An optimality score for the neurologic examination of the term newborn

Cooling for newborns with hypoxic ischaemic encephalopathy

BACKGROUND

Newborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae without adverse effects.

OBJECTIVES

To determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long-term neurodevelopmental disability and clinically important side effects.

SEARCH STRATEGY

The standard search strategy of the Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 to June 2007), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

SELECTION CRITERIA

Randomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta-analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals.

MAIN RESULTS

Eight randomised controlled trials were included in this review, comprising 638 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age [typical RR 0.76 (95% CI 0.65, 0.89), typical RD -0.15 (95% CI -0.24, -0.07), NNT 7 (95% CI 4, 14)]. Cooling also resulted in statistically significant reductions in mortality [typical RR 0.74 (95% CI 0.58, 0.94), typical RD -0.09 (95% CI -0.16, -0.02), NNT 11 (95% CI 6, 50)] and in neurodevelopmental disability in survivors [typical RR 0.68 (95% CI 0.51, 0.92), typical RD -0.13 (95% CI -0.23, -0.03), NNT 8 (95% CI 4, 33)]. Some adverse effects of hypothermia included an increase in the need for inotrope support of borderline significance and a significant increase in thrombocytopaenia.

AUTHORS' CONCLUSIONS

There is evidence from the eight randomised controlled trials included in this systematic review (n = 638) that therapeutic hypothermia is beneficial to term newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. However, this review comprises an analysis based on less than half of all infants currently known to be randomised into eligible trials of cooling. Incorporation of data from ongoing and completed randomised trials (n = 829) will be important to clarify the effectiveness of cooling and to provide more information on the safety of therapeutic hypothermia, but could also alter these conclusions. Further trials to determine the appropriate method of providing therapeutic hypothermia, including comparison of whole body with selective head cooling with mild systemic hypothermia, are required.

Safety of benzyl benzoate lotion and permethrin in pregnancy: a retrospective matched cohort study

OBJECTIVE

To assess the safety of benzyl benzoate lotion (BBL) and permethrin, topical treatments for scabies, during pregnancy.

DESIGN

A retrospective controlled cohort study.

POPULATION

Refugee and migrant women attending antenatal clinics (ANC) on the Thai-Burmese border between August 1993 and April 2006.

METHODS

Women treated with either BBL (25%) or permethrin (4%) were identified from a manual search of antenatal records. Each case of scabies was matched with four scabies-free controls for gravidity, age, smoking status, malaria, period of treatment and gestational age at treatment. Conditional Poisson regression was used to estimate risk ratios for outcomes of pregnancy (proportion of abortions, congenital abnormalities, neonatal deaths, stillbirths and premature babies), mean birthweight and estimated median gestational age, for scabies and scabies-free women, independently for BBL and permethrin.

RESULTS

There were no statistically significant differences in pregnancy outcomes between women who were treated with either BBL (n = 444) compared with their matched controls (n = 1,776) or permethrin (n = 196) treated women and their matched controls (n = 784). Overall, only 10.9% (n = 66) of treatments were in the first trimester. Retreatment rates were higher with BBL 16.4%, than permethrin 9.7%, P = 0.038. Scabies was more common during cooler periods.

CONCLUSION

We found no evidence of adverse effects on pregnancy outcome due to topical 25% BBL or 4% permethrin.

Alterations in neurobehavior at term reflect differing perinatal exposures in very preterm infants

OBJECTIVES

Preterm infants have higher rates of cognitive and behavioral difficulties at school age than their term-born peers. We hypothesized that neurobehavior at term would be different in very preterm infants compared with term infants and that perinatal exposures would be associated with these alterations in neurobehavior.

PATIENTS AND METHODS

Two standardized neurobehavioral evaluations were completed on 207 infants at term equivalent, including 168 very preterm infants (<1250 g or <30 weeks' gestation) and 39 term control infants. The assessments used were the Neonatal Intensive Care Unit Network Neurobehavioral Scale and the revised Hammersmith Neonatal Neurologic Examination. The relationship of perinatal variables to preterm infant neurobehavioral scores for both evaluations was examined.

RESULTS

Compared with term-born infants, preterm infant neurobehavior was significantly altered for the Hammersmith Neonatal Neurologic Examination total score and all of the subtotals. Similarly, preterm infants displayed altered neurobehavior for the majority of the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores. Complete perinatal data were available for 157 of 168 very preterm infants. The perinatal variables most strongly associated with altered preterm infant neurobehavior on multivariate regression analysis included the total number of days of assisted ventilation, intraventricular hemorrhage, and necrotizing enterocolitis. Positive perinatal influences on neurobehavioral performance at term on multivariate analysis included maternal antenatal steroids, female gender, and infants receiving breast milk at discharge home.

CONCLUSIONS

Preterm infants at term equivalent showed alterations in motor behavior and higher cortically integrated functions. The pattern of abnormality in neurobehavior differed in relation to perinatal exposures. Neurobehavioral examination at term equivalent age is useful in evaluating the impact of neonatal intensive care.

Popliteal angle in infants with west syndrome

The aim of this study was to clarify the relationship between neurologic findings and outcome of patients with West syndrome, focusing on the popliteal angle. The complete neurologic examination, including an assessment of the popliteal angle and muscle tone, was performed on 45 patients with West syndrome. A tight popliteal angle was determined when it was 120 degrees or less. In all 45 patients, abnormal muscle tone was not correlated with any variables. A tight popliteal angle was correlated with seizure persistence, cerebral palsy, and abnormality on magnetic resonance imaging (MRI), as well as severe developmental delay. When limited to the patients with developmental delay, a tight popliteal angle was correlated with severe developmental delay, cerebral palsy, and MRI abnormality, although abnormal muscle tone was not correlated with any items. In the delay group, eight patients had a tight popliteal angle with normal muscle tone. Among them, severe developmental delay was seen in seven (88%), seizure persistence in five (63%), and MRI abnormality in five (63%). These results suggest that a tight popliteal angle might be an indicator of poor neurologic outcome in patients with West syndrome.

Antenatal ultrasound and magnetic resonance imaging in localizing the level of lesion in spina bifida and correlation with postnatal outcome

OBJECTIVE

To compare prenatal ultrasonography and magnetic resonance imaging (MRI) in the diagnosis of spina bifida with postnatal MRI/surgical findings and to study the postnatal outcome in relation to the level of lesion and head signs on antenatal imaging.

METHODS

A retrospective study of babies referred to a tertiary neurosurgical unit with a diagnosis of spina bifida in the years 2000-2002 was performed. The levels of lesions and head signs diagnosed using antenatal ultrasonography and MRI were compared with postnatal MRI and operative findings. The levels of lesions and head signs diagnosed pre- and postnatally were used to study the correlation with neurological outcome at a mean follow-up period of 12 months.

RESULTS

Twelve antenatally diagnosed and five postnatally diagnosed cases of spina bifida were seen. The level of lesion as identified by antenatal ultrasound correlated with that observed postnatally in 8/12 cases and the antenatal ultrasound diagnosis of ventriculomegaly was confirmed postnatally in all cases. The level of lesion as identified by antenatal MRI correlated with that observed postnatally in 4/8 cases (50%) and the antenatal MRI diagnosis of ventriculomegaly was confirmed postnatally in 5/8 (63%) cases. 12/17 babies were found to have residuals in the immediate postnatal urodynamic studies, of which 83% (n = 10) required intermittent catheterization of the bladder at 12 months of age. Low spinal lesions were associated with increased bladder morbidity when compared to high spinal lesions (8/10 vs. 4/7, P < 0.05) (odds ratio (OR) = 10.0; 95% CI, 1.05-95.01). The level of spinal lesion and the presence of ventriculomegaly did not have any statistically significant correlation with motor functions, morbidity and developmental milestones.

CONCLUSIONS

Antenatal ultrasonography is a good tool in the diagnosis of spina bifida. We could not demonstrate any advantage of antenatal MRI over ultrasonography. There is better correlation of ultrasonography than MRI with postnatal MRI/operative findings in terms of level of lesion and head signs. Low spinal lesions appear to be associated with increased bladder morbidity.

Concordance between Neurologic Screening Test and Neurologic Examination in newborns

The aims of this study were to calculate concordance among results of the assessment of a population of neonates by using a screening version of neurologic assessment developed by our group with the Amiel-Tison examination, to evaluate distribution of the findings for each item in the studied population, and to develop an optimality score to aid in the detection of possible deviations in infants. Infants in this report include 107 infants born consecutively; they were mainly at-term infants, or preterm infants who, when reaching at-term corrected age, were suspected to be abnormal with a wide spectrum of complications. Newborns were tested by neurologic screening and neurologic examination. Agreement, correlations among tests, sensitivity, and specificity were calculated. Correlation among results from Neurological Screening and Neurological Examination was significant (rho = 0.759, p = 0.01), and Cronbach's alpha concordance had an acceptable value (0.83). Sensitivity and specificity of neurologic screening after Amiel-Tison examination comparison were 0.98 and 0.82, respectively. Our results support the use of the neurologic screening proposed.

The neurological examination of the newborn baby

This paper provides an overview of the value of a structured neonatal neurological examination that may be performed in different settings, from routine examination to research settings. We will report how a structured neurological examination can help to identify infants with central and peripheral nervous system involvement. We also describe a short but structured proforma to be used for the routine examination of full-term infants. We will finally describe a quantitative assessment to be used in research settings.

Ernst Moro (1874-1951)--a great pediatric career started at the rise of university-based pediatric research but was curtailed in the shadows of Nazi laws

Ernst Moro was born on December 8, 1874, in Ljubljana, the capital of Slovenia, then part of the Austro-Hungarian empire and attended university in Graz, Austria. Pediatrics, initially regarded as a part of internal medicine, was in its early days as an independent field at universities in German-speaking Europe. The first Chair of Pediatrics had been established in Vienna, Austria in 1884. Ten years later Germany was granted its first Chair in Berlin. Escherich, who held the first Chair of Pediatrics at Graz, was seen as one of the most respected pediatricians in Europe. Therefore, he was invited in 1904 to represent pediatrics together with the American Abraham Jacobi at the International World Congress on Science at the Saint Louis World Exposition in the United States. The high mortality of nearly 25% in infancy was seen as one of the main problems. Escherich's scientific work had established him as the leading bacteriologist. Moro's pediatric career started in Escherich's laboratory with experimental research on the physiology of digestion in infants. In 1900 he presented the first bacteriological characterisation of Lactobacillus acidophilus. In 1906 he received his venia legendi for his work on the bacterial flora in physiological and pathological conditions of the infantile intestine. In 1908 Moro won international reputation for his simple percutaneous skin test for tuberculosis, which was widely used in many countries as the "Moro test" at least until the 1960s. He described a carrot soup and other dietary prescriptions as helpful for diarrhoeal disease. In 1911 he became Head of the Children's Hospital at Heidelberg. In 1918 he described some features peculiar to the first 3 months; according to him this trimenon should be regarded as an own entity like the newborn period. The most famous part of the paper was the description of a milestone in the infant's neurological development, the Umklammerungsreflex (embracing reflex). In 1919 Moro was promoted from associate professor to the first 'Ordinarius', thus founding the first Chair of Pediatrics at Heidelberg and marking the beginning of a scientifically most fruitful period of international collaboration. However, as his wife was of Jewish origin, Moro slowly withdrew from hospital service starting in 1933. After early retirement in 1936, he worked as a pediatrician at home until 1948.

Neurological Examination in Healthy Term Infants Aged 3–10 Weeks

OBJECTIVES

The neurodevelopmental progress of newborn term infants is checked routinely at around 6 weeks of postnatal age. The maturation of neurological signs in this age range however has not been systematically studied and normative data are not available. The aim of this study was to document any changes in posture, tone, reflexes, behaviour and movements in low-risk full-term infants between 3 and 10 weeks of postnatal age.

STUDY DESIGN

We performed a structured neurological examination previously standardised in full-term newborns in the first 48 h after birth. In the current study, a total of 76 examinations were performed between 3 and 10 weeks of age in low-risk full-term infants.

RESULTS

The results of the examinations were divided according to postnatal age. In most items, the scores changed with time, with a definite shift in their distribution occurring around 6 weeks. At this age, a reduction in flexor tone of the limbs was observed, together with an increase in active neck tone. Visual orientation in contrast had already improved by 3 weeks when all infants were able to follow a target in a full circle compared to newborns that are often only able to follow a target in an arc.

CONCLUSIONS

Our results suggest that 6 weeks post-term birth is an important milestone for changes in neurological signs, particularly those related to muscle tone and posture, probably reflecting maturation of the nervous system. These findings provide important guidelines for the interpretation of the neurological examination performed at this age.

Popliteal angle in preterm infants with periventricular leukomalacia

The aim of this study is to clarify the usefulness of popliteal angle in infants with periventricular leukomalacia. The popliteal angle was measured at 1, 4, 8, and 12 months of corrected age in 47 infants with periventricular leukomalacia and in 103 control infants with normal development. The popliteal angle was categorized into two groups; tight, when it was < or =120 degrees , and wide, when it was >120 degrees . The severity of diplegia was defined at 2 years as follows: mild, when an infant could walk; moderate, when an infant could sit but could not walk; severe, when an infant could not sit. Tight popliteal angle was more often observed in infants with periventricular leukomalacia than in normal infants at any corrected age. The rate of tight popliteal angle was significantly lower in infants with mild diplegia than in those with moderate or severe diplegia at 8 and 12 months of corrected age. Specificity and positive predictive value were high at 8 and 12 months of corrected age, whereas sensitivity was relatively low. The results of this study suggest that evaluation of popliteal angle is useful for detection of infants with periventricular leukomalacia, although false-negative rate is high during late infancy.

Can clinical signs identify newborns with neuromuscular disorders?

OBJECTIVE

To evaluate retrospectively the prevalence of neuromuscular disorders in 83 newborns referred to a tertiary care center because of hypotonia and weakness and/or contractures, with a possible diagnosis of neuromuscular disorder. We also aimed to establish whether clinical signs could help to identify infants with neuromuscular disorders.

STUDY DESIGN

Sixty-six of the 83 infants who fulfilled the inclusion criteria (79.5%) had an identifiable disorder, which was a neuromuscular disorder in 39 (46.9%).

RESULTS

Absent or extremely reduced antigravity movements were mainly found in infants with neuromuscular disorders (sensitivity and specificity 97.4% and 75%), whereas partial range antigravity movements were more frequent in infants with other diagnosis. Contractures were mainly found in infants with peripheral nerve or muscle involvement but also were relatively frequent in infants with genetic or metabolic syndromes (sensitivity 69.2%, specificity 61.3%). Reduced fetal movements and abnormal liquor were frequent but not present consistently in infants with neuromuscular disorders (sensitivity 46.1% and 38.4%) and were found rarely in infants with other disorders (specificity 88.6% and 75.0%).

CONCLUSIONS

Severe muscle weakness and contractures are the most reliable indicators of a neuromuscular disorder and should be carefully assessed in an infant with neonatal hypotonia.

Can neurobehavioral examination predict the presence of cerebral injury in the very low birth weight infant?

This study examined in a regional cohort of 66 term age very low birth weight infants, the relationship between qualitative magnetic resonance imaging (MRI) measures of cerebral white and gray matter abnormalities and infant neurobehavioral functioning assessed by structured neurological examination. The diagnostic utility of the Dubowitz neonatal neurological examination in identifying children with severe cerebral abnormalities was also evaluated. Examination results revealed the presence of high rates of neurological abnormality, with 60% of infants scoring in the suboptimal range relative to infants born full term. Linear associations were found between the severity of structural cerebral abnormality on MRI and the quality of clinically rated infant neurobehavioral functioning, with increasing abnormalities being significantly associated with poorer neurological functioning. In particular, white matter abnormalities were significantly associated with lower mean tone and tone pattern scores and a tendency toward lower mean reflex scores. Gray matter abnormalities were significantly associated with lower tone and tone pattern scores and a tendency toward lower spontaneous movements and orientation/behavior scores. Finally, the Dubowitz Neonatal Neurological Examination was found to have relatively good sensitivity (88%; negative predictive value, 92%) but poor specificity (46%; positive predictive value, 34%) for identifying children with significant MRI abnormalities. Implications of these findings for the neurological evaluation of the very low birth weight infant are discussed.

Diffusion-weighted magnetic resonance imaging in term perinatal brain injury: a comparison with site of lesion and time from birth

OBJECTIVE

The aim of this study was to establish a more objective method for confirming tissue injury in term neonates who present with early seizures that are believed to be hypoxic-ischemic in origin.

METHODS

We studied the relationship between contemporaneous diffusion-weighted magnetic resonance imaging and conventional magnetic resonance imaging in 63 symptomatic term-born neonates and 15 control term infants performed in the neonatal period. Apparent diffusion coefficients (ADC) were obtained for multiple regions of the brain.

RESULTS

ADC values in the 15 control infants were 1 (1-1.15) (median [range]) x 10(-3)/mm2/second in the thalami and 1.1 (1-1.3) x 10(-3)/mm2/second in the lentiform nuclei, 1.5 (1.3-1.7) x 10(-3)/mm2/second in the centrum semiovale, 1.6 (1.46-1.7) x 10(-3)/mm2/second in the anterior white matter (WM), and 1.55 (1.35-1.85) x 10(-3)/mm2/second in the posterior WM with little variation over time. ADC values were significantly reduced in the first week after severe injury to either WM or basal ganglia and thalami (BGT), but values normalized at the end of the first week and then increased during week 2. ADC values were either normal or increased in moderate BGT and WM lesions when compared with controls. ADC values < 1.1 x 10(-3)/mm2/second were always associated with WM infarction and values <0.8 x 10(-3)/mm2/second with thalamic infarction.

CONCLUSION

A reduced ADC soon after delivery allows the presence of tissue infarction to be confirmed at a time when conventional imaging changes may be subtle. However, as both moderate WM and BGT lesions may have normal or increased ADC values, a normal ADC value during the first week does not signify normal tissue. ADC values should always be measured in combination with visual analysis of both conventional and diffusion-weighed images for maximum detection of pathologic tissue, and the timing of the scan needs to be taken into account when interpreting the results.

Psychomotor development and general movements in offspring of women with epilepsy and anticonvulsant therapy

While the role of antiepileptic drug (AED) therapy in teratogenesis has widely been investigated, there are few prospective studies on later postnatal development in offspring of epileptic women in utero exposed. The aim of this study was a prospective investigation of the psychomotor development in a selected population of infant born to women with epilepsy on AED therapy during pregnancy.

PATIENTS AND METHODS

Children were assessed at various times until 30 months of age by general movement (GMs) observation (at 7 days and 4 and 13 weeks), traditional neurologic examination (at 7 days and 4 and 13 weeks, 6, 9 and 12 months) and Brunet-Lezine (B-L) administration (at 30 months). We present the preliminary results of our study conducted on 11 children.

RESULTS

Psychomotor delay in children was confirmed by traditional neurological examinations scores at 7 days, 4 weeks, 13 weeks and 6 months and by B-L score at 30 months. Between 9 and 12 months of age, traditional neurologic examination became "silent". GM assessment was found to be a better predictor of psychomotor development. In fact, GM analysis, particularly at 4 weeks, was strongly correlated with the Brunet-Lezine score at 30 months. In conclusion, on the basis of these data we suggest a psychomotor delay in the offspring of epileptic women and that GMs and neurologic evaluation provide complementary information concerning psychomotor development and later outcome of these children.

Energy expenditure in neonates with Down syndrome

Resting energy expenditure was measured in term neonates with Down syndrome during the first week of life and compared with healthy neonates. Infants with Down syndrome expended 14% fewer calories than did healthy infants of the same age.

Neurological examination in the healthy term newborn

We carried out a cross-sectional study with a sample of 106 normal full-term newborns examined within 24 to 72 hours of birth. The following findings were evaluated: head and chest measurements, muscle strength, tone, tendon reflexes, superficial reflexes, primitive reflexes, and cranial nerves. All 106 newborns were considered neurologically normal. We found no differences in the neurological examination findings for newborns with different gestational ages. Primitive reflexes and appendicular tone in newborns examined at earlier postnatal ages tended to be less intense. We were able to determine the prevalence of certain neurological examination findings for the normal newborn and to discuss some differences between our results and those of other studies. Prevalence estimations for the different findings in our study may be valid for different populations as long as the same methodology is adopted.

Neurologic examination of preterm infants at term age: comparison with term infants

OBJECTIVES

The aim was to establish the range of neurologic findings in preterm infants reaching term age, their relation to gestational age at birth, and the possible differences with healthy term newborns tested during the first days of life.

STUDY DESIGN

The Dubowitz neonatal neurologic examination was performed at term age in 157 low-risk preterm infants born between 25 and 34 weeks' gestation who had cranial ultrasonograms that were normal or showed minor abnormalities. Infants were subdivided in 3 groups according to their gestational age at birth.

RESULTS

Within the preterm cohort, the range of scores for the 3 gestational age subgroups was different from each other for 21 of the 34 items, although the median scores were different only in 10 of the 34 items. The range of scores and their median in preterm infants however was wider than that found in term infants. Preterm infants examined at term were also more hyperexcitable and tended to have less flexor tone in the limbs and less extensor tone in the neck in the sitting posture.

CONCLUSIONS

The distribution of scores provides useful guidelines when a preterm infant is examined at term.

[Clinical course and prognosis in hypoxic-ischemic encephalopathy]

BACKGROUND

Establishing the value of neurological examination, and additional diagnostic methods (ultrasonography and magnetic resonance imaging of the brain) in the diagnosis and prognosis of hypoxic-ischemic encephalopathy and its treatment, tracking the clinical course, and making the prognosis of neurological development in newborn infants with hypoxic-ischemic encephalopathy.

METHODS

The group of 40 term newborn infants with suspected intrauterine asphyxia was examined. All the infants were prospectively followed until the 3rd year of age at the Clinic for Neurology and Psychiatry for Children and Youth in order to estimate their neurological development and to diagnose the occurrence of persistent neurological disorders. All the infants were analyzed by their gestational age and Apgar score in the 1st and the 5th minute of life. They were all examined neurologically and by ultrasonography in the first week of life and, repeatedly, at the age of 1, 3, 6, 9, 12, 18, as well as in the 24th month of life. They were treated by the standard methods for this disease. Finally, all the infants were examined neurologically and by magnetic resonance imaging of the brain in their 3rd year of age. On the basis of neurological finding infants were divided into 3 groups: infants with normal neurological finding, infants with mild neurological symptomatology, and infants with severe neurological disorders.

RESULTS

It was shown that neurological finding, ultrasonography and magnetic resonance imaging of the brain positively correlated with the later neurological development of the infants with hypoxic-ischemic encephalopathy.

CONCLUSION

Only the combined use of these techniques had full diagnostic and prognostic significance, emphasizing that the integrative approach was very important in the diagnosis of brain lesions in infants.

Cooling for newborns with hypoxic ischaemic encephalopathy

BACKGROUND

Newborn animal and human pilot studies suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae, without adverse effects.

OBJECTIVES

To determine whether therapeutic hypothermia in encephalopathic asphyxiated newborn infants reduces mortality and long-term neurodevelopmental disability, without clinically important side effects.

SEARCH STRATEGY

The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library (Issue 2, 2003) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue Issue 2, 2003), MEDLINE (1966 to July 2003), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

SELECTION CRITERIA

Randomised controlled trials comparing the use of therapeutic hypothermia with normothermia in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta-analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals.

MAIN RESULTS

Two randomised controlled trials were included in this review, comprising 50 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. There was no significant effect of therapeutic hypothermia on the combined outcome of death or major neurodevelopmental disability in survivors followed. No adverse effects of hypothermia on short term medical outcomes or on some 'early' indicators of neurodevelopmental outcome were detected.

REVIEWER'S CONCLUSIONS

Although two small randomised controlled trials demonstrated neither evidence of benefit or harm, current evidence is inadequate to assess either safety or efficacy of therapeutic hypothermia in newborn infants with hypoxic ischaemic encephalopathy. Therapeutic hypothermia for encephalopathic asphyxiated newborn infants should be further evaluated in well designed randomised controlled trials.

A new approach for neurological evaluation of infants in resource-poor settings

Research assessing the neurological development of infants in developing countries is scanty as no suitable standardised tests are available for field-use in constrained circumstances. We describe the development and application of two simple assessments. Firstly, we aimed to develop a test suitable for assessing acute neurological disturbances caused by such diverse effects as infections, drugs or toxins. This test (Shoklo Neurological Test) is aimed at infants between 9 and 36 months. The second test (Shoklo Developmental Test) is aimed not only to follow the evolution of the signs tested initially in the acute phase but also to evaluate later neurodevelopmental sequelae which might be caused by the same events. The latter test is suitable for infants aged from 3 to 12 months. Both tests can be performed easily in non-optimal conditions. The examinations were tested in a cohort of infants from a Karen refugee camp and administered in a rural setting by health workers, after appropriate training. In order to validate the tests we also applied them to a cohort of London infants. The Griffiths Developmental Scales were applied in the same infants and both the Shoklo Neurological and the Shoklo Developmental Tests showed good correlation with this standardised neurodevelopmental assessment.

Avaliação da idade gestacional de recém-nascidos pré-termo através do exame neurológico e das escalas neonatais e obstétrica

A mortalidade perinatal e a incidência de sequelas neurológicas em prematuros têm diminuído, dado os avanços da perinatologia. A avaliação acurada da idade gestacional (IG) é um componente essencial para o manejo dessas crianças. Procuramos avaliar o desempenho do teste neurológico em comparação com as escalas obstétrica (DUM) e neonatais (de Dubowitz e de Capurro). e comparar as idades gestacionais obtidas após a aplicação das diferentes escalas. Foram examinados 35 recém-nascidos, sendo excluídos aqueles com qualquer comorbidade. Após a aplicação das escalas e determinação das idades gestacionais, realizou-se o exame neurológico e anamnese com os pais. Os resultados obtidos demonstraram que o método neurológico de André-Thomas avalia os padrões do exame neurológico clássico do recém-nascido e, embora não seja um método amplamente utilizado na prática médica, mostrou ser fidedigno para a avaliação da IG.

Postasphyxial encephalopathy in preterm neonates

OBJECTIVE

Perinatal asphyxia is an important determinant of infant neurological outcome. There are very few studies looking exclusively at postasphyxial encephalopathy in preterm neonates.

METHODS

We studied the neurologic and sonographic abnormalities in 40 preterm babies with severe birth asphyxia during their hospital stay and till 3 months corrected age.

RESULT

87.5 % of the asphyxiated preterm babies had neonatal neurologic abnormality, compared to only 17% of the control babies (p<0.0001). Generalised hypotonia and reduced activity were the commonest abnormalities (observed in 85% of asphyxiated babies) while depressed sensorium (60%) and seizures (35%) were seen in more severe cases. White matter disease (WMD-including periventricular flare, cerebral edema and periventricular leucomalacia) was significantly more frequent in the study cases (34.5% in study cases vs 7.5% in controls, p<0.0001) as was grade 3/4 intraventricular hemorrhage(IVH) (25% in study cases vs 2.5% in controls, p<0.0001). There was 11 fold higher mortality among the asphyxiated babies (23 deaths in study cases vs 2 in controls, p<0.0001).

CONCLUSION

The survivors had a significantly higher incidence of both mild and severe neurological abnormalities at corrected age of 3 months among the asphyxiated babies. There was a good correlation between the severity of the neonatal encephalopathy as well as the sonographic findings and the outcome.

Neonatal neurological testing in resource-poor settings

The aim of the study was to design and test a neurological examination for newborns that could be performed reliably by paramedical staff in resource-poor settings. The examination was adapted from a method established by Dubowitz et al., the latest version of which includes an optimality score. The final items in the test were chosen because they were culturally acceptable, could be elicited according to strict but easily comprehensible instructions and because the expected responses could be scored by the descriptions given or by diagrams in the proforma. The shortened examination was easily taught to paramedical staff who achieved a high degree of inter-observer reliability. This shortened version of the examination was piloted by comparing newborns from a Karen refugee camp on the western border of Thailand and from a large maternity hospital in Bangkok with a standardized cohort of newborns in London. The modified shortened version of the test was sufficiently sensitive to identify a number of differences between the cohorts, notably the poor vision performance and markedly reduced tone of the Karen newborns. In conclusion, the test can be used very reliably by paramedical staff and is a useful, simple and portable tool for the neurological assessment of newborn babies where resources are limited.

A new score for postnatal clinical assessment of fetal maturity in newborn infants

OBJECTIVES

To investigate the clinical repeatability of Klimek's method of fetal maturity assessment in newborns.

METHODS

A cohort of 800 consecutive singletons was assessed immediately after birth by a pediatrician, who was unaware of the infants' gestational age. The assessment, according to Klimek's method, consisted of six criteria to evaluate posture and skin appearance, and each variable was scored from 0 to 2 points. After dividing the material into two identical groups, the results were compared with those obtained by means of Ballard's method.

RESULTS

Statistical analysis did not show statistically significant differences between the compared averages in both groups. A significant correlation between the clinically compared methods of fetal maturity grading was found (r> or =0.69, t> or =19, and P<0.001).

CONCLUSIONS

Klimek's method of fetal maturity assessment offers a possibility of objective evaluation of maturity immediately after birth. The clinical methods used to date do not have such advantages. Moreover, they require the evaluation of 12-34 parameters, their point range is more complex and their results are given on the scale of 10-50 points. In each of the applied divisions of observed newborns, there was found a high, statistically significant correlation between the indexes evaluating maturity by means of both comparable methods (i.e. Ballard and Klimek scores), which do not take into account weight and fetal age, but refer directly to fetal maturity. The new scale, which has been proposed, is simple and produces comparable results encompassing full maturity in the range of only 6-12 points.

Outcome after intrapartum asphyxia in term infants

Investigatory techniques, particularly magnetic resonance (MR) imaging and spectroscopy, performed in the early neonatal period on infants suspected of intrapartum asphyxia i.e. abnormal fetal heart recording, poor cord gases, low Apgar scores and the need for resuscitation, or with neonatal encephalopathy or seizures, have allowed a much better understanding of the patterns of brain injury and the biochemical processes that follow these events. It is usually possible to distinguish these patterns from those seen in other, often confounding, diagnoses. This has allowed far more precision about the timing of insults and in the prediction of particularly motor, feeding and visual outcome and to some extent intellectual outcome. Long-term neurological and psychometric follow-up of infants in whom detailed perinatal clinical histories and examination, haematological and biochemical investigation and MR brain scans are obtained will allow even more accurate prediction of outcome in the future. Such studies also help to validate standardized neonatal and infant clinical neurological examinations, making them useful tools to predict outcome.

Optimality score for the neurologic examination of the infant at 12 and 18 months of age

The aim of this study was to develop and validate a simple, quantifiable, neurologic examination for infants between 2 and 24 months of age. The assessment consists of 37 items, divided into 3 sections. The first section includes 26 items assessing cranial nerve function, posture, movements, tone, and reflexes; the second section of 8 items documents the development of motor function, and the third section of 3 items evaluates the state of behavior. We applied this assessment to a cohort of ninety-two 12-month-old infants and forty-three 18-month-old infants, with no known perinatal risk factors. The proforma presented has been designed according to the frequency distribution of the neurologic findings in this cohort. Each item is scored individually, and a global score is the sum of all individual scores. The quantitative score enhances the value of this examination, both in clinical practice and in research settings.