The value of a scoring system for hypoxic ischaemic encephalopathy in predicting neurodevelopmental outcome

Neonatal Sleep-Wake Analyses Predict 18-month Neurodevelopmental Outcomes

Objectives

The neurological examination of critically ill neonates is largely limited to reflexive behavior. The exam often ignores sleep-wake physiology that may reflect brain integrity and influence long-term outcomes. We assessed whether polysomnography and concurrent cerebral near-infrared spectroscopy (NIRS) might improve prediction of 18-month neurodevelopmental outcomes.

Methods

Term newborns with suspected seizures underwent standardized neurologic examinations to generate Thompson scores and had 12-hour bedside polysomnography with concurrent cerebral NIRS. For each infant, the distribution of sleep-wake stages and electroencephalogram delta power were computed. NIRS-derived fractional tissue oxygen extraction (FTOE) was calculated across sleep-wake stages. At age 18-22 months, surviving participants were evaluated with Bayley Scales of Infant Development (Bayley-III), 3rd edition.

Results

Twenty-nine participants completed Bayley-III. Increased newborn time in quiet sleep predicted worse 18-month cognitive and motor scores (robust regression models, adjusted r2 = 0.22, p = .007, and 0.27, .004, respectively). Decreased 0.5-2 Hz electroencephalograph (EEG) power during quiet sleep predicted worse 18-month language and motor scores (adjusted r2 = 0.25, p = .0005, and 0.33, .001, respectively). Predictive values remained significant after adjustment for neonatal Thompson scores or exposure to phenobarbital. Similarly, an attenuated difference in FTOE, between neonatal wakefulness and quiet sleep, predicted worse 18-month cognitive, language, and motor scores in adjusted analyses (each p < .05).

Conclusions

These prospective, longitudinal data suggest that inefficient neonatal sleep-as quantified by increased time in quiet sleep, lower electroencephalogram delta power during that stage, and muted differences in FTOE between quiet sleep and wakefulness-may improve prediction of adverse long-term outcomes for newborns with neurological dysfunction.

Plasma Biomarkers of Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy

OBJECTIVES

To evaluate plasma brain specific proteins and cytokines as biomarkers of brain injury in newborns with hypoxic-ischemic encephalopathy (HIE) and, secondarily, to assess the effect of erythropoietin (Epo) treatment on the relationship between biomarkers and outcomes.

STUDY DESIGN

A study of candidate brain injury biomarkers was conducted in the context of a phase II multicenter randomized trial evaluating Epo for neuroprotection in HIE. Plasma was collected at baseline (<24 hours) and on day 5. Brain injury was assessed by magnetic resonance imaging (MRI) and neurodevelopmental assessments at 1 year. The relationships between Epo, brain-specific proteins (S100B, ubiquitin carboxy-terminal hydrolase-L1 [UCH-L1], total Tau, neuron specific enolase), cytokines (interleukin [IL]-1β, IL-6, IL-8, IL-10, IL-12P70, IL-13, interferon-gamma [IFN-γ], tumor necrosis factor alpha [TNF-α], brain-derived neurotrophic factor [BDNF], monocyte chemoattractant protein-1), and brain injury were assessed.

RESULTS

In 50 newborns with encephalopathy, elevated baseline S100B, Tau, UCH-L1, IL-1β, IL-6, IL-8, IL-10, IL-13, TNF-α, and IFN-γ levels were associated with increasing brain injury severity by MRI. Higher baseline Tau and lower day 5 BDNF were associated with worse 1 year outcomes. No statistically significant evidence of Epo treatment modification on biomarkers was detected in this small cohort.

CONCLUSIONS

Elevated plasma brain-specific proteins and cytokine levels in the first 24 hours of life are associated with worse brain injury by MRI in newborns with HIE. Only Tau and BDNF levels were found to be related to neurodevelopmental outcomes. The effect of Epo treatment on the relationships between biomarkers and brain injury in HIE requires further study.

TRIAL REGISTRATION

ClinicalTrials.gov: 01913340.

Severity of asphyxia is a covariate of phenobarbital clearance in newborns undergoing hypothermia

AIM

Phenobarbital (PB) pharmacokinetics (PK) in asphyxiated newborns show large variability, not only explained by hypothermia (HT). We evaluated potential relevant covariates of PK of PB in newborns treated with or without HT for hypoxic-ischemic encephalopathy (HIE).

METHODS

Clearance (CL), distribution volume (Vd) and elimination half-life (t_1/2) were calculated using one-compartment analysis. Covariates were clinical characteristics (weight, gestational age, hepatic, renal, and circulatory status), comedication and HIE severity [time to reach normal aEEG pattern (T_normaEEG), dichotomous, within 24 h] and asphyxia severity [severe aspyhxia = pH ≤7.1 + Apgar score ≤5 (5 min), dichotomous]. Student's t-test, two-way ANOVA, correlation and Pearson's chi-square test were used.

RESULTS

Forty newborns were included [14 non-HT; 26 HT with T_normaEEG <24 h in 14/26 (group_1-HT) and T_normaEEG ≥24 h in 12/26 (group_2-HT)]. Severe asphyxia was present in 26/40 [5/14 non-HT, 11/14 and 10/12 in both HT groups]. PB-CL, Vd and t_1/2 were similar between the non-HT and HT group. However, within the HT group, PB-CL was significantly different between group_1-HT and group_2-HT (p = .043). ANOVA showed that HT (p = .034) and severity of asphyxia (p = .038) reduced PB-CL (-50%).

CONCLUSION

The interaction of severity of asphyxia and HT is associated with a clinical relevant reduced PB-CL, suggesting the potential relevance of disease characteristics beyond HT itself.

The prognostic value of proton magnetic resonance spectroscopy in term newborns treated with therapeutic hypothermia following asphyxia

OBJECTIVE

The purpose of this study was to correlate brain metabolism assessed shortly after therapeutic hyperthermia by 1H magnetic resonance spectroscopy (MRS), with neurodevelopmental outcome.

METHODS

At the age of 6.0±1.8days, brain metabolites of 35 term asphyxiated newborns, treated with therapeutic hypothermia, were quantified by multivoxel proton MRS of a volume cranial to the corpus callosum, containing both gray and white matter. At the age of 30months the Bayley Scale of Infant Development-III was performed.

RESULTS

Infants that died had lower gray matter NAA levels than infants that survived (P=0.005). In surviving infants (28 of 35) there was a trend of negative correlation between gray matter choline levels and gross motor outcome (r=-0.45). In the white matter, choline correlated negatively with fine motor skills (r=-0.40), and creatine positively with gross motor skills (r=0.58, P=0.02). There was no relationship between lactate levels and outcome.

CONCLUSION

MRS of asphyxiated neonates treated by therapeutic hypothermia can serve as predictor of outcome. Unlike previously reported associations in untreated asphyxiates, lactate levels had no relationship with outcome, which indicates that one of the working mechanisms of therapeutic hypothermia is reduction of the metabolic rate.

Estimation of initial phenobarbital dosing in term neonates with moderate-to-severe hypoxic ischaemic encephalopathy following perinatal asphyxia

WHAT IS KNOWN AND OBJECTIVE

Phenobarbital is the first-line treatment of seizures in asphyxiated neonates; however, due to the high pharmacokinetic variability in this population, there is no consensus on the optimal dosage regimen. This study was conducted to identify variables that affect phenobarbital fate during routine clinical care and then to evaluate the dosage schedule that could be applied in term asphyxiated neonates with respect to achieving the target therapeutic range.

METHODS

Phenobarbital pharmacokinetics was calculated based on serum concentrations measurements using one-compartmental model. Body weight, body surface area, gestational age, creatinine clearance, total bilirubin, alanine aminotransferase, aspartate aminotransferase, international normalized ratio, Apgar scores, umbilical cord arterial pH and base excess were explored as covariates in linear regression models. Based on this analysis, phenobarbital loading and maintenance dose regimen were projected.

RESULTS AND DISCUSSION

In the whole study population (N = 36), phenobarbital volume of distribution, clearance and half-life median (interquartile range) values were 0.49 (0.38-0.59) L/kg, 0.0045 (0.0034-0.0055) L/h/kg and 75.1 (60.2-103.3) hours, respectively. The drug volume of distribution was associated with body weight, length and body surface area, whereas clearance was not in relationship with any explored features. Weight-normalized loading dose of 15 mg/kg and weight-normalized daily maintenance dose of 3 mg/kg proved to be optimal in our study population to reach phenobarbital therapeutic range.

WHAT IS NEW AND CONCLUSIONS

This study presents basis for phenobarbital initial dosing in term asphyxiated neonates during first week of life. Phenobarbital weight-normalized loading dose of 15 mg/kg lead to simulated target peak concentrations in 72% of neonates, weight-normalized maintenance dose of 3 mg/kg lead to steady state within therapeutic window in the same proportion of patients.

Population-Based Study of the National Implementation of Therapeutic Hypothermia in Infants with Hypoxic-Ischemic Encephalopathy

Data on the incidence of hypoxic-ischemic encephalopathy (HIE) in the first 6 hours of life together with the implementation of therapeutic hypothermia (TH) are relevant to delineate actions to achieve the lowest rates of neonatal mortality, morbidity, and long-term impact on health associated with HIE. This is population-based national survey study, including newborns ≥35 weeks of gestation with moderate-to-severe HIE from all level III neonatal care units, to provide the incidence of HIE for the period 2012-2013, and the implementation of TH up to June 2015 in Spain. Incidence rate was 0.77 per 1000 live births (95% confidence interval 0.72-0.83). By June 2015, 63% (57/90) of the units had implemented TH; 95% of them performed servo-controlled whole-body TH. For the 2-year period, 86% of the newborns diagnosed with moderate-to-severe HIE received TH. Active TH increased in use from 78% in 2012 to 85% in 2013 (p = 0.01). The main reasons for not cooling were a delay in the diagnosis (31/682) and the fact that the treatment was not offered (20/682). Interhospital patient transfer was performed using passive hypothermia, by appropriately trained personnel in 61% of centers. Eighteen percent of newborns with moderate or severe HIE died, without significant differences between the 2 years. Up-to-date knowledge of the national coverage of neonatal care of infants with HIE in developed countries is a prerequisite to reducing the load of HIE in this area and to facilitating coordinated, eliminate investigation.

Breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy

BACKGROUND

Specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (HIE) have not yet been well described in the literature. Considering the relatively high incidence of HIE in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding.

OBJECTIVE

To systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild HIE from admission to discharge.

METHOD

A case study of a 2-day old neonate with mild HIE in a neonatal intensive care unit at an urban teaching hospital, is presented. Data were prospectively collected during four sessions in a 12-day period until the participant's discharge. Feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study.

RESULTS

After parenteral feeding, nasogastric tube feeding commenced. Breastfeeding was introduced on Day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. No penetration or aspiration was identified instrumentally. After 13 days, the neonate was breastfeeding safely.

CONCLUSION

Although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. Breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. The case study highlights the unexpected long duration of feeding difficulties in an infant with mild HIE and indicates further research.

Neonatal Hypoxia Ischaemia: Mechanisms, Models, and Therapeutic Challenges

Neonatal hypoxia-ischaemia (HI) is the most common cause of death and disability in human neonates, and is often associated with persistent motor, sensory, and cognitive impairment. Improved intensive care technology has increased survival without preventing neurological disorder, increasing morbidity throughout the adult population. Early preventative or neuroprotective interventions have the potential to rescue brain development in neonates, yet only one therapeutic intervention is currently licensed for use in developed countries. Recent investigations of the transient cortical layer known as subplate, especially regarding subplate's secretory role, opens up a novel set of potential molecular modulators of neonatal HI injury. This review examines the biological mechanisms of human neonatal HI, discusses evidence for the relevance of subplate-secreted molecules to this condition, and evaluates available animal models. Neuroserpin, a neuronally released neuroprotective factor, is discussed as a case study for developing new potential pharmacological interventions for use post-ischaemic injury.

Erythropoietin monotherapy in perinatal asphyxia with moderate to severe encephalopathy: a randomized placebo-controlled trial

OBJECTIVE

Erythropoietin (EPO) is neuroprotective after asphyxia in animal studies. The efficacy and safety of EPO monotherapy in term neonates with hypoxic ischemic encephalopathy (HIE) is uncertain.

STUDY DESIGN

Hundred term neonates with moderate or severe HIE were randomized by random permuted block algorithm to receive either EPO 500 U kg^-1 per dose in 2 ml saline intravenously (50 neonates) on alternate days for a total of five doses with the first dose given by 6 h of age (treatment group) or 2 ml of normal saline (50 neonates) similarly for a total of five doses (placebo group) in a double-blind study. No hypothermia was given. The primary outcome was combined end point of death or moderate or severe disability at mean age of 19 months (s.d., 0.61).

RESULTS

Death or moderate or severe disability occurred in 40% of neonates in the treatment group vs 70% in the placebo group (risk ratio, 0.57; 95% confidence interval (CI) 0.38 to 0.85; P=0.003). Death occurred in 16% of patients in both the groups (risk ratio, 1.0; 95% CI 0.33 to 2.9; P=0.61). The risk of cerebral palsy was lower among survivors in the treatment group (risk ratio, 0.52; 95% CI 0.25 to 1.03; P=0.04) and lesser number of babies were on anticonvulsants at assessment (risk ratio, 0.47; 95% CI 0.20 to 1.01; P=0.03). Neonatal brain magnetic resonance imaging showed more abnormalities in the placebo group (relative risk, 0.66; 95% CI 0.42 to 1.03; P=0.04)). Improvement in other neurological outcomes was not significant.

CONCLUSION

EPO monotherapy reduces the risk of death or disability in term neonates with moderate or severe encephalopathy.

Routine oro/nasopharyngeal suction versus no suction at birth

BACKGROUND

Oro/nasopharyngeal suction is a method used to clear secretions from the oropharynx and nasopharynx through the application of negative pressure via a suction catheter or bulb syringe. Traditionally, airway oro/nasopharyngeal suction at birth has been used routinely to remove fluid rapidly from the oropharynx and nasopharynx in vigorous and non-vigorous infants at birth. Concerns relating to the reported adverse effects of oro/nasopharyngeal suctioning led to a practice review and routine oro/nasopharyngeal suctioning is no longer recommended for vigorous infants. However, it is important to know whether there is any clear benefit or harm for infants whose oro/nasopharyngeal airway is suctioned compared to infants who are not suctioned.

OBJECTIVES

To evaluate the effect of routine oropharyngeal/nasopharyngeal suction compared to no suction on mortality and morbidity in newly born infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 3), MEDLINE via PubMed (1966 to April 18, 2016), Embase (1980 to April 18, 2016), and CINAHL (1982 to April 18, 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised, quasi-randomised controlled trials and cluster randomised trials that evaluated the effect of routine oropharyngeal/nasopharyngeal suction compared to no suction on mortality and morbidity in newly born infants with and without meconium-stained amniotic fluid.

DATA COLLECTION AND ANALYSIS

The review authors extracted from the reports of the clinical trials, data regarding clinical outcomes including mortality, need for resuscitation, admission to neonatal intensive care, five minute Apgar score, episodes of apnoea and length of hospital stay.

MAIN RESULTS

Eight randomised controlled trials met the inclusion criteria and only included term infants (n = 4011). Five studies included infants with no fetal distress and clear amniotic fluid, one large study included vigorous infants with clear or meconium-stained amniotic fluid, and two large studies included infants with thin or thick meconium-stained amniotic fluid. Overall, there was no statistical difference between oro/nasopharyngeal suction and no oro/nasopharyngeal suction for all reported outcomes: mortality (typical RR 2.29, 95% CI 0.94 to 5.53; typical RD 0.01, 95% CI -0.00 to 0.01; I² = 0%, studies = 2, participants = 3023), need for resuscitation (typical RR 0.85, 95% CI 0.69 to 1.06; typical RD -0.01, 95% CI -0.03 to 0.00; I² = 0%, studies = 5, participants = 3791), admission to NICU (typical RR 0.82, 95% CI 0.62 to 1.08; typical RD -0.03, 95% CI -0.08 to 0.01; I² = 27%, studies = 2, participants = 997) and Apgar scores at five minutes (MD -0.03, 95% CI -0.08 to 0.02; I² not estimated, studies = 3, participants = 330).

AUTHORS' CONCLUSIONS

The currently available evidence does not support or refute the benefits or harms of routine oro/nasopharyngeal suction over no suction. Further high-quality studies are required in preterm infants or term newborn infants with thick meconium amniotic fluid. Studies should investigate long-term effects such as neurodevelopmental outcomes.

Early warning- and track and trigger systems for newborn infants: A review

Tools for clinical assessment and escalation of observation and treatment are insufficiently established in the newborn population. We aimed to provide an overview over early warning- and track and trigger systems for newborn infants and performed a nonsystematic review based on a search in Medline and Cinahl until November 2015. Search terms included 'infant, newborn', 'early warning score', and 'track and trigger'. Experts in the field were contacted for identification of unpublished systems. Outcome measures included reference values for physiological parameters including respiratory rate and heart rate, and ways of quantifying the extent of deviations from the reference. Only four neonatal early warning scores were published in full detail, and one system for infants with cardiac disease was considered as having a more general applicability. Temperature, respiratory rate, heart rate, SpO₂, capillary refill time, and level of consciousness were parameters commonly included, but the definition and quantification of 'abnormal' varied slightly. The available scoring systems were designed for term and near-term infants in postpartum wards, not neonatal intensive care units. In conclusion, there is a limited availability of neonatal early warning scores. Scoring systems for high-risk neonates in neonatal intensive care units and preterm infants were not identified.

MRI and spectroscopy in (near) term neonates with perinatal asphyxia and therapeutic hypothermia

BACKGROUND

Previous studies have demonstrated the association of abnormalities on diffusion-weighted MRI (DW-MRI) and proton magnetic resonance spectroscopy (¹H-MRS) in infants with perinatal asphyxia. The use of therapeutic hypothermia might change this association.

AIM

To study the association between DW-MRI and ¹H-MRS and outcome after perinatal asphyxia and therapeutic hypothermia in infants with a gestational age of ≥36 weeks.

PATIENTS AND METHODS

Infants with perinatal asphyxia and therapeutic hypothermia (n=88) were included when an MR examination was performed within 7 days after birth. Apparent diffusion coefficient (ADC) values of the basal ganglia and thalamus were calculated, as were lactate/N-acetylaspartate (LAC/NAA) and N-acetylaspartate/choline (NAA/Cho) ratios. Death or an abnormal neurodevelopment at ≥24 months was considered an adverse outcome. Receiver operating characteristic analysis was performed to determine cut-off levels.

RESULTS

Of the 88 infants, 22 died and 7 had an adverse neurodevelopmental outcome. In infants with an adverse outcome, ADC values of the basal ganglia and thalamus were significantly lower, and Lac/NAA ratios were significantly higher than in infants with a normal outcome. Areas under the curve of ADC of the basal ganglia, thalami and Lac/NAA ratio were 0.89, 0.88 and 0.87, respectively. NAA/Cho ratios were in this cohort not associated with outcome.

CONCLUSIONS

During and after therapeutic hypothermia, low ADC values and high Lac/NAA ratios of the basal ganglia and thalamus are associated with an adverse outcome in infants with perinatal asphyxia.

Therapeutic hypothermia for neonatal encephalopathy: a report from the first 3 years of the Baby Cooling Registry of Japan

Therapeutic hypothermia is recommended for moderate and severe neonatal encephalopathy, but is being applied to a wider range of neonates than originally envisaged. To examine the clinical use of therapeutic hypothermia, data collected during the first 3 years (2012-2014) of the Baby Cooling Registry of Japan were analysed. Of 485 cooled neonates, 96.5% were ≥36 weeks gestation and 99.4% weighed ≥1,800 g. Severe acidosis (pH < 7 or base deficit ≥16 mmol/L) was present in 68.9%, and 96.7% required resuscitation for >10 min. Stage II/III encephalopathy was evident in 88.3%; hypotonia, seizures and abnormal amplitude-integrated electroencephalogram were observed in the majority of the remainder. In-hospital mortality was 2.7%; 90.7% were discharged home. Apgar scores and severity of acidosis/encephalopathy did not change over time. The time to reach the target temperature was shorter in 2014 than in 2012. The proportion undergoing whole-body cooling rose from 45.4% to 81.6%, while selective head cooling fell over time. Mortality, duration of mechanical ventilation and requirement for tube feeding at discharge remained unchanged. Adherence to standard cooling protocols was high throughout, with a consistent trend towards cooling being achieved more promptly. The mortality rate of cooled neonates was considerably lower than that reported in previous studies.

Human Umbilical Cord Blood CD34-Positive Cells as Predictors of the Incidence and Short-Term Outcome of Neonatal Hypoxic-Ischemic Encephalopathy: A Pilot Study

BACKGROUND AND PURPOSE

Neonatal hypoxic-ischemic encephalopathy (HIE) is one of the leading causes of neurological handicap in developing countries. Human umbilical cord blood (hUCB) CD34-positive (CD34⁺) stem cells exhibit the potential for neural repair. We tested the hypothesis that hUCB CD34⁺ stem cells and other cell types [leukocytes and nucleated red blood cells (NRBCs)] that are up-regulated during the acute stage of perinatal asphyxia (PA) could play a role in the early prediction of the occurrence, severity, and mortality of HIE.

METHODS

This case-control pilot study investigated consecutive neonates exposed to PA. The hUCB CD34⁺ cell count in mononuclear layers was assayed using a flow cytometer. Twenty full-term neonates with PA and 25 healthy neonates were enrolled in the study.

RESULTS

The absolute CD34⁺ cell count (p=0.02) and the relative CD34⁺ cell count (CD34⁺%) (p<0.001) in hUCB were higher in the HIE patients (n=20) than the healthy controls. The hUCB absolute CD34⁺ cell count (p=0.04), CD34⁺% (p<0.01), and Hobel risk scores (p=0.04) were higher in patients with moderate-to-severe HIE (n=9) than in those with mild HIE (n=11). The absolute CD34⁺ cell count was strongly correlated with CD34⁺% (p<0.001), Hobel risk score (p=0.04), total leukocyte count (TLC) (p<0.001), and NRBC count (p=0.01). CD34⁺% was correlated with TLC (p=0.02).

CONCLUSIONS

hUCB CD34⁺ cells can be used to predict the occurrence, severity, and mortality of neonatal HIE after PA.

A Comparison of the Thompson Encephalopathy Score and Amplitude-Integrated Electroencephalography in Infants with Perinatal Asphyxia and Therapeutic Hypothermia

BACKGROUND

In previous studies clinical signs or amplitude-integrated electroencephalography (aEEG)-based signs of encephalopathy were used to select infants with perinatal asphyxia for treatment with hypothermia.

AIM

The objective of this study was to compare Thompson encephalopathy scores and aEEG, and relate both to outcome.

SUBJECTS AND METHODS

Thompson scores, aEEG, and outcome were compared in 122 infants with perinatal asphyxia and therapeutic hypothermia. Of these 122 infants, 41 died and 7 had an adverse neurodevelopmental outcome. A receiver operating characteristics (ROC) analysis was also performed.

RESULTS

Thompson scores were higher in infants with more abnormal aEEG background patterns (ANOVA, p < 0.001). The ROC analysis demonstrated that a Thompson score of 11 or higher or an aEEG background pattern of continuous low voltage or worse was associated with an adverse outcome (AUC 0.84 for both).

CONCLUSIONS

High Thompson scores and a suppressed aEEG background pattern are associated with an adverse outcome after perinatal asphyxia and therapeutic hypothermia. Further studies are needed to identify the best technique with which to select patients for therapeutic hypothermia.

Clinical hypoxic-ischemic encephalopathy score of the Iberoamerican Society of Neonatology (Siben): A new proposal for diagnosis and management

Summary Hypoxic ischemic encephalopathy is a major complication of perinatal asphyxia, with high morbidity, mortality and neurologic sequelae as cerebral palsy, mostly in poor or developing countries. The difficulty in the diagnosis and management of newborns in these countries is astonishing, thus resulting in unreliable data on this pathology and bad outcomes regarding mortality and incidence of neurologic sequelae. The objective of this article is to present a new clinical diagnostic score to be started in the delivery room and to guide the therapeutic approach, in order to improve these results.

To Study the Correlation of Thompson Scoring in Predicting Early Neonatal Outcome in Post Asphyxiated Term Neonates

INTRODUCTION

Throughout the world each year, an estimated 23% of the 4 million neonatal deaths and 8% of all deaths in <5 years of age are associated with signs of asphyxia at birth.

AIM

To study the role of cord arterial blood gas analysis at birth and serial Thompson score in predicting the early neonatal outcome in post asphyxiated term neonates.

MATERIALS AND METHODS

The study was conducted in Department of Paediatrics, in Neonatal Intensive Care Unit (NICU), Hindu Rao Hospital, New Delhi from May 2014 to February. 2015. This study was a prospective cross-sectional study. During this period, a total of 145 post asphyxiated term neonates born in labour room/obstetric operation theatre were recruited. An informed consent was taken from all the parents. The protocol was approved by the institutional ethical committee. Inclusion criteria were full-term babies with low-Apgar score i.e., 1 min score of ≤ 7 National Neonatal Perinatal Database 2010 (NNPD 2010).

STATISTICAL ANALYSIS

SPSS 17.0 Software has been used for data analysis. The data were expressed in terms of Means, Standard Deviation and Proportion, followed by comparison between groups through chi-square test or Fisher's-exact test. A p-value of less than 0.05 was considered as statistically significant.

RESULTS

The present study was carried out on 145 post asphyxiated full-term babies with low-Apgar score i.e., 1min score of ≤7mild Thompson score on day I,2,3 were 96 (66.2%), 119 (82.06%), 125 (86.20%), moderate Thompson score on day 1,3, 7 were 13 (8.9%), 6 (4.13%), 2 (1.37%) and severe Thompson score on day 1, 3, 7 were 36 (24.8%), 13 (8.96%), 7 (4.82%) respectively. Total 11 patients died out of 145 post asphyxiated full-term babies within 7 days, among 11 patients, 7 died within 3 days. There was clinical improvement among HIE patients as indicated by serial Thompson score done on day 1, 3 and 7. Among 145 patients 62(42.8%) had seizure and 83(57.2%) did not have seizure. Most common type of seizure was subtle seizure in 25 (40.3%) followed by multifocal in 21 (33.9%) and tonic in 16(25.8%).

CONCLUSION

There is statistically significant correlation between morbidity and day 1 Thompson score (p-value 0.024). There is statistically significant correlation between mortality and day 1 Thompson score (p-value 0.001). Thompson score allows a very precise description of infants by assigning a numeric score rather than 'mild', 'moderate' or 'severe'. Inter-rater reliability is very good with a kappa co-efficient of 0.87.

Birth Asphyxia and Hypoxic-Ischemic Brain Injury in the Preterm Infant

Birth asphyxia, also termed perinatal hypoxia-ischemia, is a modifiable condition as evidenced by improved outcomes of infants ≥36 weeks' gestation provided hypothermia treatment in randomized trials. Preterm animal models of asphyxia in utero demonstrate that hypothermia can provide short-term neuroprotection for the developing brain, supporting the interest in extending therapeutic hypothermia to preterm infants. This review focuses on the challenge of identifying preterm infants with perinatal asphyxia; the neuropathology of hypoxic-ischemic brain injury across extreme, moderate, and late preterm infants; and patterns of brain injury, use of therapeutic hypothermia, and approach to patient selection for neuroprotective treatments among preterm infants.

Early cranial ultrasound findings among infants with neonatal encephalopathy in Uganda: an observational study

BACKGROUND

In sub-Saharan Africa, the timing and nature of brain injury and their relation to mortality in neonatal encephalopathy (NE) are unknown. We evaluated cranial ultrasound (cUS) scans from term Ugandan infants with and without NE for evidence of brain injury.

METHODS

Infants were recruited from a national referral hospital in Kampala. Cases (184) had NE and controls (100) were systematically selected unaffected term infants. All had cUS scans <36 h reported blind to NE status.

RESULTS

Scans were performed at median age 11.5 (interquartile range (IQR): 5.2-20.2) and 8.4 (IQR: 3.6-13.5) hours, in cases and controls respectively. None had established antepartum injury. Major evolving injury was reported in 21.2% of the cases vs. 1.0% controls (P < 0.001). White matter injury was not significantly associated with bacteremia in encephalopathic infants (odds ratios (OR): 3.06 (95% confidence interval (CI): 0.98-9.60). Major cUS abnormality significantly increased the risk of neonatal death (case fatality 53.9% with brain injury vs. 25.9% without; OR: 3.34 (95% CI: 1.61-6.95)).

CONCLUSION

In this low-resource setting, there was no evidence of established antepartum insult, but a high proportion of encephalopathic infants had evidence of major recent and evolving brain injury on early cUS imaging, suggesting prolonged or severe acute exposure to hypoxia-ischemia (HI). Early abnormalities were a significant predictor of death.

Therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy had favourable outcomes at a referral hospital in a middle-income country

AIM

This South African study documented the survival and neurodevelopmental outcomes of infants with hypoxic-ischaemic encephalopathy (HIE) after introducing cooling to a neonatal intensive care unit and identified early markers for neurodevelopmental outcome.

METHODS

We retrospectively reviewed infants that received cooling according to the Total Body Hypothermia trial protocol from 2008 to 2011. Infants were screened with the Bayley Scales of Infant and Toddler Development, Third Edition, at one year of age and underwent neurological and hearing assessments.

RESULTS

Data on 99 infants with HIE showed that 45% of cases were moderate, 23% severe and 32% mild. An abnormal amplitude integrated electro-encephalogram (aEEG) background was documented in 45 cases within 24 hours. Magnetic resonance imaging (MRI) scans were consistent with HIE in all but one case. We reviewed 50 traceable survivors at one year. Development was significantly impaired in nine and 41 were normal or mildly impaired. A severely abnormal aEEG background, severe HIE and an abnormal MRI were associated with death and severe impairment. A good suck, mild HIE, primiparity and normal MRI were associated with good outcomes.

CONCLUSION

Most infants with HIE survived without major impairment. Previously described predictors of neurodevelopmental outcome were good surrogate markers in this population.

The Thompson Encephalopathy Score and Short-Term Outcomes in Asphyxiated Newborns Treated With Therapeutic Hypothermia

BACKGROUND

The Thompson encephalopathy score is a clinical score to assess newborns suffering from perinatal asphyxia. Previous studies revealed a high sensitivity and specificity of the Thompson encephalopathy score for adverse outcomes (death or severe disability). Because the Thompson encephalopathy score was developed before the use of therapeutic hypothermia, its value was reassessed.

OBJECTIVE

The purpose of this study was to assess the association of the Thompson encephalopathy score with adverse short-term outcomes, defined as death before discharge, development of severe epilepsy, or the presence of multiple organ failure in asphyxiated newborns undergoing therapeutic hypothermia.

METHODS

The study period ranged from November 2010 to October 2014. A total of 12 tertiary neonatal intensive care units participated. Demographic and clinical data were collected from the "PharmaCool" multicenter study, an observational cohort study analyzing pharmacokinetics of medication during therapeutic hypothermia. With multiple logistic regression analyses the association of the Thompson encephalopathy scores with outcomes was studied.

RESULTS

Data of 142 newborns were analyzed (male: 86; female: 56). Median Thompson score was 9 (interquartile range: 8 to 12). Median gestational age was 40 weeks (interquartile range 38 to 41), mean birth weight was 3362 grams (standard deviation: 605). All newborns manifested perinatal asphyxia and underwent therapeutic hypothermia. Death before discharge occurred in 23.9% and severe epilepsy in 21.1% of the cases. In total, 59.2% of the patients had multiple organ failure. The Thompson encephalopathy score was not associated with multiple organ failure, but a Thompson encephalopathy score ≥12 was associated with death before discharge (odds ratio: 3.9; confidence interval: 1.3 to 11.2) and with development of severe epilepsy (odds ratio: 8.4; confidence interval: 2.5 to 27.8).

CONCLUSION

The Thompson encephalopathy score is a useful clinical tool, even in cooled asphyxiated newborns. A score ≥12 is associated with adverse outcomes (death before discharge and development of severe epilepsy). The Thompson encephalopathy score is not associated with the development of multiple organ failure.

Short and long term prognosis in perinatal asphyxia: An update

Interruption of blood flow and gas exchange to the fetus in the perinatal period, known as perinatal asphyxia, can, if significant, trigger a cascade of neuronal injury, leading on to neonatal encephalopathy (NE) and resultant long-term damage. While the majority of infants who are exposed to perinatal hypoxia-ischaemia will recover quickly and go on to have a completely normal survival, a proportion will suffer from an evolving clinical encephalopathy termed hypoxic-ischaemic encephalopathy (HIE) or NE if the diagnosis is unclear. Resultant complications of HIE/NE are wide-ranging and may affect the motor, sensory, cognitive and behavioural outcome of the child. The advent of therapeutic hypothermia as a neuroprotective treatment for those with moderate and severe encephalopathy has improved prognosis. Outcome prediction in these infants has changed, but is more important than ever, as hypothermia is a time sensitive intervention, with a very narrow therapeutic window. To identify those who will benefit from current and emerging neuroprotective therapies we must be able to establish the severity of their injury soon after birth. Currently available indicators such as blood biochemistry, clinical examination and electrophysiology are limited. Emerging biological and physiological markers have the potential to improve our ability to select those infants who will benefit most from intervention. Biomarkers identified from work in proteomics, metabolomics and transcriptomics as well as physiological markers such as heart rate variability, EEG analysis and radiological imaging when combined with neuroprotective measures have the potential to improve outcome in HIE/NE. The aim of this review is to give an overview of the literature in regards to short and long-term outcome following perinatal asphyxia, and to discuss the prediction of this outcome in the early hours after birth when intervention is most crucial; looking at both currently available tools and introducing novel markers.

Moderate hypothermia within 6 h of birth plus inhaled xenon versus moderate hypothermia alone after birth asphyxia (TOBY-Xe): a proof-of-concept, open-label, randomised controlled trial

Background

Moderate cooling after birth asphyxia is associated with substantial reductions in death and disability, but additional therapies might provide further benefit. We assessed whether the addition of xenon gas, a promising novel therapy, after the initiation of hypothermia for birth asphyxia would result in further improvement.

Methods

Total Body hypothermia plus Xenon (TOBY-Xe) was a proof-of-concept, randomised, open-label, parallel-group trial done at four intensive-care neonatal units in the UK. Eligible infants were 36–43 weeks of gestational age, had signs of moderate to severe encephalopathy and moderately or severely abnormal background activity for at least 30 min or seizures as shown by amplitude-integrated EEG (aEEG), and had one of the following: Apgar score of 5 or less 10 min after birth, continued need for resuscitation 10 min after birth, or acidosis within 1 h of birth. Participants were allocated in a 1:1 ratio by use of a secure web-based computer-generated randomisation sequence within 12 h of birth to cooling to a rectal temperature of 33·5°C for 72 h (standard treatment) or to cooling in combination with 30% inhaled xenon for 24 h started immediately after randomisation. The primary outcomes were reduction in lactate to N-acetyl aspartate ratio in the thalamus and in preserved fractional anisotropy in the posterior limb of the internal capsule, measured with magnetic resonance spectroscopy and MRI, respectively, within 15 days of birth. The investigator assessing these outcomes was masked to allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00934700, and with ISRCTN, as ISRCTN08886155.

Findings

The study was done from Jan 31, 2012, to Sept 30, 2014. We enrolled 92 infants, 46 of whom were randomly assigned to cooling only and 46 to xenon plus cooling. 37 infants in the cooling only group and 41 in the cooling plus xenon group underwent magnetic resonance assessments and were included in the analysis of the primary outcomes. We noted no significant differences in lactate to N-acetyl aspartate ratio in the thalamus (geometric mean ratio 1·09, 95% CI 0·90 to 1·32) or fractional anisotropy (mean difference −0·01, 95% CI −0·03 to 0·02) in the posterior limb of the internal capsule between the two groups. Nine infants died in the cooling group and 11 in the xenon group. Two adverse events were reported in the xenon group: subcutaneous fat necrosis and transient desaturation during the MRI. No serious adverse events were recorded.

Interpretation

Administration of xenon within the delayed timeframe used in this trial is feasible and apparently safe, but is unlikely to enhance the neuroprotective effect of cooling after birth asphyxia.

Funding

UK Medical Research Council.

Neonatal neurological examination in well newborn term Ugandan infants

BACKGROUND

Newborn neurological examinations have mostly been developed in high-resource settings with cohorts comprising predominantly white Caucasian infants. No comparison has been made with different populations.

AIMS

To (i) establish the range of neurological findings in apparently well newborn term Ugandan infants, (ii) compare these findings to published data for equivalent term UK infants and (iii) correlate the neurological findings with perinatal characteristics and cranial ultrasound (cUS) imaging.

METHODS

Low-risk term Ugandan infants were recruited from the postnatal ward at Mulago Hospital, Kampala, Uganda. Neurological examination (1) and cUS were performed. The raw data and neurological optimality scores were compared to published data from UK infants (1). Gestational age, postnatal age, sex, maternal parity and HIV status, mode of delivery, birth weight and head circumference were correlated with raw scores.

RESULTS

Ugandan infants showed significantly stronger palmar grasp, better auditory and visual orientation, less irritability and less need for consoling but had poorer tone, poorer quality of spontaneous movements and more abnormal signs than UK infants. No correlation was found between raw scores and cUS findings, gestational age, sex, birth weight and head circumference. Significantly fewer Ugandan infants had optimal scores based on the UK data.

CONCLUSION

The neurological status of low-risk hospital-born term Ugandan infants differs from that of low-risk UK infants. The study findings have implications for assessing normality in Ugandan infants and raise concerns about the use of this UK "optimality" score in other research settings. Further work is needed to understand fully the reasons for the differences.

Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature

BACKGROUND

Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries.

METHODS

High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed.

RESULTS

6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified.

CONCLUSION

Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.

Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score: A Pilot Study

This study evaluated the interrater reliability and perceived importance of components of a developed neonatal adaption score, Neonatal Resuscitation Adaptation Score (NRAS), for evaluation of resuscitation need in the delivery room for extremely premature to term infants. Similar to the Apgar, the NRAS highest score was 10, but greater weight was given to respiratory and cardiovascular parameters. Evaluation of provider (N = 17) perception and scoring pattern was recorded for 5 clinical scenarios of gestational ages 23 to 40 weeks at 1 and 5 minutes and documenting NRAS and Apgar score. Providers assessed the tool twice within a 1-month interval. NRAS showed superior interrater reliability (P < .001) and respiratory component reliability (P < .001) for all gestational ages compared to the Apgar score. These findings identify an objective tool in resuscitation assessment of infants, especially those of smaller gestation age, allowing for greater discrimination of postbirth transition in the delivery room.

Subcutaneous fat necrosis in neonates with hypoxic ischaemic encephalopathy registered in the Swiss National Asphyxia and Cooling Register

Background

Neonates with hypoxic ischaemic encephalopathy (HIE) are routinely treated with therapeutic hypothermia (TH) for 72 h in order to improve neurological outcome. Subcutaneous fat necrosis (SCFN) is an adverse event occurring in neonates with HIE.

Methods

We analyzed risk factors for SCFN regarding demographic factors, cooling methods and deviation from target temperature range during hypothermia therapy. Data of all neonates registered in the National Asphyxia and Cooling Register in Switzerland between 2011 and 2013 were analyzed.

Results

2.8 % of all cooled neonates with HIE developed SCFN. Perinatal and neonatal characteristics did not differ between neonates with and without SCFN. Applied cooling methods did not correlate with the occurrence of SCFN. In neonates with SCFN 83.3 % of all noted temperatures were within the target temperature range versus 77.5 % in neonates without SCFN. Neonates with SCFN showed 3.6 % of all measured temperatures below target temperature range compared to 12.7 % in neonates without SCFN.

Conclusion

Subcutaneous fat necrosis in the neonate with HIE undergoing TH is a potential adverse event that seems to occur independently from the whole-body cooling method applied and proportion of temperature measurements outside target temperature range. In this cohort, moderate overcooling associated with moderate hypothermia (33.0–34.0 °C) does not seem to be an independent risk factor for SCFN. There is no correlation between the severity of HIE and incidence of SCFN.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0395-7) contains supplementary material, which is available to authorized users.

Salivary lactate dehydrogenase levels can provide early diagnosis of hypoxic-ischaemic encephalopathy in neonates with birth asphyxia

AIM

Timely detection of hypoxic-ischaemic encephalopathy (HIE) is crucial for selecting neonates who are likely to benefit from neuroprotective therapy. This study evaluated the efficacy of salivary lactate dehydrogenase (LDH) in the early diagnosis of HIE among neonates with perinatal asphyxia.

METHODS

We prospectively enrolled 30 neonates who needed resuscitation at birth or had a history of delayed cry into the HIE group if they developed HIE within 12 h of birth. The control group comprised 30 neonates who had no evidence of HIE, but had intrapartum foetal distress or needed resuscitation at birth. LDH was measured using saliva samples collected within 12 h of birth.

RESULTS

Salivary LDH was significantly higher in the HIE group, with a median of 2578 and an interquartile range (IQR) of 1379-3408 international units per litre (IU/L), than in the control group (median 558.5, IQR: 348-924 IU/L, p < 0.001). The test demonstrated excellent discriminating ability: the area under the curve was 0.92 and the levels of 893 IU/L showed a sensitivity of 90% and a specificity of 73.3%.

CONCLUSION

Measuring salivary LDH among neonates with birth asphyxia provided an early and accurate diagnosis of HIE and could be used as a triage tool.

Early predictors of outcome in infants treated with hypothermia for hypoxic-ischaemic encephalopathy

Hypoxic-ischaemic encephalopathy (HIE) is a leading cause of acquired neonatal brain injury. Assessment of the severity of cerebral injury and likely neurological outcome in infants with HIE is important for determining management and prognosis, for counselling parents, and for selection for neuroprotective trials. The condition of the infant at birth, the severity of HIE, neurophysiological tests, including amplitude-integrated electroencephalography (aEEG), biochemical markers, and neuroimaging have been used to assess prognosis and predict long-term outcome. The predictive accuracy of these indicators in the early postnatal period is modest. Neurophysiological assessment seems to be most helpful during the first 24 to 48 hours after birth whilst magnetic resonance imaging (MRI) seems most informative later. Several biochemical markers, including serum S100β and neuron-specific enolase (NSE), are also associated with HIE but their levels depend on the timing of sampling and their prognostic value is uncertain. Comprehensive neurophysiological assessment and neuroimaging may be limited to specialist centres. Therapeutic hypothermia is now standard care in infants with moderate to severe HIE so it is important to examine the influence of hypothermia on the assessment of prognosis in these infants.

Prediction of outcome methods assessing short- and long-term outcome after therapeutic hypothermia

Therapeutic hypothermia has significantly changed outcomes for newborns suffering neonatal encephalopathy. Outcome predictors established in the pre-cooling era may not automatically be transferred to the cooling era. This article reviews how the reliability of routinely used outcome predictors has changed. We summarize current knowledge about why this may be the case and when to best obtain and analyze different clinical, biochemical, and imaging outcome markers to predict outcome in cooled asphyxiated newborns.

The impact of a register on the management of neonatal cooling in Switzerland

BACKGROUND

Therapeutic hypothermia following hypoxic ischaemic encephalopathy in term infants was introduced into Switzerland in 2005. Initial documentation of perinatal and resuscitation details was poor and neuromonitoring insufficient. In 2011, a National Asphyxia and Cooling Register was introduced.

AIMS

To compare management of cooled infants before and after introduction of the register concerning documentation, neuromonitoring, cooling methods and evaluation of temperature variability between cooling methods.

STUDY DESIGN

Data of cooled infants before the register was in place (first time period: 2005-2010) and afterwards (second time period: 2011-2012) was collected with a case report form.

RESULTS

150 infants were cooled during the first time period and 97 during the second time period. Most infants were cooled passively or passively with gel packs during both time periods (82% in 2005-2010 vs 70% in 2011-2012), however more infants were cooled actively during the second time period (18% versus 30%). Overall there was a significant reduction in temperature variability (p < 0.001) comparing the two time periods. A significantly higher proportion of temperature measurements within target temperature range (72% versus 77%, p < 0.001), fewer temperature measurements above (24% versus 7%, p < 0.001) and more temperatures below target range (4% versus 16%, p < 0.001) were recorded during the second time period. Neuromonitoring improved after introduction of the cooling register.

CONCLUSION

Management of infants with HIE improved since introducing the register. Temperature variability was reduced, more temperature measurements in the target range and fewer temperature measurements above target range were observed. Neuromonitoring has improved, however imaging should be performed more often.

Establishing a hypothermia service for infants with suspected hypoxic-ischemic encephalopathy

The translation of new treatments based upon established evidence into clinical practice is often difficult. The establishment of a therapeutic hypothermia (TH) service and a related cooling register would provide the opportunity to examine how a new therapy becomes implemented in a country or region. The objectives of a TH program should be: to provide guidance to clinicians who are considering the introduction of this new therapy; to ensure standardized clinical practices; to audit the implementation and conduct of TH; to provide surveillance for cooling-related adverse effects; and to evaluate the subsequent neurodevelopmental outcome. Prior to the use of TH, the most important practices to prioritize during its implementation should be identified and include the following: ensure timely identification of infants with neonatal encephalopathy; develop a coordinated system with the local or regional referral cooling center; develop a transport team capable of performing cooling during transport; ensure that each participating unit has access to a national encephalopathy register, and have developmental follow-up arrangements in place that are appropriate and uniform for the region/country.

Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in Uganda: a qualitative study

PURPOSE

The study investigated maternal experiences of caring for a child affected by neurological impairment after neonatal encephalopathy (NE) ("birth asphyxia") in Uganda.

METHODS

Between September 2011 and October 2012 small group and one-on-one in-depths interviews were conducted with mothers recruited to the ABAaNA study examining outcomes from NE in Mulago hospital, Kampala. Data were analysed thematically with the aid of Nvivo 8 software.

FINDINGS

Mothers reported caring for an infant with impairment was often complicated by substantial social, emotional and financial difficulties and stigma. High levels of emotional distress, feelings of social isolation and fearfulness about the future were described. Maternal health-seeking ability was exacerbated by high transport costs, lack of paternal support and poor availability of rehabilitation and counselling services. Meeting and sharing experiences with similarly affected mothers was associated with more positive maternal caring experiences.

CONCLUSION

Mothering a child with neurological impairment after NE is emotionally, physically and financially challenging but this may be partly mitigated by good social support and opportunities to share caring experiences with similarly affected mothers. A facilitated, participatory, community-based approach to rehabilitation training may have important impacts on maximising participation and improving the quality of life of affected mothers and infants. Implications for Rehabilitation Caring for an infant with neurological impairment after NE in Uganda has substantial emotional, social and financial impacts on families and is associated with high levels of emotional stress, feelings of isolation and stigma amongst mothers. Improved social support and the opportunity to share experiences with other similarly affected mothers are associated with a more positive maternal caring experience. High transport costs, lack of paternal support and poor availability of counselling and support services were barriers to maternal healthcare seeking. Studies examining the feasibility, acceptability and impact of early intervention programmes are warranted to maximise participation and improve the quality of life for affected mothers and their infants.

Serum tau protein level serves as a predictive factor for neurological prognosis in neonatal asphyxia

BACKGROUND

Tau protein is a microtubule-associated protein that is present in axons. Elevated tau protein levels in cerebrospinal fluid or serum are associated with several central nervous system diseases and can indicate neuronal injury.

OBJECTIVE

In the present study, we measured and then compared serum tau protein levels between infants with neonatal asphyxia and control subjects. We examined these data to investigate the correlation between serum tau protein levels and neurological outcomes after neonatal asphyxia.

PATIENTS AND METHODS

Serum tau protein levels were determined by an enzyme-linked immunosorbent assay in 19 neonates with neonatal asphyxia. Of these 19 neonates, 3 had severe spastic tetraplegia, and 1 had west syndrome. A group of 19 unaffected neonates was included in the study as a control group.

RESULTS

Serum tau protein levels on postnatal day 3 were significantly higher in the poor outcome group than those in the good outcome (p=0.010) and control groups (p=0.006). On postnatal day 7, serum tau protein levels again were significantly higher in the poor outcome group than those in the good outcome (p=0.007) and control groups (p=0.006).

CONCLUSIONS

The present findings indicate serum tau protein levels measured on postnatal days 3 and 7 can predict neurological prognosis following neonatal asphyxia.

Arterial spin-labelling perfusion MRI and outcome in neonates with hypoxic-ischemic encephalopathy

PURPOSE

Hyperperfusion may be related to outcome in neonates with hypoxic-ischemic encephalopathy (HIE). The purpose of this study was to evaluate whether arterial spin labelling (ASL) perfusion is associated with outcome in neonates with HIE and to compare the predictive value of ASL MRI to known MRI predictive markers.

METHODS

Twenty-eight neonates diagnosed with HIE and assessed with MR imaging (conventional MRI, diffusion-weighted MRI, MR spectroscopy [MRS], and ASL MRI) were included. Perfusion in the basal ganglia and thalami was measured. Outcome at 9 or 18 months of age was scored as either adverse (death or cerebral palsy) or favourable.

RESULTS

The median (range) perfusion in the basal ganglia and thalami (BGT) was 63 (28-108) ml/100 g/min in the neonates with adverse outcome and 28 (12-51) ml/100 g/min in the infants with favourable outcome (p < 0.01). The area-under-the-curve was 0.92 for ASL MRI, 0.97 for MRI score, 0.96 for Lac/NAA and 0.92 for ADC in the BGT. The combination of Lac/NAA and ASL MRI results was the best predictor of outcome (r(2) = 0.86, p < 0.001).

CONCLUSION

Higher ASL perfusion values in neonates with HIE are associated with a worse neurodevelopmental outcome. A combination of the MRS and ASL MRI information is the best predictor of outcome.

KEY POINTS

• Arterial spin labelling MRI can predict outcome in neonates with hypoxic-ischemic encephalopathy • Basal ganglia and thalami perfusion is higher in neonates with adverse outcome • Arterial spin labelling complements known MRI parameters in the prediction of outcome • The combined information of ASL and MRS measurements is the best predictor of outcome.

[Use of therapeutic hypothermia in sudden unexpected postnatal collapse]

Sudden postnatal collapse of a full-term newborn is uncommon but may result in severe consequences: these include death; epilepsy; and motor, cognitive, or sensory impairment. Most authors suggest applying a therapeutic hypothermia approach when a previously healthy newborn develops moderate or severe encephalopathy after a sudden postnatal collapse occurring within the first hours or days after birth. However, this technique has still not been validated by randomized trials. Only a few cases have been reported in the literature. This article describes five apparently healthy newborns, born between 2007 and 2012, who suffered moderate to severe encephalopathy following a postnatal collapse on their first day of life. It describes their clinical history as well as their treatment and follow-up. The article focuses on the implementation of hypothermia in this indication and its limitations. Two newborns underwent classic therapeutic hypothermia, two others underwent temperature regulation (one at 34.5 °C, the other one for only 15 h because she quickly improved). One newborn, with severe pulmonary arterial hypertension, did not receive therapeutic hypothermia. Two newborns died (one had classic hypothermia and the other hypothermia at 34.5 °C), the outcome of the three survivors at three years, 18 months, and 15 months is good with only transient postural anomalies. Follow-up must be continued to assess their cognitive development and particularly their memorization processes. Additional research and centralization of the cases is required to evaluate the feasibility, safety, and benefits of therapeutic hypothermia in this situation.

A refined approach to evaluating global developmental delay for the international medical community

BACKGROUND

Global developmental delay is usually defined as significant delay in two or more domains of development. Etiologic diagnosis generally proves difficult and the etiology remains undetermined in up to 62% of these children. Those in whom an etiology is established generally undergo an exhaustive and costly diagnostic evaluation, even though this may not change the medical or therapeutic management of the delay. The history and physical examination may provide up to 40% of etiologic diagnoses if adequately conducted.

METHODS

We performed a critical review of the literature on global developmental delay via PubMed.

RESULTS

Five major etiologic categories for global developmental delay were identified and traits of the history and physical examination suggestive for their diagnosis were described. Additionally, current diagnostic tools and their benefits and limitations were appraised.

CONCLUSIONS

We propose an improved approach to enhance clinical diagnosis in both resource-rich and resource-limited settings favoring early intervention and management.

Effect of low-level prenatal mercury exposure on neonate neurobehavioral development in China

BACKGROUND

This study aimed to assess the effects of low-level prenatal mercury exposure on neonate neurobehavioral development in China.

METHODS

In total, 418 mother-neonate pairs were included in the study. Maternal urine, hair, and blood samples and cord blood samples were used to document prenatal exposure to mercury. The Neonatal Behavioral Neurological Assessment was used to estimate neurobehavioral development in the neonates at 3 days of age.

RESULTS

Total mercury level was significantly higher in cord blood than that in maternal blood. A strong correlation was found between total mercury levels in maternal blood and those in cord blood (r = 0.7431; P < 0.0001). Trend analysis revealed that mothers who consumed more fish had higher blood and cord blood mercury levels (all P < 0.0001). Significant differences were also found between male and female cord blood mercury levels among groups with different fish consumption frequencies (all P < 0.0001). Cord blood mercury level was significantly associated with total Neonatal Behavioral Neurological Assessment scores (β = 0.03; standard error = 0.01; P = 0.0409), passive muscle tone (odds ratio = 1.07; 95% confidence interval = 1.12-1.13; P = 0.0071), and active muscle tone (odds ratio = 1.06; 95% confidence interval = 1.01-1.11; P = 0.0170) scores after adjustment, respectively.

CONCLUSIONS

Neonatal neurodevelopment was associated with prenatal exposure to mercury. Women with high mercury levels should avoid intake seafood excessively during pregnancy. Long-term effects of exposure to mercury on childhood development need to be further explored.

Therapeutic cooling for perinatal asphyxia-Indian experience

Therapeutic hypothermia (TH) has been established as standard of care for term babies with perinatal asphyxia in developed countries. However, it is yet to gain momentum in India. This review summarizes some of the TH trials conducted in India and the various related issues in adapting the same for the Indian context.

Impact of NICU design on environmental noise

For neonates requiring intensive care, the optimal sound environment is uncertain. Minimal disruptions from medical staff create quieter environments for sleep, but limit language exposure necessary for proper language development. There are two models of neonatal intensive care units (NICUs): open-bay, in which 6-to-10 infants are cared for in a single large room; and single-room, in which neonates are housed in private, individual hospital rooms. We compared the acoustic environments in the two NICU models. We extracted the audio tracks from video-electroencephalography (EEG) monitoring studies from neonates in an open-bay NICU and compared the acoustic environment to that recorded from neonates in a new single-room NICU. From each NICU, 18 term infants were studied (total N=36; mean gestational age 39.3±1.9 weeks). Neither z-scores of the sound level variance (0.088±0.03 vs. 0.083±0.03, p=0.7), nor percent time with peak sound variance (above 2 standard deviations; 3.6% vs. 3.8%, p=0.6) were different. However, time below 0.05 standard deviations was higher in the single-room NICU (76% vs. 70%, p=0.02). We provide objective evidence that single-room NICUs have equal sound peaks and overall noise level variability compared with open-bay units, but the former may offer significantly more time at lower noise levels.

Neonatal encephalopathic cerebral injury in South India assessed by perinatal magnetic resonance biomarkers and early childhood neurodevelopmental outcome

Although brain injury after neonatal encephalopathy has been characterised well in high-income countries, little is known about such injury in low- and middle-income countries. Such injury accounts for an estimated 1 million neonatal deaths per year. We used magnetic resonance (MR) biomarkers to characterise perinatal brain injury, and examined early childhood outcomes in South India.

METHODS

We recruited consecutive term or near term infants with evidence of perinatal asphyxia and a Thompson encephalopathy score ≥6 within 6 h of birth, over 6 months. We performed conventional MR imaging, diffusion tensor MR imaging and thalamic proton MR spectroscopy within 3 weeks of birth. We computed group-wise differences in white matter fractional anisotropy (FA) using tract based spatial statistics. We allocated Sarnat encephalopathy stage aged 3 days, and evaluated neurodevelopmental outcomes aged 3½ years using Bayley III.

RESULTS

Of the 54 neonates recruited, Sarnat staging was mild in 30 (56%); moderate in 15 (28%) and severe in 6 (11%), with no encephalopathy in 3 (6%). Six infants died. Of the 48 survivors, 44 had images available for analysis. In these infants, imaging indicated perinatal rather than established antenatal origins to injury. Abnormalities were frequently observed in white matter (n = 40, 91%) and cortex (n = 31, 70%) while only 12 (27%) had abnormal basal ganglia/thalami. Reduced white matter FA was associated with Sarnat stage, deep grey nuclear injury, and MR spectroscopy N-acetylaspartate/choline, but not early Thompson scores. Outcome data were obtained in 44 infants (81%) with 38 (79%) survivors examined aged 3½ years; of these, 16 (42%) had adverse neurodevelopmental outcomes.

CONCLUSIONS

No infants had evidence for established brain lesions, suggesting potentially treatable perinatal origins. White matter injury was more common than deep brain nuclei injury. Our results support the need for rigorous evaluation of the efficacy of rescue hypothermic neuroprotection in low- and middle-income countries.

Evolution of the Thompson score during the first 6 h in infants with perinatal asphyxia

AIM

This study aimed to determine the evolution of the Thompson score, which provides composite grading of encephalopathy signs, during the first 6 h of birth in neonates with perinatal asphyxia.

METHODS

Twenty term infants with perinatal asphyxia were prospectively studied from the University Hospital of Kinshasa during a 12-month period. The Thompson score was performed after 1 h, then hourly until 6 h of birth.

RESULTS

Fourteen infants had a Thompson score ≥7 and six had a score <7 after 1 h of birth. The Thompson score remained higher than 7 after 3 h in nine infants (64.3%) and in four infants (25.6%) after 6 h. After 3 h of birth, four infants moved from a score ≥7 to a score below 7. After 6 h, five infants had a score below 7. Seventy per cent of patients had a Thompson score higher than 7 after 1 h, 45% after 3 h and 20% after 6 h.

CONCLUSION

The Thompson score changes over the time during the first 6 h of birth, and this should be taken into account when it is being used as an entry criterion for cooling.

Quantitative sleep stage analyses as a window to neonatal neurologic function

OBJECTIVE

To test the hypothesis that neonatal sleep physiology reflects cerebral dysfunction, we compared neurologic examination scores to the proportions of recorded sleep/wake states, sleep depth, and sleep fragmentation in critically ill neonates.

METHODS

Newborn infants (≥35 weeks gestation) who required intensive care and were at risk for seizures were monitored with 8- to 12-hour polysomnograms (PSGs). For each infant, the distribution of sleep-wake states, entropy of the sequence of state transitions, and delta power from the EEG portion of the PSG were quantified. Standardized neurologic examination (Thompson) scores were calculated.

RESULTS

Twenty-eight infants participated (mean gestational age 39.0 ± 1.6 weeks). An increased fraction of quiet sleep correlated with worse neurologic examination scores (Spearman rho = 0.54, p = 0.003), but the proportion of active sleep did not (p > 0.1). Higher state entropy corresponded to better examination scores (rho = -0.43, p = 0.023). Decreased delta power during quiet sleep, but not the power at other frequencies, was also associated with worse examination scores (rho = -0.48, p = 0.009). These findings retained significance after adjustment for gestational age or postmenstrual age at the time of the PSG. Sleep stage transition probabilities were also related to examination scores.

CONCLUSIONS

Among critically ill neonates at risk for CNS dysfunction, several features of recorded sleep-including analyses of sleep stages, depth, and fragmentation-showed associations with neurologic examination scores. Quantitative PSG analyses may add useful objective information to the traditional neurologic assessment of critically ill neonates.

Prevalence of bloodstream pathogens is higher in neonatal encephalopathy cases vs. controls using a novel panel of real-time PCR assays

BACKGROUND

In neonatal encephalopathy (NE), infectious co-morbidity is difficult to diagnose accurately, but may increase the vulnerability of the developing brain to hypoxia-ischemia. We developed a novel panel of species-specific real-time PCR assays to identify bloodstream pathogens amongst newborns with and without NE in Uganda.

METHODOLOGY

Multiplex real-time PCR assays for important neonatal bloodstream pathogens (gram positive and gram negative bacteria, cytomegalovirus (CMV), herpes simplex virus(HSV) and P. falciparum) were performed on whole blood taken from 202 encephalopathic and 101 control infants. Automated blood culture (BACTEC) was performed for all cases and unwell controls.

PRINCIPAL FINDINGS

Prevalence of pathogenic bacterial species amongst infants with NE was 3.6%, 6.9% and 8.9%, with culture, PCR and both tests in combination, respectively. More encephalopathic infants than controls had pathogenic bacterial species detected (8.9%vs2.0%, p = 0.028) using culture and PCR in combination. PCR detected bacteremia in 11 culture negative encephalopathic infants (3 Group B Streptococcus, 1 Group A Streptococcus, 1 Staphylococcus aureus and 6 Enterobacteriacae). Coagulase negative staphylococcus, frequently detected by PCR amongst case and control infants, was considered a contaminant. Prevalence of CMV, HSV and malaria amongst cases was low (1.5%, 0.5% and 0.5%, respectively).

CONCLUSION/SIGNIFICANCE

This real-time PCR panel detected more bacteremia than culture alone and provides a novel tool for detection of neonatal bloodstream pathogens that may be applied across a range of clinical situations and settings. Significantly more encephalopathic infants than controls had pathogenic bacterial species detected suggesting that infection may be an important risk factor for NE in this setting.

Hypothermia for perinatal brain hypoxia-ischemia in different resource settings: a systematic review

OBJECTIVE

To assess the effect of hypothermia on mortality of neonates with hypoxic-ischemic encephalopathy in different economic resources settings.

METHODS

We searched for randomized controlled trials on MEDLINE, Embase and other databases. Duplicate reviewers selected the studies and extracted data. We calculated meta-analyses of the relative risks (RR) and 95% confidence intervals (95% CI), and used meta-regression to evaluate the gross domestic product per capita influence on hypothermia efficacy.

RESULTS

Sixteen studies were included (n = 1889); eight were conducted in lower income countries (n = 662). Hypothermia significantly reduced mortality (RR = 0.77; 95% CI: 0.65-0.92). Meta-regression revealed that hypothermia efficacy does not increase as the gross domestic product per capita rises.

CONCLUSIONS

There is enough evidence to support hypothermia as the standard care for hypoxic-ischemic encephalopathy. Evidence from low-resource settings is limited, but hypothermia efficacy was not shown to be associated with better resources countries.

Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990

BACKGROUND

Intrapartum hypoxic events ("birth asphyxia") may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.

METHODS

Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.

RESULTS

In 2010, 1.15 million babies (uncertainty range: 0.89-1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000-440,000) neonates with NE died in 2010; 233,000 (163,000-342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000-319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.

CONCLUSION

Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.