Ethical challenges in the use of therapeutic hypothermia in Indian neonatal units

Preterm Infant Outcomes after Randomization to Initial Resuscitation with FiO2 0.21 or 1.0

OBJECTIVE

To determine rates of death or neurodevelopmental impairment (NDI) at 2 years corrected age (primary outcome) in children <32 weeks' gestation randomized to initial resuscitation with a fraction of inspired oxygen (FiO₂) value of 0.21 or 1.0.

STUDY DESIGN

Blinded assessments were conducted at 2-3 years corrected age with the Bayley Scales of Infant and Toddler Development, Third Edition or the Ages and Stages Questionnaire by intention to treat.

RESULTS

Of the 290 children enrolled, 40 could not be contacted and 10 failed to attend appointments. Among the 240 children for whom outcomes at age 2 years were available, 1 child had a lethal congenital anomaly, 1 child had consent for follow-up withdrawn, and 23 children died. The primary outcome, which was available in 238 (82%) of those randomized, occurred in 47 of the 117 (40%) children assigned to initial FiO₂ 0.21 and in 38 of the 121 (31%) assigned to initial FiO₂ 1.0 (OR, 1.47; 95% CI, 0.86-2.5; P = .16). No difference in NDI was found in 215 survivors randomized to FiO₂ 0.21 vs 1.0 (OR, 1.26; 95% CI, 0.70-2.28; P = .11). In post hoc exploratory analyses in the whole cohort, children with a 5-minute blood oxygen saturation (SpO₂) <80% were more likely to die or to have NDI (OR, 1.85; 95% CI, 1.07-3.2; P = .03).

CONCLUSIONS

Initial resuscitation of infants <32 weeks' gestation with initial FiO₂ 0.21 had no significant effect on death or NDI compared with initial FiO₂ 1.0. Further evaluation of optimum initial FiO₂, including SpO₂ targeting, in a large randomized controlled trial is needed.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Network Registry ACTRN 12610001059055 and the National Malaysian Research Registry NMRR-07-685-957.

Therapeutic Hypothermia for Birth Asphyxia in Neonates

India contributes to the highest neonatal mortality globally. Birth asphyxia is one of the leading causes of neonatal mortality in India. A large number of neonates who suffer from birth asphyxia progress to Hypoxic Ischemic Encephalopathy (HIE). The risk of a neonate progressing to severe form of HIE is many times higher in the low and middle income countries (LMICs) with ill developed health infrastructure. Till date LMICs have had a low institutional delivery rate, poor regionalization of care, lack of adequate transport facilities and ill equipped neonatal intensive care facilities. This has lead to a tremendous burden on the health care systems with a cohort of developmentally challenged neonates surviving into adulthood. Recently, Therapeutic Hypothermia (TH) has emerged as an evidence based intervention to reduce mortality and neurodevelopmental disability associated with asphyxia induced encephalopathy. TH has become the gold standard in the management of such cases in the western world. Extension of this knowledge to the LMICs and countries like India require a better understanding of the unique sociocultural issues associated with asphyxial brain injury in neonates. The high incidence of sepsis and presence of economic constraints make this problem more complex in such countries. The current review has tried to address these issues and looked at the basics of this complex topic from the perspective of a general pediatrician.

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.