to the hypothermia group and 106 to the control group. Adverse events were similar in the two groups during the 72 hours of cooling. Primary outcome data were available for 205 infants. Death or moderate or severe disability occurred in 45 of 102 infants (44 percent) in the hypothermia group and 64 of 103 infants (62 percent) in the control group (risk ratio, 0.72; 95 percent confidence interval, 0.54 to 0.95; P=0.01). Twenty-four infants (24 percent) in the hypothermia group and 38 (37 percent) in the control group died (risk ratio, 0.68; 95 percent confidence interval, 0.44 to 1.05; P=0.08). There was no increase in major disability among survivors; the rate of cerebral palsy was 15 of 77 (19 percent) in the hypothermia group as compared with 19 of 64 (30 percent) in the control group (risk ratio, 0.68; 95 percent confidence interval, 0.38 to 1.22; P=0.20). CONCLUSIONS Whole-body hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Seetha Shankaran
- Division of Neonatal-Perinatal Medicine, Wayne State University, Children's Hospital of Michigan, Detroit, MI 48201, USA.
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Talati AJ, Yang W, Yolton K, Korones SB, Bada HS. Combination of early perinatal factors to identify near-term and term neonates for neuroprotection. J Perinatol 2005; 25:245-50. [PMID: 15703778 DOI: 10.1038/sj.jp.7211259] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine early predictors of abnormal outcome at > or =24 months' age in neonates at risk for hypoxic-ischemic brain injury. STUDY DESIGN A prospective cohort study with developmental follow-up of > or =24 months. Infants were selected based on risk factors, and neurologic outcome was determined. Variables affecting the outcome were evaluated with univariate and multivariate methods, and a scoring system was devised to predict adverse outcome. RESULTS A total of 41 infants born > or =35 weeks' gestational age with possibility of hypoxic-ischemic insult were enrolled. In all, 39 (95%) had known outcomes, of whom 17 (48%) had an abnormal neurologic outcome, including five deaths. The variables within the first hour of life correlating with the adverse outcome were 1- and 5-minute Apgar scores, intubation in the delivery room and cord/initial base-deficit > or =20 mmol/l. A scoring system was derived based on significant variables, and a score > or =5 had a 90% positive predictive value for abnormal outcome. Seizures, multiorgan failure and abnormal imaging studies were also significantly associated with abnormal outcome. CONCLUSIONS The proposed scoring system, being highly predictive of outcome at 24 months' age, may be potentially useful in selecting subjects for preventive or therapeutic interventions to prevent or minimize neurologic morbidity due to hypoxic brain injury.
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Affiliation(s)
- Ajay J Talati
- Departments of Pediatrics and Obstetrics and Gynecology, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
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117
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Affiliation(s)
- Richard Cooke
- Neonatal Unit, Liverpool Women's Hospital, Liverpool L8 7 sS, UK.
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118
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Shah P, Riphagen S, Beyene J, Perlman M. Multiorgan dysfunction in infants with post-asphyxial hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004; 89:F152-5. [PMID: 14977901 PMCID: PMC1756028 DOI: 10.1136/adc.2002.023093] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Multiorgan dysfunction (MOD) is one of four consensus based criteria for the diagnosis of intrapartum asphyxia. The theoretical concept behind MOD is the diving reflex (conservation of blood flow to vital organs at the cost of non-vital organs). OBJECTIVES To assess the patterns of involvement of each major organ/system and combinations of involvement in infants with post-asphyxial hypoxic-ischaemic encephalopathy (HIE), and to describe this in relation to long term outcome. DESIGN Retrospective cohort study. SETTING Regional tertiary neonatal intensive care unit at the Hospital for Sick Children, Toronto, Canada. PATIENTS Term neonates with post-intrapartal asphyxial HIE assessed for kidney, cardiovascular system, lung, and liver function. OUTCOME Death and presence or absence of severe neurodevelopmental disability. RESULTS Out of 130 of 144 eligible infants with outcome data, 80 (62%) had severe adverse outcome and 50 (38%) had good outcome. All infants had evidence of MOD (at least one organ dysfunction in addition to HIE). Renal, cardiovascular, pulmonary, and hepatic dysfunction was present in 58-88% of infants with good outcome and 64-86% of infants with adverse outcome. CONCLUSIONS MOD was present in all the infants with severe post-asphyxial HIE. However, there was no association between MOD and outcome in these infants. No relation between individual or combinations of organ involvements and long term outcomes was observed.
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Affiliation(s)
- P Shah
- Department of Paediatrics, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada.
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119
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Abstract
There has been much progress in understanding the pathogenesis of hypoxic-ischemic brain injury in the near-term and term infant. Although gaps in our knowledge base persist, advances over the past two decades have led to the development of specific brain oriented therapies directed at critical events contributing to tissue damage. The primary goal of these interventions is to prevent or attenuate neurologic and developmental sequelae of brain injury. Examples of current potential treatments include modest reductions in brain temperature, receptor antagonists of excitatory neurotransmitters, reductions in O2 free radicals, blockade of inflammatory mediators, and inhibition of apoptotic pathways. At present, some of these treatments have sufficient animal data that demonstrate benefit, to justify moving experiments from the laboratory to the clinical arena. Modest hypothermia represents the neuroprotective intervention that has been investigated in the most complete fashion for the newborn, and there are multiple ongoing clinical trials testing its efficacy. This review will address specific challenges that are pertinent to the evaluation of any neuroprotective therapy implemented shortly after birth. Specific issues to be covered include the therapeutic window, establishing a diagnosis of hypoxic-ischemic encephalopathy, patient selection, characteristics of an effective therapy, safety considerations, appropriate outcome variables, and sample size considerations. Since clinical trials of brain hypothermia are in progress, many of these issues will be addressed from the perspective of this specific intervention.
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Affiliation(s)
- Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.
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120
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Abstract
Investigations in animal models of hypoxic-ischemic injury have not translated into clinical trials of success because of the complex pathology of hypoxic-ischemic brain injury in neonates, the difficulty in defining the onset and duration and severity of the injury, the underlying predisposing disorders of the mothers or the infant, the side effects of many of the investigational drugs precluded clinical use, and many of the investigational agents interfered with only one step of the cascade of events that lead to brain injury. It is possible that a combination of therapeutic agents, including those that affect different levels of the cascade to cell death, will have the greatest neuroprotective effects. Modest hypothermia postpones secondary energy failure and can prolong the window while pharmacotherapeutic agents can be used. It is possible that in the future, sequential administration of agents or strategies that are initiated in the intrapartum period and continued postnatally will be the optimum method for treating infants who are at highest risk for brain injury following acute hypoxic-ischemic asphyxia.
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Affiliation(s)
- Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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121
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Abstract
Epidemiological studies in a number of Western countries have attributed 6-14% of sensorineural hearing impairment from birth or early childhood to problems relating to the birth process [1-4]. In spite of this association it is not always clear in individual instances whether adverse perinatal conditions identified subsequently have been causative of a hearing loss or not. It is possible that the hearing impairment was the consequence of an earlier intrauterine insult or is a coincidental finding. Infants carrying genetic mutations for hearing loss may coincidentally experience perinatal stress. It is therefore important to investigate the cause of a hearing loss discovered in infancy irrespective of the history of the infant having experienced adverse conditions surrounding the time of birth.
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Affiliation(s)
- V Newton
- Department of Autodiological Medicine, Manchester Royal Infirmary and University of Manchester, Manchester, UK.
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122
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Abstract
Asphyxia remains one of the main causes of later disability in term infants. Despite many publications identifying possible predictors of outcome in this population of interest, little is known of the long-term developmental outcome of asphyxiated term neonates. Observational studies have largely focused on short-term outcomes, with an emphasis on significant neurologic sequelae and intellectual impairments. This article reviews the literature that has described the developmental outcome of asphyxiated term newborns. As part of this review, we have also highlighted the evolution of the definition of asphyxia and delineated appropriate markers that should be used in future research on this population.
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Affiliation(s)
- M E Dilenge
- Division of Pediatric Neurology, Montreal Children's Hospital, PQ.
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123
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Battin MR, Dezoete JA, Gunn TR, Gluckman PD, Gunn AJ. Neurodevelopmental outcome of infants treated with head cooling and mild hypothermia after perinatal asphyxia. Pediatrics 2001; 107:480-4. [PMID: 11230586 DOI: 10.1542/peds.107.3.480] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the neurodevelopmental outcome of infants treated with head cooling with systemic hypothermia after hypoxic-ischemic encephalopathy. STUDY DESIGN Infants >/=37 weeks' gestation, who had an umbilical artery pH </=7.09 or Apgar score </=6 at 5 minutes, plus clinical encephalopathy. Infants with major congenital abnormalities were excluded. TRIAL DESIGN Infants were allocated to either no cooling (rectal temperature = 37.0 +/- 0.2 degrees C, n = 15), or, sequentially, to head cooling accompanied by different levels of systemic hypothermia, including minimal cooling, rectal temperature 36.5 degrees C to 36 degrees C (n = 6), and mild cooling, to either 35.9 degrees C to 35.5 degrees C (n = 6), 35 +/- 0.5 degrees C (n = 6) or 34.5 +/- 0.5 degrees C (n = 7). Head cooling was accomplished by circulating cooled water through a coil of tubing wrapped around the head for up to 72 hours. Survivors were followed up with regular neurologic examination by a neonatologist until 18 months of age, then with blinded developmental testing using the revised Bayley Scales. RESULTS A total of 40 term infants were enrolled from 2 to 5 hours after birth. The control and the cooled groups were not significantly different for gestation, birth weight, Apgar score, and initial pH. There were 6 early neonatal deaths (3 normothermic and 3 cooled), and 1 death in infancy associated with severe spastic cerebral palsy in a normothermic infant. Six normothermic, 1 minimally cooled, and 4 mildly cooled infants had early stage 1 encephalopathy; all but 1 had a good outcome. Among infants with early stage 2 or 3 encephalopathy, an adverse outcome was found in 4 of 9 normothermic infants (44%) and 4 of 5 minimally cooled infants (80%), whereas in the combined mildly cooled groups, an adverse outcome was found in 4 of 15 infants (26%, odds ratio 0.46 [0.08, 2.56] vs normothermia). CONCLUSIONS The present study supports the safety of hypothermia, with no evidence of late adverse effects in any infant. Among infants with moderate to severe encephalopathy at enrollment, there was a tendency toward better outcome. These results emphasize the relatively wide range of outcomes using purely clinical criteria for enrollment. Therapeutic hypothermia should not be used outside of stringent, multicenter trials.
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Affiliation(s)
- M R Battin
- Newborn Service, National Women's Hospital, Auckland, New Zealand.
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124
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Gire C, Nicaise C, Roussel M, Soula F, Girard N, Somma-Mauvais H, Lagier P, Dejode JM, Farnarier G, Garnier JM. [Hypoxic-ischemic encephalopathy in the full-term newborn. Contribution of electroencephalography and MRI or computed tomography to its prognostic evaluation. Apropos of 26 cases]. Neurophysiol Clin 2000; 30:97-107. [PMID: 10812578 DOI: 10.1016/s0987-7053(00)00061-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
OBJECTIVES Perinatal asphyxia complicated by hypoxic ischemic brain injury still remains the source of neurological lesions often serious and definitive. A major aim of neonatologists is to appreciate the severity of the hypoxic ischemic brain injury in the first days of life and to evaluate the forecast. The purpose of this work is to establish a relation between clinical signs, EEG, neuroimaging (MRI and CTS) and neuro-development. MATERIALS AND METHODS 26 neonates from paediatric resuscitation unit (Hospital North, Marseille) were enrolled in a retrospective study since February 1994 to December 1997. All the newborns had at least one anamnestic criteria of perinatal asphyxia, an early electroencephalogram in the first two days of life and another between the third and the seventh day of life, and neuroimaging in the first 15 days of life: CTS in five cases and MRI in 21 cases. RESULTS There was a good electro-clinic (P: 0.01) and prognostic (P: 0.03) correlation in patients within stage 3 of the "Sarnat classification". In the stage 2, the EEG did not provide valuable information about severity of the injury, and neuroimaging (especially MRI) allowed better prognosis. Diffuse brain injury or lesions of basal ganglia in MRI were associated, independently of clinical settings and EEG tracings, with a poor neurodevelopmental outcome (P: 0.02). The MRI was diagnostic in four cases of congenital encephalopathy complicated with neonatal suffering. CONCLUSION Our study confirms the interest of the association of clinical settings, EEG tracings and MRI in the diagnosis and the prognostic of the hypoxic-ischemic encephalopathy in term neonate.
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Affiliation(s)
- C Gire
- Service de pédiatrie et de néonatologie, hôpital Nord, Marseille, France
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125
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126
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Korst LM, Phelan JP, Wang YM, Martin GI, Ahn MO. Acute fetal asphyxia and permanent brain injury: a retrospective analysis of current indicators. THE JOURNAL OF MATERNAL-FETAL MEDICINE 1999; 8:101-6. [PMID: 10338063 DOI: 10.1002/(sici)1520-6661(199905/06)8:3<101::aid-mfm6>3.0.co;2-l] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine whether a term neonate who has had sufficient intrapartum asphyxia to produce persistent brain injury will manifest the following four criteria: profound acidemia (arterial pH <7.00), an APGAR score < or =3 for 5 min or longer, seizures within 24 h of birth, and multiorgan system dysfunction. METHODS Singleton, liveborn, neurologically impaired neonates > or =37 weeks gestation who lived at least 6 days and had sufficient documentation of current intrapartum asphyxia criteria were retrospectively analyzed. Of these infants, solely neonates with acute fetal asphyxia due to a sudden prolonged FHR deceleration that lasted until delivery from a catastrophic event, e.g., uterine rupture, cord prolapse, were included. Organ system dysfunction was defined by separate criteria for each organ system. Dysfunction in one or more was defined as multiorgan system dysfunction. RESULTS Of the 292 eligible infants in the registry, 47 satisfied the entry criteria. In these 47 neonates, 10 (21%) satisfied all 4 criteria for intrapartum asphyxia. CONCLUSIONS Our retrospective study suggests that currently used indicators to define permanent fetal brain injury are not valid.
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Affiliation(s)
- L M Korst
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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127
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Ivanov I, Neshterova M. The diagnostic and prognostic implications of brain hyperechogenicity in hypoxic-ischaemic encephalopathy grade II. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 1998; 8:7-15. [PMID: 9795001 DOI: 10.1016/s0929-8266(98)00045-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To study from a practical viewpoint the type, intensity and spread of brain hyperechogenicities (BHE) and their diagnostic and prognostic implications in patients with the most common, and most variable in presentation and prognosis, second grade of hypoxic-ischaemic encephalopathy (HIE). METHODS Full-term newborns (75) with HIE gr.II were examined and divided into subgrades IIa and IIb, depending on the evidence of neurological improvement on day 7 after birth. Ultrasound examination was performed with a 5-MHz transducer. All patients were evaluated for intensity of BHE by a score system and those with focal lesions had also the number of affected loci with BHE counted. In 27 of these infants the BHE data were analyzed according to the outcome after the 11th month. A control group of 31 healthy neonates was also studied. RESULTS We obtained 84% sensitivity and 77% specificity of BHE in HIE gr.II. Of the patients, 96% demonstrated different combinations of focal BHE, and only four demonstrated diffuse BHE. A significant correlation was found between the BHE variables (intensity score and number of loci) and clinical severity. The difference in intensity scores between HIE IIa and IIb was significant in the first 2 weeks after birth. The combination of clinical severity with the BHE variables could predict the outcome with 70.4% accuracy. CONCLUSION BHE (focal or diffuse) could serve as additional diagnostic, grading and prognostic criterion in HIE gr.II.
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Affiliation(s)
- I Ivanov
- Department of Pediatrics, Plovdiv Medical University, 15a Vassil Aprilov St., Plovdiv 4000, Bulgaria.
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128
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129
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Marro PJ, Hoffman D, Schneiderman R, Mishra OP, Delivoria-Papadopoulos M. Effect of allopurinol on NMDA receptor modification following recurrent asphyxia in newborn piglets. Brain Res 1998; 787:71-7. [PMID: 9518556 DOI: 10.1016/s0006-8993(97)01453-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The present study tests the hypothesis that repeated episodes of asphyxia will lead to alterations in the characteristics of the N-methyl-d-aspartate (NMDA) receptor in the brain cell membrane of newborn piglets and that pre-treatment with allopurinol, a xanthine oxidase inhibitor, will prevent these modifications. Eighteen newborn piglets were studied. Six untreated and six allopurinol treated animals were subjected to eight asphyxial episodes and compared to six normoxic, normocapneic controls. Brain cell membrane Na+,K+-ATPase activity was determined to assess membrane function. Na+,K+-ATPase activity was decreased from control following asphyxia in both the untreated and treated animals (47.7+/-3.2 vs. 43.0+/-2.2 and 41.0+/-5.3 micromol Pi/mg protein/h, p<0.05, respectively). 3H-MK-801 binding studies were performed to measure NMDA receptor binding characteristics. The receptor density (Bmax) in the untreated asphyxia group was decreased compared to control animals (0.80+/-0.11 vs. 1.13+/-0.33, p<0.05); furthermore, the dissociation constant (Kd) was also decreased (3.8+/-0.7 vs. 9.2+/-2.2, p<0.05), indicating an increase in receptor affinity. In contrast, Bmax in the allopurinol treated asphyxia group was similar to control (1. 06+/-0.37); and Kd was higher (lower affinity) than in the untreated group (6.5+/-1.4, p<0.05). The data indicate that recurrent asphyxial episodes lead to alterations in NMDA receptor characteristics; and that despite cell membrane dysfunction as seen by a decrease in Na+,K+-ATPase activity, allopurinol prevents modification of NMDA receptor-ion channel binding characteristics induced by repeated episodes of asphyxia.
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Affiliation(s)
- P J Marro
- Department of Pediatrics, Maine Medical Center, Portland, ME 04102-3134, USA
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130
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Ekert P, Perlman M, Steinlin M, Hao Y. Predicting the outcome of postasphyxial hypoxic-ischemic encephalopathy within 4 hours of birth. J Pediatr 1997; 131:613-7. [PMID: 9386669 DOI: 10.1016/s0022-3476(97)70072-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To build models that predict severe adverse outcome within 4 hours of birth in patients with postasphyxial hypoxic-ischemic encephalopathy. The goal was to develop models for selecting patients for therapeutic trials of neuroprotective medications. STUDY DESIGN Retrospective cohort study with follow-up to a minimum age of 12 months of 164 "outborn" term infants admitted to a tertiary neonatal intensive care unit, and 14 "inborn" term infants in the two tertiary perinatal centers in a regionalized setting. After performing univariate screening tests, multivariate models of association between risk factors and "severe adverse outcome" (death or major neurosensory impairment) were constructed. RESULTS Of 178 infants with postasphyxial hypoxic-ischemic encephalopathy of defined severity admitted consecutively between 1985 and 1992, 48 died, 40 survived with major neurosensory impairment, and 13 were lost to follow-up. The important predictors of severe adverse outcome in the first 4 hours were delayed onset of breathing, administration of chest compressions, and seizures. At 60 minutes of age, based on predicted probabilities of > 0.50, the sensitivity of the predictive model was 85% and specificity 68%. The parameter estimates of the predictive models are reported. CONCLUSIONS Age of onset of breathing, administration of chest compressions, and age of onset of seizures were the most important variables predictive of adverse outcome in this study. Although fairly sensitive and specific, these predictive models should be applied with caution. To build more accurate models, a template for the conduct of a large, multicenter prospective study is provided.
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Affiliation(s)
- P Ekert
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
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131
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van den Berg PP, Nelen WL, Jongsma HW, Nijland R, Kollée LA, Nijhuis JG, Eskes TK. Neonatal complications in newborns with an umbilical artery pH < 7.00. Am J Obstet Gynecol 1996; 175:1152-7. [PMID: 8942481 DOI: 10.1016/s0002-9378(96)70021-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Our purpose was to determine the significance of an umbilical artery pH < 7.00 in relation to neonatal morbidity and mortality. STUDY DESIGN Between 1986 and 1993 acid-base assessment of the umbilical artery was performed routinely in 10,699 deliveries. In a retrospective cohort study 84 nonanomalous neonates with an umbilical artery pH < 7.00 were individually matched with 84 neonates with an umbilical artery pH > 7.24. Matched variables included year of delivery, gender, parity, maternal age, delivery mode, fetal presentation, gestational age, and birth weight. Differences in morbidity between the two groups during the neonatal period (until 28 days after delivery) were investigated. RESULTS Neonates with an umbilical artery pH < 7.00 versus > 7.24 showed significant differences in the following: neonatal condition directly post partum; neurologic, respiratory, cardiovascular, and gastrointestinal complications; and neonatal intensive care unit admissions. No significance was found in renal dysfunction and mortality rate. The proportion of premature infants (< 37 weeks) was 17% in both groups. In the acidotic group a 1-minute Apgar score < or = 3 and a 5-minute Apgar score < 7 was predictive for neonatal complications. CONCLUSIONS Severe intrapartum asphyxia, quantified by an umbilical artery pH < 7.00, poses a threat to the neonate's health.
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Affiliation(s)
- P P van den Berg
- Department of Obstetrics and Gynecology, University Hospital Nijmegen, The Netherlands
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132
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Abstract
Dr Bailey, Director of the National Institute of Neurological Diseases and Blindness, Bethesda, Maryland, introduced the 1956 symposium on 'Neurological and psychological deficits of asphyxia neonatorum' by saying. 'Medical research in regard to cerebral palsy and other neurological disabilities has been relatively neglected. For a truly comprehensive attack on this problem we must focus a sharper scientific search for greater knowledge of those adverse biological factors which operate in the perinatal period. The proper point of departure in such a search is through controlled animal observations, for which purpose monkeys are best suited' (Windle, 1958). Our understanding of the significance of asphyxia is built on the foundation of the laboratory research that has followed upon this initiative. Laboratory studies in fetal monkeys and fetal lambs have clearly demonstrated that the fetus can initially compensate for an asphyxial insult and protect the vital organs. However, if the hypoxaemia progresses to a severe metabolic acidosis and cardiovascular decompensation with hypotension, brain damage will occur. There is a growing body of clinical evidence that supports the contention that the human fetus responds in a similar manner. The varied nature of hypoxic and ischaemic insults has been well demonstrated in animal studies. Total anoxia and isolated cerebral ischaemia are uncommon events in the human fetus. The common insult, particularly during labour, is a degree of hypoxia present over a variable period of time. This is fortunate in that such insults are associated with a period of fetal compensation that may last several hours, during which time a diagnosis of a developing metabolic acidosis can be made. This is the clinician's window of opportunity, when a definitive diagnosis of an asphyxial insult can be made and if necessary intervention made before the threshold of decompensation has been reached. A consensus on the threshold of decompensation has yet to be achieved. However, there is a growing body of evidence that the threshold is in the range of an umbilical artery base deficit of 12-16 mmol/l. Since the aim of the obstetrician during labour is the prevention of asphyxial morbidity and mortality, the determination of this threshold is important to provide criteria for clinical action. A blood gas and acid-base assessment with the determination of a metabolic acidosis is the best measure of an asphyxial insult that may be of clinical significance. The definition of the threshold of metabolic acidosis requiring intervention will continue to be clarified with future clinical research. However, there are many factors that will influence the fetal response to an asphyxial insult, which may require that a range of threshold be acknowledged. The effect upon the fetus will be influenced by whether the asphyxial event is the first or the last of a series of asphyxial episodes, and the duration of the asphyxial episode. The characteristics of the fetus, i.e. maturity (pre-term versus term), and fetal growth small for gestational age (SGA) or appropriate for gestational age (AGA) may influence the fetal response to an asphyxial insult. Improved understanding of these issues will provide a better rationale for clinical management.
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Affiliation(s)
- J A Low
- Department of Obstetrics & Gynaecology & Paediatrics, Queen's University/Kingston General Hospital, Ontario, Canada
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133
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Korkman M, Liikanen A, Fellman V. Neuropsychological consequences of very low birth weight and asphyxia at term: follow-up until school-age. J Clin Exp Neuropsychol 1996; 18:220-33. [PMID: 8780957 DOI: 10.1080/01688639608408277] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This prospective, longitudinal study examined neuropsychological consequences of different conditions associated with risks of perinatal asphyxia. Four groups of children, 5 to 9 years of age, were studied: (1) very low birth weight (VLBW) children born small for gestational age (SGA) (n = 34); (2) VLBW children born appropriate for gestational age (AGA) (n = 43); (3) children with signs of birth asphyxia at term (birth asphyxia) (n = 36), and (4) control children (n = 45). Moderately and severely disabled children were excluded. The WISC-R and the NEPSY, a new neuropsychological assessment consisting of attention, language, motor, sensory, visuospatial, and memory subtests, were administered. The VLBW-SGA group had the poorest test results. The VLBW-AGA group was somewhat less impaired, whereas the birth asphyxia group performed at the control group level. Impairment, when present, tended to be diffuse in all groups, affecting psychometric intelligence, naming, visuo-motor performance, tactile finger discrimination, attention, and phonological analysis.
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Affiliation(s)
- M Korkman
- Department of Child Neurology, Children's Castle Hospital, Finland
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134
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Abstract
Modern intensive monitoring of the fetus during labor affords the opportunity for the greatest possible safety to the infant, whilst at the same time dispensing with unnecessary operations to terminate labor which can be dangerous for the mother and her child. Developments over the past 28 years, since cardiotocography has been in clinical use, have unfortunately also been accompanied by confusion and mistakes. We think that there are two main reasons for this: I. Many who use cardiotocography have not assessed its efficiency correctly. Heart rate pattern with all their variations have too often been regarded as the only diagnostic criteria for the determination of fetal hypoxia. However this procedure only allows a rough selection of actually endangered fetuses. In more than 50% of the cases with a suspicious or pathologic cardiotocogram there is no concrete clinical evidence of manifest danger of hypoxia. II. Investigations concerning the practical importance of monitoring the fetus during labor were often not based on actual clinical indications. Attempts were made to prove that continuous electronic monitoring of the fetal heart rate could be replaced by simple traditional auscultation. Furthermore due to failure to appreciate the real efficiency of cardiotocography, this truly excellent method was in fact blamed for the faults arising from wrong interpretation, instead of underlining the lack of logic of the investigators concerned. After all, several prospective studies, that have examined the efficiency of various monitoring strategies, demonstrate the shortcomings of these techniques in the clinical setting and have shown them to have no relevance in every practice. Presently the most suitable way to monitor the fetus during labor is to combine cardiotocography with a biochemical method. At the moment fetal blood analysis is the most suitable test to be performed in cases where the cardiotocogram is not normal. Then the role of fetal blood analysis is to find out whether in fact a danger of hypoxia is threatened or not. Today the most urgent task when monitoring the fetus during labor is not so much to reduce the number of cases of cerebral palsy since these are seldom caused by intrapartum asphyxia. The major objective is now recognised to be to prevent early morbidity of the fetus, newborn, and the consequences that flow from this. The excellent results of combined intensive monitoring of the fetus during labor are particularly well illustrated by the intrapartum mortality in our hospital during different periods when monitoring practice has been progressively and methodically improved by stages. During the period when monitoring consisted of simple auscultation used on its own, the intrapartum mortality was 0.56%. After the introduction of fetal blood analysis--at that time cardiotocography did not yet exist--the mortality sank to 0.32%. During the first ten years of cardiotocography combined with fetal blood analysis the mortality reduced further to 0.17%, and during the following 13 years it reached to a minimal level of 0.4%. Finally, in this review, other aspects are commented on such as oximetry. Oximetry, presently used as pulse oximetry, as an additional biochemical method will possibly be incorporated as the third method of monitoring the fetus during labor. Oximetry could also be used as an automatic alarm system in the labor ward when fetal O2 levels drop below a particular limit to draw the attention of the staff to the case concerned. Up to now this has not been convincingly achieved with the use of cardiotocography.
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Affiliation(s)
- E Saling
- Institute of Perinatal Medicine, Berlin, Fed. Rep. of Germany
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135
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Martín-Ancel A, García-Alix A, Gayá F, Cabañas F, Burgueros M, Quero J. Multiple organ involvement in perinatal asphyxia. J Pediatr 1995; 127:786-93. [PMID: 7472837 DOI: 10.1016/s0022-3476(95)70174-5] [Citation(s) in RCA: 176] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES (1) To evaluate the frequency and spectrum of severity of multisystem dysfunction after perinatal asphyxia and (2) to analyze the relationship between the clinical and biochemical markers of perinatal asphyxia and multiorgan involvement. STUDY DESIGN Seventy-two consecutive term newborn infants with perinatal asphyxia were studied prospectively. Systematic neurologic, renal, pulmonary, cardiac, and gastrointestinal evaluations were performed. Involvement of each organ was classified as moderate or severe. RESULTS Involvement of one or more organs occurred in 82% of the infants; the central nervous system (CNS) was most frequently involved (72%). Severe CNS injury (7 infants) always occurred with involvement of other organs, although moderate CNS involvement was isolated in 14 infants. Renal involvement occurred in 42%, pulmonary in 26%, cardiac in 29%, and gastrointestinal in 29% of the infants; 15% neonates had renal failure and 19% had respiratory failure. The Apgar scores at 1 and 5 minutes were the only perinatal factors related to the number of organs involved and the severity of involvement; the Apgar score at 5 minutes had the stronger independent association. No relationship or organ dysfunction was found with the umbilical cord arterial blood pH, meconium-stained amniotic fluid, umbilical cord abnormalities, presentation, or type of delivery. CONCLUSIONS Our findings indicate that the Apgar score at 5 minutes, in infants who have other criteria for asphyxia, is the perinatal marker that may best identify infants at risk of organ dysfunction.
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Affiliation(s)
- A Martín-Ancel
- Department of Pediatrics, La Paz Children's Hospital, Autonoma University of Madrid, Spain
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136
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Thornberg E, Ekström-Jodal B. Cerebral function monitoring: a method of predicting outcome in term neonates after severe perinatal asphyxia. Acta Paediatr 1994; 83:596-601. [PMID: 7919755 DOI: 10.1111/j.1651-2227.1994.tb13088.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The cerebral function monitor (CFM), a simplified one-channel EEG monitor, was evaluated in predicting outcome after severe perinatal asphyxia in 38 term infants. Survivors were followed until 1.5-2.5 years of age. All those 17 infants who survived without major neurological handicap showed continuous activity on the CFM trace during the first and/or second day of life. Twenty of the 21 infants who either died or developed severe neurological damage had burst suppression or paroxysmal activity on the first or second day of life. Thus cerebral function monitoring can be a valuable tool in predicting prognosis for infants with severe perinatal asphyxia.
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Affiliation(s)
- E Thornberg
- Department of Anesthesiology and Intensive Care, Ostra Hospital, University of Göteborg, Sweden
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137
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Low JA, Panagiotopoulos C, Derrick EJ. Newborn complications after intrapartum asphyxia with metabolic acidosis in the term fetus. Am J Obstet Gynecol 1994; 170:1081-7. [PMID: 8166190 DOI: 10.1016/s0002-9378(94)70101-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Our purpose was to determine the newborn complications after respiratory or metabolic acidosis at delivery and to demonstrate the characteristics of an asphyxial insult predictive of these complications. STUDY DESIGN Fifty-nine term fetuses with metabolic acidosis were matched with 59 fetuses with normal blood gas measures at delivery. Fifty-one fetuses with respiratory acidosis were also examined. A complication score expressed the magnitude of newborn complications during the 10 days after delivery. RESULTS Newborn complications were not increased after respiratory acidosis. Newborn complications after metabolic acidosis increase in frequency and severity with the increasing severity and duration of the metabolic acidosis. Thirty-two of the 59 newborns in the metabolic acidosis group had a high complication score. The index values predictive of high scores were the duration of the metabolic acidosis and the Apgar score at 1 minute. CONCLUSIONS Intrapartum fetal asphyxia with a severe metabolic acidosis accounts for complications in all newborn systems. The probability of a high complication score increases from 14% with favorable index values to 85% with unfavorable index values.
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Affiliation(s)
- J A Low
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
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