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Gang S, Janko J, Lamprecht E, Riedl D, Konzett K, Simma B. Significant correlation between serum biomarkers and outcome in neonatal hypoxic-ischaemic encephalopathy. Acta Paediatr 2024. [PMID: 39086013 DOI: 10.1111/apa.17368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 06/27/2024] [Accepted: 07/19/2024] [Indexed: 08/02/2024]
Abstract
AIM Associations between serum biomarkers S100 calcium-binding protein B (S100B) and neuron-specific enolase (NSE) in neonates with hypoxic-ischaemic encephalopathy (HIE) offer contradicting data in regard to neurocognitive outcome. The aim of our study was to provide another dataset to answer this question if S100B or NSE correlates to outcome in neonatal HIE. In addition, we investigate whether amplitude-integrated EEG (aEEG) or magnetic resonance imaging (MRI) also has predictive value. METHODS In neonates with HIE born in Vorarlberg, Austria, (n = 34) from 2012to 2020, NSE and S100B serum levels were measured on day one. aEEG was installed at admission and MRI performed within 7 days. Surviving children (n = 27) were categorised as good or poor outcome by using an age-appropriate neurocognitive test and a standardised neurological follow-up. Positive and negative predictive values and receiver operating characteristic curves were calculated to evaluate the prognostic value. RESULTS S100B showed best positive and negative predictive value, 72.7% and 90.5%, respectively, and a significant area under the curve of 0.820. NSE showed a positive and a negative predictive value of 43.8% and 81.3% and an area under the curve of 0.757. Severely abnormal aEEG and abnormal MRI significantly correlated with outcome (p = 0.024 and 0.001 respectively). CONCLUSION S100B and NSE on day one, severely abnormal aEEG and abnormal MRI show a significant correlation and good predictive value for neurocognitive outcome.
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Affiliation(s)
- Stefanie Gang
- Department of Pediatrics and Adolescent Medicine, Academic Teaching Hospital, Feldkirch, Austria
| | - Johanna Janko
- Department of Pediatrics and Adolescent Medicine, Academic Teaching Hospital, Feldkirch, Austria
| | - Eileen Lamprecht
- Department of Pediatrics and Adolescent Medicine, Academic Teaching Hospital, Feldkirch, Austria
| | - David Riedl
- Clinic for Psychiatry II, Department of Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Medical University of Innsbruck, Innsbruck, Austria
| | - Karin Konzett
- Department of Pediatrics and Adolescent Medicine, Academic Teaching Hospital, Feldkirch, Austria
| | - Burkhard Simma
- Department of Pediatrics and Adolescent Medicine, Academic Teaching Hospital, Feldkirch, Austria
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Hua T, Nguyen TT, Nguyen TT. Progression of Amplitude-Integrated Electroencephalography and Neurological Outcomes in Neonates With Hypoxic-Ischemic Encephalopathy: A Single-Institution Cohort Study in Vietnam. Cureus 2024; 16:e62317. [PMID: 38882227 PMCID: PMC11177235 DOI: 10.7759/cureus.62317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/18/2024] Open
Abstract
Background The characteristics of amplitude-integrated electroencephalography (aEEG) are associated with neurological outcomes in neonates with hypoxic-ischemic encephalopathy (HIE). We perform a longitudinal analysis of continuous monitoring of aEEG during therapeutic hypothermia and explore the association between aEEG interpretation and clinical neurological outcomes. Method We conducted a prospective cohort study on HIE neonates undergoing hypothermia with aEEG monitoring. Results A total of 37 HIE infants underwent hypothermia with improved aEEG background activity in 28 (75.7%) neonates, of which 18 (48.6%) neonates had background activity returned to a continuous pattern, and the median recovery time was 26.5 hours. Sleep-wake cycle (SWC) appeared in 14 (37.8%) cases, with a median onset time of 34.5 hours. Seizure activity on aEEG was present in 26 (70.3%) infants. Factors associated with poor outcomes at discharge included low voltage or flat trace background activity, a lack of improvement in background activity after hypothermia, and the absence of SWC. Neonates who took longer than 62 hours to return to continuous background activity (time to normal trace) or did not have SWC before the end of hypothermia were more likely to have unfavorable outcomes at discharge. Conclusions Longitudinal analysis of aEEG during hypothermia should be implemented in neonatal care units. The progression of these features on aEEG may predict neurological outcomes for HIE neonates.
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Affiliation(s)
- Thu Hua
- Department of Pediatrics, Children's Hospital 2, Ho Chi Minh, VNM
| | - Thien T Nguyen
- Department of Pediatrics and Neonatology, Children's Hospital 2, Ho Chi Minh, VNM
| | - Tinh T Nguyen
- Department of Pediatrics, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, VNM
- Department of Neonatology, Children's Hospital 2, Ho Chi Minh, VNM
- Department of Neonatology, Ho Chi Minh University Medical Center, Ho Chi Minh, VNM
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Montazeri S, Nevalainen P, Metsäranta M, Stevenson NJ, Vanhatalo S. Clinical outcome prediction with an automated EEG trend, Brain State of the Newborn, after perinatal asphyxia. Clin Neurophysiol 2024; 162:68-76. [PMID: 38583406 DOI: 10.1016/j.clinph.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To evaluate the utility of a fully automated deep learning -based quantitative measure of EEG background, Brain State of the Newborn (BSN), for early prediction of clinical outcome at four years of age. METHODS The EEG monitoring data from eighty consecutive newborns was analyzed using the automatically computed BSN trend. BSN levels during the first days of life (a of total 5427 hours) were compared to four clinical outcome categories: favorable, cerebral palsy (CP), CP with epilepsy, and death. The time dependent changes in BSN-based prediction for different outcomes were assessed by positive/negative predictive value (PPV/NPV) and by estimating the area under the receiver operating characteristic curve (AUC). RESULTS The BSN values were closely aligned with four visually determined EEG categories (p < 0·001), as well as with respect to clinical milestones of EEG recovery in perinatal Hypoxic Ischemic Encephalopathy (HIE; p < 0·003). Favorable outcome was related to a rapid recovery of the BSN trend, while worse outcomes related to a slow BSN recovery. Outcome predictions with BSN were accurate from 6 to 48 hours of age: For the favorable outcome, the AUC ranged from 95 to 99% (peak at 12 hours), and for the poor outcome the AUC ranged from 96 to 99% (peak at 12 hours). The optimal BSN levels for each PPV/NPV estimate changed substantially during the first 48 hours, ranging from 20 to 80. CONCLUSIONS We show that the BSN provides an automated, objective, and continuous measure of brain activity in newborns. SIGNIFICANCE The BSN trend discloses the dynamic nature that exists in both cerebral recovery and outcome prediction, supports individualized patient care, rapid stratification and early prognosis.
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Affiliation(s)
- Saeed Montazeri
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Päivi Nevalainen
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjo Metsäranta
- Department of Pediatrics, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nathan J Stevenson
- Brain Modelling Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sampsa Vanhatalo
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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4
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Pawale D, Fursule A, Tan J, Wagh D, Patole S, Rao S. Prevalence of hearing impairment in neonatal encephalopathy due to hypoxia-ischemia: a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03261-w. [PMID: 38769399 DOI: 10.1038/s41390-024-03261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/17/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND This systematic review was undertaken to estimate the overall prevalence of hearing impairment in survivors of neonatal HIE. METHODS PubMed, EMBASE, CINAHL, EMCARE and Cochrane databases, mednar (gray literature) were searched till January 2023. Randomized controlled trials and observational studies were included. The main outcome was estimation of overall prevalence of hearing impairment in survivors of HIE. RESULTS A total of 71studies (5821 infants assessed for hearing impairment) were included of which 56 were from high income countries (HIC) and 15 from low- or middle-income countries (LMIC). Overall prevalence rate of hearing impairment in cooled infants was 5% (95% CI: 3-6%, n = 4868) and 3% (95% CI: 1-6%, n = 953) in non-cooled HIE infants. The prevalence rate in cooled HIE infants in LMICs was 7% (95% CI: 2-15%) and in HICs was 4% (95% CI: 3-5%). The prevalence rate in non-cooled HIE infants in LMICs was 8% (95% CI: 2-17%) and HICs was 2% (95% CI: 0-4%). CONCLUSIONS These results would be useful for counseling parents, and in acting as benchmark when comparing institutional data, and while monitoring future RCTs testing new interventions in HIE. There is a need for more data from LMICs and standardization of reporting hearing impairment. IMPACT The overall prevalence rate of hearing impairment in cooled infants with HIE was 5% (95% CI: 3-6%) and 3% (95% CI: 1-6%) in the non-cooled infants. The prevalence rate in cooled HIE infants in LMICs was 7% (95% CI: 2-15%) and in HICs was 4% (95% CI: 3-5%). The prevalence rate in non-cooled HIE infants in LMICs was 8% (95% CI: 2-17%) and HICs was 2% (95% CI: 0-4%). These results would be useful for counseling parents, and in acting as benchmark when comparing institutional data, and while monitoring future RCTs testing new interventions in HIE.
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Affiliation(s)
- Dinesh Pawale
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
| | - Anurag Fursule
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
| | - Jason Tan
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Deepika Wagh
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Sanjay Patole
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- Department of Neonatology, King Edwards Memorial Hospital, Perth, WA, Australia
| | - Shripada Rao
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia.
- School of Medicine, University of Western Australia, Crawley, WA, Australia.
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Montaldo P, Cirillo M, Burgod C, Caredda E, Ascione S, Carpentieri M, Puzone S, D’Amico A, Garegrat R, Lanza M, Moreno Morales M, Atreja G, Shivamurthappa V, Kariholu U, Aladangady N, Fleming P, Mathews A, Palanisami B, Windrow J, Harvey K, Soe A, Pattnayak S, Sashikumar P, Harigopal S, Pressler R, Wilson M, De Vita E, Shankaran S, Thayyil S. Whole-Body Hypothermia vs Targeted Normothermia for Neonates With Mild Encephalopathy: A Multicenter Pilot Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249119. [PMID: 38709535 PMCID: PMC11074808 DOI: 10.1001/jamanetworkopen.2024.9119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/22/2024] [Indexed: 05/07/2024] Open
Abstract
Importance Although whole-body hypothermia is widely used after mild neonatal hypoxic-ischemic encephalopathy (HIE), safety and efficacy have not been evaluated in randomized clinical trials (RCTs), to our knowledge. Objective To examine the effect of 48 and 72 hours of whole-body hypothermia after mild HIE on cerebral magnetic resonance (MR) biomarkers. Design, Setting, and Participants This open-label, 3-arm RCT was conducted between October 31, 2019, and April 28, 2023, with masked outcome analysis. Participants were neonates at 6 tertiary neonatal intensive care units in the UK and Italy born at or after 36 weeks' gestation with severe birth acidosis, requiring continued resuscitation, or with an Apgar score less than 6 at 10 minutes after birth and with evidence of mild HIE on modified Sarnat staging. Statistical analysis was per intention to treat. Interventions Random allocation to 1 of 3 groups (1:1:1) based on age: neonates younger than 6 hours were randomized to normothermia or 72-hour hypothermia (33.5 °C), and those 6 hours or older and already receiving whole-body hypothermia were randomized to rewarming after 48 or 72 hours of hypothermia. Main Outcomes and Measures Thalamic N-acetyl aspartate (NAA) concentration (mmol/kg wet weight), assessed by cerebral MR imaging and thalamic spectroscopy between 4 and 7 days after birth using harmonized sequences. Results Of 225 eligible neonates, 101 were recruited (54 males [53.5%]); 48 (47.5%) were younger than 6 hours and 53 (52.5%) were 6 hours or older at randomization. Mean (SD) gestational age and birth weight were 39.5 (1.1) weeks and 3378 (380) grams in the normothermia group (n = 34), 38.7 (0.5) weeks and 3017 (338) grams in the 48-hour hypothermia group (n = 31), and 39.0 (1.1) weeks and 3293 (252) grams in the 72-hour hypothermia group (n = 36). More neonates in the 48-hour (14 of 31 [45.2%]) and 72-hour (13 of 36 [36.1%]) groups required intubation at birth than in the normothermic group (3 of 34 [8.8%]). Ninety-nine neonates (98.0%) had MR imaging data and 87 (86.1%), NAA data. Injury scores on conventional MR biomarkers were similar across groups. The mean (SD) NAA level in the normothermia group was 10.98 (0.92) mmol/kg wet weight vs 8.36 (1.23) mmol/kg wet weight (mean difference [MD], -2.62 [95% CI, -3.34 to -1.89] mmol/kg wet weight) in the 48-hour and 9.02 (1.79) mmol/kg wet weight (MD, -1.96 [95% CI, -2.66 to -1.26] mmol/kg wet weight) in the 72-hour hypothermia group. Seizures occurred beyond 6 hours after birth in 4 neonates: 1 (2.9%) in the normothermia group, 1 (3.2%) in the 48-hour hypothermia group, and 2 (5.6%) in the 72-hour hypothermia group. Conclusions and Relevance In this pilot RCT, whole-body hypothermia did not improve cerebral MR biomarkers after mild HIE, although neonates in the hypothermia groups were sicker at baseline. Safety and efficacy of whole-body hypothermia should be evaluated in RCTs. Trial Registration ClinicalTrials.gov Identifier: NCT03409770.
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Mario Cirillo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Elisabetta Caredda
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Serena Ascione
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Mauro Carpentieri
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Simona Puzone
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | | | - Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Marianna Lanza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Maria Moreno Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Gaurav Atreja
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | | | - Ujwal Kariholu
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | - Narendra Aladangady
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Paul Fleming
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Asha Mathews
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | | | - Joanne Windrow
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Karen Harvey
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Aung Soe
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Santosh Pattnayak
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Palaniappan Sashikumar
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Sundeep Harigopal
- Neonatal Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, United Kingdom
| | - Martin Wilson
- Centre for Human Brain Health and School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Enrico De Vita
- MRI Physics, Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
- Department of Pediatrics, The University of Texas at Austin, Dell Children’s Hospital, Austin, Texas
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
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Sakpichaisakul K, El-Dib M, Munster C, Supapannachart KJ, Yang E, Walsh BH, Volpe JJ, Inder TE. Amplitude-Integrated Electroencephalography Evolution and Magnetic Resonance Imaging Injury in Mild and Moderate to Severe Neonatal Encephalopathy. Am J Perinatol 2024; 41:e2463-e2473. [PMID: 37369240 DOI: 10.1055/a-2118-2953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVE This study aimed to describe the evolution of amplitude-integrated electroencephalography (aEEG) in neonatal encephalopathy (NE) during therapeutic hypothermia (TH) and evaluate the association between aEEG parameters and magnetic resonance imaging (MRI) injury. STUDY DESIGN aEEG data of infants who underwent TH were reviewed for background, sleep wake cycling (SWC), and seizures. Conventional electroencephalography (cEEG) background was assessed from the reports. Discordance of background on aEEG and cEEG was defined if there was a difference in the severity of the background. MRI injury (total score ≥ 5) was assessed by using the Weeke scoring system. RESULTS A total of 46 infants were included; 23 (50%) with mild NE and 23 (50%) with moderate to severe NE. Comparing mild NE with moderate to severe NE, the initial aEEG background differed with more mild being continuous (70 vs. 52%), with fewer being discontinuous (0 vs. 22%) and flat tracing (0 vs. 4%), whereas burst suppression (4 vs. 4%) and low voltage (26 vs. 18%) did not differ. There was a notably common discordance between the background assessment on cEEG with aEEG in 82% with continuous and 40% low voltage aEEG background. MRI abnormalities were identified in four infants with mild NE and seven infants with moderate to severe NE. MRI injury was associated with aEEG seizures in infants with moderate to severe NE. CONCLUSION aEEG seizures are useful to predict MRI injury in moderate to severe NE infants. There is a large discrepancy between aEEG, cEEG, and MRI in neonates treated by TH. KEY POINTS · MRI injury was identified in 29% of moderate NE infants and in 50% of severe NE infants.. · aEEG seizures were associated with MRI injury in the moderate to severe NE infants.. · MRI injury was identified in 16% infants with mild NE.. · Mild NE infants with normal aEEG were unlikely to have MRI injury.. · There was a large discrepancy between aEEG, cEEG, and MRI in infants treated by TH..
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Affiliation(s)
- Kullasate Sakpichaisakul
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Division of Neurology, Queen Sirikit National Institute of Child Health, Ministry of Public Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chelsea Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Krittin J Supapannachart
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brain H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Joseph J Volpe
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ryan MAJ, Malhotra A. Electrographic monitoring for seizure detection in the neonatal unit: current status and future direction. Pediatr Res 2024:10.1038/s41390-024-03207-2. [PMID: 38684885 DOI: 10.1038/s41390-024-03207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
Neonatal neurocritical intensive care is dedicated to safeguarding the newborn brain by prioritising clinical practices that promote early identification, diagnosis and treatment of brain injuries. The most common newborn neurological emergency is neonatal seizures, which may also be the initial clinical indication of neurological disease. A high seizure burden in the newborn period independently contributes to increased mortality and morbidity. The majority of seizures in newborns are subclinical (without clinical presentation), and hence identification may be difficult. Neuromonitoring techniques most frequently used to monitor brain wave activity include conventional electroencephalography (cEEG) or amplitude-integrated EEG (aEEG). cEEG with video is the gold standard for diagnosing and treating seizures. Many neonatal units do not have access to cEEG, and frequently those that do, have little access to real-time interpretation of monitoring. IMPACT: EEG monitoring is of no benefit to an infant without expert interpretation. Whilst EEG is a reliable cot-side tool and of diagnostic and prognostic use, both conventional EEG and amplitude-integrated EEG have strengths and limitations, including sensitivity to seizure activity and ease of interpretation. Automated seizure detection requires a sensitive and specific algorithm that can interpret EEG in real-time and identify seizures, including their intensity and duration.
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Affiliation(s)
- Mary Anne J Ryan
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
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8
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Langeslag JF, Onland W, Groenendaal F, de Vries LS, van Kaam AH, de Haan TR. Association Between Seizures and Neurodevelopmental Outcome at Two and Five Years in Asphyxiated Newborns With Therapeutic Hypothermia. Pediatr Neurol 2024; 153:152-158. [PMID: 38387280 DOI: 10.1016/j.pediatrneurol.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 01/09/2024] [Accepted: 01/25/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To investigate the association between the presence and severity of seizures in asphyxiated newborns and their neurodevelopmental outcome at ages two and five years. METHODS Retrospective data analysis from a prospectively collected multicenter cohort of 186 term-born asphyxiated newborns undergoing therapeutic hypothermia (TH) in 11 centers in the Netherlands and Belgium. Seizures were diagnosed by amplitude-integrated electroencephalography (EEG) and raw EEG signal reading up to 48 hours after rewarming. Neurodevelopmental outcome was assessed by standardized testing at age two and five years. Primary outcome was death or long-term neurodevelopmental impairment (NDI) including cerebral palsy. Associations were calculated using univariate and multivariate logistic regression analyses adjusting for Thompson score and a validated brain magnetic resonance imaging (MRI) score. RESULTS Seventy infants (38%) had seizures during TH or rewarming, and 44 (63%) of these needed two or more antiseizure medications (ASMs). Overall mortality was 21%. Follow-up data from 147 survivors were available for 137 infants (93%) at two and for 94 of 116 infants (81%) at five years. NDI was present in 26% at two and five years. Univariate analyses showed a significant association between seizures and death or NDI, but this was no longer significant after adjusting for Thompson and MRI score in the multivariate analysis; this was also true for severe seizures (need for two or more ASMs) or seizures starting during rewarming. CONCLUSION The presence or severity of seizures in newborns undergoing TH for hypoxic-ischemic encephalopathy was not independently associated with death or NDI up to age five years after adjusting for several confounders.
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Affiliation(s)
- Juliette F Langeslag
- Department of Neonatology, Amsterdam UMC Location University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Amsterdam UMC Location University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, the Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Brain Center, Utrecht, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC Location University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands
| | - Timo R de Haan
- Department of Neonatology, Amsterdam UMC Location University of Amsterdam, Emma Children's Hospital, Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Amsterdam, the Netherlands.
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9
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Hortigüela MM, Martínez-Biarge M, Conejo D, Vega-Del-Val C, Arnaez J. Motor, cognitive and behavioural outcomes after neonatal hypoxic-ischaemic encephalopathy. An Pediatr (Barc) 2024; 100:104-114. [PMID: 38331678 DOI: 10.1016/j.anpede.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION The current neurodevelopmental status of patients with neonatal hypoxic-ischaemic encephalopathy (HIE) in Spain is unknown. Recent European studies highlight a shift of severe pathology towards mild motor disorders and emotional problems. The aim of this study was to analyse neurodevelopmental outcomes in a cohort of neonates with HIE at age 3 years. PATIENTS AND METHOD Multicentre observational study of neonates born at 35 or more weeks of gestation with moderate to severe HIE in 2011-2013 in 12 hospitals in a large Spanish region (91 217 m2), with the recruitment extended through 2017 in the coordinating hospital. We analysed the findings of neonatal neuroimaging and neurodevelopmental test scores at 3 years (Bayley-III, Peabody Picture Vocabulary Test and Child Behavior Checklist). The sample included 79 controls with no history of perinatal asphyxia. RESULTS Sixty-three patients were recruited, of whom 5 (7.9%) were excluded due to other pathology and 14 (24%) died. Of the 44 survivors, 42 (95.5%) were evaluated. Of these 42, 10 (24%) had adverse outcomes (visual or hearing impairment, epilepsy, cerebral palsy or developmental delay). Other detected problems were minor neurological signs in 6 of the 42 (14%) and a higher incidence of emotional problems compared to controls: introversion (10.5% vs. 1.3%), anxiety (34.2% vs. 11.7%) and depression (28.9% vs. 7.8%) (P < .05). The severity of the lesions on neuroimaging was significantly higher in patients with motor impairment (P = .004) or who died or had an adverse outcome (P = .027). CONCLUSION In addition to classical sequelae, the followup of patients with neonatal HIE should include the diagnosis and treatment of minor motor disorders and social and emotional problems.
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Affiliation(s)
| | | | - David Conejo
- Servicio de Pediatría, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Juan Arnaez
- Unidad de Neonatología, Hospital Universitario de Burgos, Burgos, Spain; Neurología Neonatal, Fundación NeNe, Madrid, Spain; SIBEN, Nueva Yersey, USA.
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10
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Taccone FS, Annoni F. Temperature management after cardiac arrest: what is next after the TTM-2 and BOX trials? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:504-506. [PMID: 37490845 DOI: 10.1093/ehjacc/zuad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium
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11
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Variane GFT, Rodrigues DP, Pietrobom RFR, França CN, Netto A, Magalhães M. Newborns at high risk for brain injury: the role of the amplitude-integrated electroencephalography. J Pediatr (Rio J) 2022; 98:565-571. [PMID: 34986412 PMCID: PMC9617284 DOI: 10.1016/j.jped.2021.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 10/04/2021] [Accepted: 10/21/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Amplitude-integrated electroencephalography (aEEG) is a simplified bedside neurophysiology tool that has been implemented in the neonatal intensive care unit and studied in an extensive range of clinical applications in the past decade. This critical review aimed to evaluate a variety of clinical applications of aEEG monitoring in diagnosis, clinical management, and prognosis assessment in critically ill neonates. SOURCES The databases of Pubmed, SciELO, Lilacs, and Cochrane, books, and other online resources were consulted, as well as sources of professional experiences. SUMMARY OF FINDINGS The clinical use of aEEG to access real-time brain function, background activity, and utility in seizures detection has been described. A critical review was realized considering the authors' professional experience. Newborns with hypoxic-ischemic encephalopathy and seizures screening represent the most common studied population. However, several studies have shown interesting applications on preterm infants, newborns with congenital heart disease, and other clinical situations of high risk of injury to the developing brain. CONCLUSION The aEEG has shown to be a useful non-invasive bedside monitor that aids in evaluating brain function, background activity, and cyclicity. aEEG findings have also demonstrated good prognostic value in a group of critically ill neonates. The aEEG seizure diagnosis capability has limitations, which have been already well established. The use of neonatal brain monitoring such as aEEG was shown to give valuable information in several high-risk clinical situations.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Divisão Neonatal, Grupo Santa Joana, São Paulo, SP, Brazil; Divisão Neonatal, Departamento de Pediatria, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Daniela Pereira Rodrigues
- Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil; Escola Paulista de Enfermagem, Departamento de Enfermagem Pediátrica, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Rafaela Fabri Rodrigues Pietrobom
- Divisão Neonatal, Departamento de Pediatria, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil
| | - Carolina Nunes França
- Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil; Programa de Pós-Graduação em Ciências da Saúde, Universidade de Santo Amaro, São Paulo, SP, Brazil
| | - Alexandre Netto
- Divisão Neonatal, Departamento de Pediatria, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil
| | - Maurício Magalhães
- Divisão Neonatal, Departamento de Pediatria, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Organização Protegendo Cérebros e Salvando Futuros, São Paulo, SP, Brazil; Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
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12
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Elbayiyev S, Çevirici T, Güngör AA, Kadıoğlu Şimşek G, Kanmaz Kutman HG, Canpolat FE. A novel scoring system (YASHMA) predicting brain injury in asphyxiated newborns. J Trop Pediatr 2022; 68:6749661. [PMID: 36201231 DOI: 10.1093/tropej/fmac082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy is a complication of adverse intrapartum events and birth asphyxia resulting in brain injury and mortality in late preterm and term newborns. OBJECTIVES In this study, we aimed to predict brain damage on magnetic resonance imaging (MRI) with a new scoring system. METHODS Yieldly And Scorable Holistic Measuring of Asphyxia (YASHMA) is generated for detection of brain injury in asphyxiated newborns. Total scores were calculated according to scores of birth weight, gestation weeks, APGAR scores at first and fifth minutes, aEEG patterns and epileptic status of patients. The major outcome of the scoring system was to determine correlation between poor scores and neonatal brain injury detected on MRI. RESULTS In hypothermia group with brain injury, low gestational weeks and lowest APGAR scores, abnormal aEEG findings were statistically different from others. YASHMA scores were statistically significant with high sensitivity, specificity, AUC and 95% confidence interval values. CONCLUSIONS YASHMA scoring system is feasible and can be suggestive for detecting brain injury in low-income countries.
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Affiliation(s)
- Sarkhan Elbayiyev
- University of Health Sciences, Ankara City Hospital, Department of Neonatology, Ankara 06800, Turkey
| | - Tevfik Çevirici
- University of Health Sciences, Ankara City Hospital, Department of Neonatology, Ankara 06800, Turkey
| | - Ahmet Alptuğ Güngör
- University of Health Sciences, Ankara City Hospital, Department of Neonatology, Ankara 06800, Turkey
| | - Gülsüm Kadıoğlu Şimşek
- University of Health Sciences, Ankara City Hospital, Department of Neonatology, Ankara 06800, Turkey
| | | | - Fuat Emre Canpolat
- University of Health Sciences, Ankara City Hospital, Department of Neonatology, Ankara 06800, Turkey
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13
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Meder U, Cseko AJ, Szakacs L, Balogh CD, Szakmar E, Andorka C, Kovacs K, Dobi M, Brandt FA, Szabo M, Szabo AJ, Jermendy A. Longitudinal Analysis of Amplitude-Integrated Electroencephalography for Outcome Prediction in Hypoxic-Ischemic Encephalopathy. J Pediatr 2022; 246:19-25.e5. [PMID: 35430248 DOI: 10.1016/j.jpeds.2022.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/23/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the prognostic accuracy of longitudinal analysis of amplitude-integrated electroencephalography (aEEG) background activity to predict long-term neurodevelopmental outcome in neonates with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia. STUDY DESIGN This single-center observational study included 149 neonates for derivation and 55 neonates for validation with moderate-severe HIE and of gestational age ≥35 weeks at a tertiary neonatal intensive care unit. Single-channel aEEG background pattern, sleep-wake cycling, and seizure activity were monitored over 84 hours during therapeutic hypothermia and rewarming, then scored for each 6-hour interval. Neurodevelopmental outcome was assessed using the Bayley Scales of Infant Development, Second Edition. Favorable outcome was defined as having both a Mental Development Index (MDI) score and Psychomotor Development Index (PDI) score ≥70, and adverse outcome was defined as either an MDI or a PDI <70 or death. Regression modeling for longitudinal analysis of repeatedly measured data was applied, and area under the receiver operating characteristic curve (AUC) was calculated. RESULTS Longitudinal aEEG background analysis combined with sleep-wake cycling score had excellent predictive value (AUC, 0.90; 95% CI, 0.85-0.95), better than single aEEG scores at any individual time point. The model performed well in the independent validation cohort (AUC, 0.87; 95% CI, 0.62-1.00). The reclassification rate of this model compared with the conventional analysis of aEEG background at 48 hours was 18% (24 patients); 14% (18 patients) were reclassified correctly. Our results were used to develop a user-friendly online outcome prediction tool. CONCLUSIONS Longitudinal analysis of aEEG background activity and sleep-wake cycling is a valuable and accurate prognostic tool.
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Affiliation(s)
- Unoke Meder
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna J Cseko
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Laszlo Szakacs
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Csenge D Balogh
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Eniko Szakmar
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Csilla Andorka
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Kata Kovacs
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marianna Dobi
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Ferenc A Brandt
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Miklos Szabo
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabo
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; MTA-SE Pediatric and Nephrology Research Group, Budapest, Hungary
| | - Agnes Jermendy
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
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14
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Rao R, Mietzsch U, DiGeronimo R, Hamrick SE, Dizon MLV, Lee KS, Natarajan G, Yanowitz TD, Peeples ES, Flibotte J, Wu TW, Zaniletti I, Mathur AM, Massaro A. Utilization of Therapeutic Hypothermia and Neurological Injury in Neonates with Mild Hypoxic-Ischemic Encephalopathy: A Report from Children's Hospital Neonatal Consortium. Am J Perinatol 2022; 39:319-328. [PMID: 32892328 DOI: 10.1055/s-0040-1716341] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study was aimed to describe utilization of therapeutic hypothermia (TH) in neonates presenting with mild hypoxic-ischemic encephalopathy (HIE) and associated neurological injury on magnetic resonance imaging (MRI) scans in these infants. STUDY DESIGN Neonates ≥ 36 weeks' gestation with mild HIE and available MRI scans were identified. Mild HIE status was assigned to hyper alert infants with an exaggerated response to arousal and mild HIE as the highest grade of encephalopathy recorded. MRI scans were dichotomized as "injury" versus "no injury." RESULTS A total of 94.5% (257/272) neonates with mild HIE, referred for evaluation, received TH. MRI injury occurred in 38.2% (104/272) neonates and affected predominantly the white matter (49.0%, n = 51). Injury to the deep nuclear gray matter was identified in (10.1%) 20 infants, and to the cortex in 13.4% (n = 14 infants). In regression analyses (odds ratio [OR]; 95% confidence interval [CI]), history of fetal distress (OR = 0.52; 95% CI: 0.28-0.99) and delivery by caesarian section (OR = 0.54; 95% CI: 0.31-0.92) were associated with lower odds, whereas medical comorbidities during and after cooling were associated with higher odds of brain injury (OR = 2.31; 95% CI: 1.37-3.89). CONCLUSION Majority of neonates with mild HIE referred for evaluation are being treated with TH. Odds of neurological injury are over two-fold higher in those with comorbidities during and after cooling. Brain injury predominantly involved the white matter. KEY POINTS · Increasingly, neonates with mild HIE are being referred for consideration for hypothermia therapy.. · Drift in clinical practice shows growing number of neonates treated with hypothermia as having mild HIE.. · MRI data show that 38% of neonates with mild HIE have brain injury, predominantly in the white matter..
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Affiliation(s)
- Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Ulrike Mietzsch
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Robert DiGeronimo
- Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington
| | | | - Maria L V Dizon
- Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Kyong-Soon Lee
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Toby D Yanowitz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tai-Wei Wu
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Isabella Zaniletti
- Department of Pediatrics, Children's Hospitals Association, Kansas City, Kansas
| | - Amit M Mathur
- Department of Pediatrics, St. Louis University School of Medicine, St. Louis, Missouri
| | - An Massaro
- Department of Pediatrics, Children's National Health Systems, Washington, Dist. of Columbia
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15
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Variane GFT, Magalhães M, Pietrobom RFR, Netto A, Rodrigues DP, Gasperini R, Sant’Anna GM. Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil. PLoS One 2022; 17:e0262581. [PMID: 35020756 PMCID: PMC8754327 DOI: 10.1371/journal.pone.0262581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 12/29/2021] [Indexed: 11/19/2022] Open
Abstract
Background
Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs.
Methods
A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up.
Discussion
The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring.
Trial registration
NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Neonatal Division, Grupo Santa Joana, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- * E-mail:
| | - Maurício Magalhães
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Rafaela Fabri Rodrigues Pietrobom
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Alexandre Netto
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Gasperini
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
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16
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Nordvik T, Schumacher EM, Larsson PG, Pripp AH, Løhaugen GC, Stiris T. Early spectral EEG in preterm infants correlates with neurocognitive outcomes in late childhood. Pediatr Res 2022; 92:1132-1139. [PMID: 35013563 PMCID: PMC9586859 DOI: 10.1038/s41390-021-01915-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 10/04/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evidence regarding the predictive value of early amplitude-integrated electroencephalography (aEEG)/EEG on neurodevelopmental outcomes at school age and beyond is lacking. We aimed to investigate whether there is an association between early postnatal EEG and neurocognitive outcomes in late childhood. METHODS This study is an observational prospective cohort study of premature infants with a gestational age <28 weeks. The total absolute band powers (tABP) of the delta, theta, alpha, and beta bands were analyzed from EEG recordings during the first three days of life. At 10-12 years of age, neurocognitive outcomes were assessed using the Wechsler Intelligence Scale for Children 4th edition (WISC-IV), Vineland adaptive behavior scales 2nd edition, and Behavior Rating Inventory of Executive Function (BRIEF). The mean differences in tABP were assessed for individuals with normal versus unfavorable neurocognitive scores. RESULTS Twenty-two infants were included. tABP values in all four frequency bands were significantly lower in infants with unfavorable results in the main composite scores (full intelligence quotient, adaptive behavior composite score, and global executive composite score) on all three tests (p < 0.05). CONCLUSIONS Early postnatal EEG has the potential to assist in predicting cognitive outcomes at 10-12 years of age in extremely premature infants <28 weeks' gestation. IMPACT Evidence regarding the value of early postnatal EEG in long-term prognostication in preterm infants is limited. Our study suggests that early EEG spectral analysis correlates with neurocognitive outcomes in late childhood in extremely preterm infants. Early identification of infants at-risk of later impairment is important to initiate early and targeted follow-up and intervention.
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Affiliation(s)
- Tone Nordvik
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Neonatal Intensive Care, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Eva M. Schumacher
- grid.55325.340000 0004 0389 8485Department of Neonatal Intensive Care, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Pål G. Larsson
- grid.55325.340000 0004 0389 8485Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Are H. Pripp
- grid.55325.340000 0004 0389 8485Oslo Center of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Gro C. Løhaugen
- grid.414311.20000 0004 0414 4503Department of Pediatrics, Sørlandet Hospital, Arendal, Norway
| | - Tom Stiris
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. .,Department of Neonatal Intensive Care, Oslo University Hospital, Ullevål, Oslo, Norway.
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17
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Sun X, Xue F, Wen J, Gao L, Li Y, Yang L, Cui H. Longitudinal Analysis of Sleep-Wake States in Neonatal Rats Subjected to Hypoxia-Ischemia. Nat Sci Sleep 2022; 14:335-346. [PMID: 35256868 PMCID: PMC8898167 DOI: 10.2147/nss.s352035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Sleep is necessary for brain maturation in infants. Perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of chronic neurological disease in infants. Although the developmental changes of electroencephalogram (EEG) in human newborns have been described, little is known about the EEG normal maturation characteristics in rodents and the changes in sleep-awake states caused by hypoxia-ischemia (HI). This study aimed to investigate the pathological response of sleep-wake states in neonatal rats with HIE. METHODS We constructed HIE and sham models on postnatal day (P) 3 rats and continuously monitored them using electroencephalography and electromyography for up to P12. The distribution of sleep-wake states was analyzed to estimate the effects of HIE. RESULTS Compared with the sham group, the HI group showed lower rapid eye movement (REM) sleep percentage, but wake percentage and frequency was higher during P4-P12. The frequency of REM and non-rapid eye movement (NREM) sleep increased and the duration of REM and NREM sleep decreased after HI induction. However, it gradually returned to the normal level with an increase in daytime. CONCLUSION HI damage alters the sleep-wake patterns during early neural development. The findings provide a comprehensive assessment of serial sleep-wake state recordings in neonatal rats from P4-P12.
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Affiliation(s)
- Xiaowei Sun
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Fenqin Xue
- Department of Core Facility Center, Capital Medical University, Beijing, People's Republic of China
| | - Jialin Wen
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Limin Gao
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yang Li
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lijun Yang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hong Cui
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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18
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Sun X, Xue F, Wen J, Gao L, Li Y, Jiang Q, Yang L, Cui H. Seizure Characteristics and Background Amplitude-Integrated Electroencephalography Activity in Neonatal Rats Subjected to Hypoxia-Ischemia. Front Pediatr 2022; 10:837909. [PMID: 35463911 PMCID: PMC9021695 DOI: 10.3389/fped.2022.837909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/14/2022] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of epilepsy and chronic neurologic morbidity in premature infants. This study aimed to investigate the characteristics of acute seizures and the pattern of background activity on amplitude-integrated electroencephalography (aEEG) in neonatal rats with HIE. METHODS Hypoxia-ischemia (HI) was induced in postnatal day (P) 3 neonatal rats (n = 12) by ligation of the left carotid artery and exposure to airtight hypoxia for 2 h. Data regarding seizure type, frequency, and duration and those related to neurobehavioral development were collected, and the integrated power of background EEG was analyzed to evaluate the effect of HI. RESULTS All neonatal rats in the HI group experienced frequent seizures during hypoxia, and 83.3% of rats (10/12) experienced seizures immediately after hypoxia. Seizure frequency and duration gradually decreased with increasing age. The mortality rate of the HI group was 8.33% (1/12); 120 h after HI induction, only 27.3% (3/11) of pups had low-frequency and short-duration electrographic seizures, respectively. HI rats, which presented seizure activities 96 h after HI insult, exhibited an increase in righting reflex time and a decrease in forelimb grip reflex time. Background EEG was significantly inhibited during HI induction and immediately after hypoxia and gradually recovered 72 h after hypoxia. CONCLUSION Seizures caused by HI brain damage in premature infants can be simulated in the P3 neonatal rat model.
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Affiliation(s)
- Xiaowei Sun
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fenqin Xue
- Core Facility Center, Capital Medical University, Beijing, China
| | - Jialin Wen
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Limin Gao
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yang Li
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qianqian Jiang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lijun Yang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong Cui
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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19
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Spencer APC, Brooks JCW, Masuda N, Byrne H, Lee-Kelland R, Jary S, Thoresen M, Goodfellow M, Cowan FM, Chakkarapani E. Motor function and white matter connectivity in children cooled for neonatal encephalopathy. Neuroimage Clin 2021; 32:102872. [PMID: 34749285 PMCID: PMC8578038 DOI: 10.1016/j.nicl.2021.102872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/13/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
Therapeutic hypothermia reduces the incidence of severe motor disability, such as cerebral palsy, following neonatal hypoxic-ischaemic encephalopathy. However, cooled children without cerebral palsy at school-age demonstrate motor deficits and altered white matter connectivity. In this study, we used diffusion-weighted imaging to investigate the relationship between white matter connectivity and motor performance, measured using the Movement Assessment Battery for Children-2, in children aged 6-8 years treated with therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy at birth, who did not develop cerebral palsy (cases), and matched typically developing controls. Correlations between total motor scores and diffusion properties in major white matter tracts were assessed in 33 cases and 36 controls. In cases, significant correlations (FDR-corrected P < 0.05) were found in the anterior thalamic radiation bilaterally (left: r = 0.513; right: r = 0.488), the cingulate gyrus part of the left cingulum (r = 0.588), the hippocampal part of the left cingulum (r = 0.541), and the inferior fronto-occipital fasciculus bilaterally (left: r = 0.445; right: r = 0.494). No significant correlations were found in controls. We then constructed structural connectivity networks, for 22 cases and 32 controls, in which nodes represent brain regions and edges were determined by probabilistic tractography and weighted by fractional anisotropy. Analysis of whole-brain network metrics revealed correlations (FDR-corrected P < 0.05), in cases, between total motor scores and average node strength (r = 0.571), local efficiency (r = 0.664), global efficiency (r = 0.677), clustering coefficient (r = 0.608), and characteristic path length (r = -0.652). No significant correlations were found in controls. We then investigated edge-level association with motor function using the network-based statistic. This revealed subnetworks which exhibited group differences in the association between motor outcome and edge weights, for total motor scores (P = 0.0109) as well as for balance (P = 0.0245) and manual dexterity (P = 0.0233) domain scores. All three of these subnetworks comprised numerous frontal lobe regions known to be associated with motor function, including the superior frontal gyrus and middle frontal gyrus. The subnetwork associated with total motor scores was highly left-lateralised. These findings demonstrate an association between impaired motor function and brain organisation in school-age children treated with therapeutic hypothermia for neonatal hypoxic-ischaemic encephalopathy.
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Affiliation(s)
- Arthur P C Spencer
- Clinical Research and Imaging Centre, University of Bristol, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan C W Brooks
- Clinical Research and Imaging Centre, University of Bristol, Bristol, UK; School of Psychology, University of East Anglia, Norwich, UK
| | - Naoki Masuda
- Department of Mathematics, State University of New York at Buffalo, Buffalo, NY, USA; Computational and Data-Enabled Science and Engineering Program, State University of New York at Buffalo, Buffalo, NY, USA
| | - Hollie Byrne
- Clinical Research and Imaging Centre, University of Bristol, Bristol, UK; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Richard Lee-Kelland
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sally Jary
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marianne Thoresen
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marc Goodfellow
- Living Systems Institute, University of Exeter, Exeter, UK; Wellcome Trust Centre for Biomedical Modelling and Analysis, University of Exeter, Exeter, UK; EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter, Exeter, UK; College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Frances M Cowan
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Department of Paediatrics, Imperial College London, London, UK
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.
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20
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Weng B, Yan C, Chen Y, Gong X, Cai C. Efficiency Evaluation of Neuroprotection for Therapeutic Hypothermia to Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurosci 2021; 15:668909. [PMID: 34650397 PMCID: PMC8505668 DOI: 10.3389/fnins.2021.668909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background: To evaluate the safety and neurological outcomes of therapeutic hypothermia to neonatal hypoxic-ischemic encephalopathy (HIE). Materials and Methods: Medical records of 61 neonates with moderate to severe HIE were retrospectively enrolled and divided into a therapeutic hypothermia group (n = 36) and conventional therapy group (n = 25). Results: No significant difference in the incidence of severe adverse events was found between the two groups. Minimum and maximum voltages of amplitude-integrated electroencephalography (aEEG) recording results showed statistically significant differences in therapeutic hypothermia group after 72 h. The neonatal behavioral neurological assessment (NBNA) on the 28th day after birth and Bayley Scales of Infant Development, second edition (BSID II) scores at 18 months old were significant higher in the therapeutic hypothermia group than the conventional therapy group. Conclusion: Therapeutic hypothermia for neonates with moderate to severe HIE improved the development of the nervous system in 0-18-month-old infants and showed a predominant role in reducing death and major neuron development-associated disabilities.
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Affiliation(s)
| | | | | | | | - Cheng Cai
- Department of Neonatology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
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21
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Wood TR, Vu PT, Comstock BA, Law JB, Mayock DE, Heagerty PJ, Burbacher T, Bammler TK, Juul SE. Cytokine and chemokine responses to injury and treatment in a nonhuman primate model of hypoxic-ischemic encephalopathy treated with hypothermia and erythropoietin. J Cereb Blood Flow Metab 2021; 41:2054-2066. [PMID: 33554708 PMCID: PMC8327104 DOI: 10.1177/0271678x21991439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Predicting long-term outcome in infants with hypoxic-ischemic encephalopathy (HIE) remains an ongoing clinical challenge. We investigated plasma biomarkers and their association with 6-month outcomes in a nonhuman primate model of HIE with or without therapeutic hypothermia (TH) and erythropoietin (Epo). Twenty-nine Macaca nemestrina were randomized to control cesarean section (n = 7) or 20 min of umbilical cord occlusion (UCO, n = 22) with either no treatment (n = 11) or TH/Epo (n = 11). Initial injury severity was scored using 30-min arterial pH, base deficit, and 10-min Apgar score. Twenty-four plasma cytokines, chemokines, and growth factors were measured 3, 6, 24, 72, and 96 h after UCO. Interleukin 17 (IL-17) and macrophage-derived chemokine (MDC) differentiated the normal/mild from moderate/severe injury groups. Treatment with TH/Epo was associated with increased monocyte chemotactic protein-4 (MCP-4) at 3 h-6h, and significantly lower MCP-4 and MDC at 24 h-72h, respectively. IL-12p40 was lower at 24 h-72h in animals with death/cerebral palsy (CP) compared to survivors without CP. Baseline injury severity was the single best predictor of death/CP, and predictions did not improve with the addition of biomarker data. Circulating chemokines associated with the peripheral monocyte cell lineage are associated with severity of injury and response to therapy, but do not improve ability to predict outcomes.
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Affiliation(s)
- Thomas R Wood
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Phuong T Vu
- Department of Biostatistics, University of Washington, Seattle, WA, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Janessa B Law
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Dennis E Mayock
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Thomas Burbacher
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
| | - Theo K Bammler
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
| | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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22
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Ambalavanan N, Shankaran S, Laptook AR, Carper BA, Das A, Carlo WA, Cotten CM, Duncan AF, Higgins RD. Early Determination of Prognosis in Neonatal Moderate or Severe Hypoxic-Ischemic Encephalopathy. Pediatrics 2021; 147:peds.2020-048678. [PMID: 33986149 PMCID: PMC8168606 DOI: 10.1542/peds.2020-048678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early determination of prognosis is important in neonates with hypoxic-ischemic encephalopathy (HIE). Our objective was to test scoring systems developed earlier (original scoring system) and develop new prognostic models. METHODS Secondary analysis of data from the multicenter randomized controlled trial of longer, deeper, or usual care cooling in neonatal HIE (NCT01192776) that enrolled 364 neonates diagnosed with moderate or severe HIE. The primary outcome was death or moderate or severe disability at 18 to 22 months, and secondary outcome was death during initial hospitalization. Testing of early neurologic clinical examination (<6 hours of age) and the original scoring system for prognostic ability was done, followed by development of new scoring systems and classification and regression tree (CART) models by using early clinical variables (<6 hours of age). RESULTS For death or disability, the original scoring system correctly classified 75% (95% confidence interval: 69%-81%), whereas the new scoring system correctly classified 78% (73%-82%), and the CART model correctly classified 76% (72%-81%). Early neurologic clinical examination also had a correct classification rate of 76% (71%-80%). Depth and duration of cooling did not affect prediction. Only a few components of the early neurologic examination were associated with poor outcome. For death, the original scoring system correctly classified 72% (66%-77%), the new scoring system 68% (63%-72%), the new CART model 87% (83%-90%), and early neurologic evaluation 81% (77%-85%). CONCLUSIONS The 3 models (scoring system, CART, and early neurologic evaluation) were comparable in predicting death or disability. For in-hospital death, CART models were superior to scoring systems and early neurologic examination.
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Affiliation(s)
- Namasivayam Ambalavanan
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;
| | - Seetha Shankaran
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
| | - Benjamin A. Carper
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, North Carolina
| | - Abhik Das
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Rockville, Maryland
| | - Waldemar A. Carlo
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - C. Michael Cotten
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
| | - Andrea F. Duncan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and,College of Health and Human Services, George Mason University, Fairfax, Virginia
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23
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Gundersen JK, Chakkarapani E, Jary S, Menassa DA, Scull-Brown E, Frymoyer A, Walløe L, Thoresen M. Morphine and fentanyl exposure during therapeutic hypothermia does not impair neurodevelopment. EClinicalMedicine 2021; 36:100892. [PMID: 34308308 PMCID: PMC8257990 DOI: 10.1016/j.eclinm.2021.100892] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypothermia-treated and intubated infants with moderate or severe hypoxic-ischemic encephalopathy (HIE) usually receive morphine for sedation and analgesia (SA) during therapeutic hypothermia (TH) and endotracheal ventilation. Altered drug pharmacokinetics in this population increases the risk of drug accumulation. Opioids are neurotoxic in preterm infants. In term infants undergoing TH, the long-term effects of morphine exposure are unknown. We examined the effect of opioid administration during TH on neurodevelopmental outcome and time to extubation after sedation ended. METHODS In this prospectively collected population-based cohort of 282 infants with HIE treated with TH (2007-2017), the cumulative opioid dose of morphine and equipotent fentanyl (10-60 µg/kg/h) administered during the first week of life was calculated. Clinical outcomes and concomitant medications were also collected. Of 258 survivors, 229 underwent Bayley-3 neurodevelopmental assessments of cognition, language and motor function at 18-24 months. Multivariate stepwise linear regression analysis was used to examine the relation between cumulative opioid dose and Bayley-3 scores. Three severity-groups (mild-moderate-severe) were stratified by early (<6 h) amplitude-integrated electroencephalography (aEEG) patterns. FINDINGS The cumulative dose of opioid administered as SA during TH was median (IQR) 2121 µg/kg (1343, 2741). Time to extubation was independent of SA dose (p > 0.2). There was no significant association between cumulative SA dose and any of the Bayley-3 domains when analysing the entire cohort or any of the aEEG severity groups. INTERPRETATION Higher cumulative opioid doses in TH-treated infants with HIE was not associated with worse Bayley-3 scores at 18-24 months of age. FUNDING The Bristol cooling program was funded by the Children's Medical Research Charity SPARKS managing donations for our research from the UK and US, the UK Moulton Foundation, the Lærdal Foundation for Acute Medicine in Norway and the Norwegian Research Council (JKG).
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Affiliation(s)
- Julia K Gundersen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David A Menassa
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- The Queen's College, University of Oxford, Oxford, United Kingdom
| | - Emma Scull-Brown
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, California, United States
| | - Lars Walløe
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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24
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Thoresen M, Jary S, Walløe L, Karlsson M, Martinez-Biarge M, Chakkarapani E, Cowan FM. MRI combined with early clinical variables are excellent outcome predictors for newborn infants undergoing therapeutic hypothermia after perinatal asphyxia. EClinicalMedicine 2021; 36:100885. [PMID: 34308304 PMCID: PMC8257962 DOI: 10.1016/j.eclinm.2021.100885] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Binary prediction-models for outcome [death, cognition, presence and severity of cerebral palsy (CP)], using MRI and early clinical data applicable for individual outcome prediction have not been developed. METHODS From Dec 1st 2006 until Dec 31st 2013, we recruited 178 infants into a population-based cohort with moderate or severe hypoxic-ischaemic encephalopathy (HIE) including postnatal collapse (PNC, n = 12) and additional diagnoses (n = 12) using CoolCap/TOBY-trial entry-criteria including depressed amplitude-integrated EEG (aEEG). Early clinical/biochemical variables and MRI scans (median day 8) were obtained in 168 infants. Injury severity was scored for cortex, basal ganglia/thalami (BGT), white matter (WM) and posterior limb of the internal capsule, summating to a total injury score (TIS, range 0-11). Outcome was categorized as adverse or favourable at 18-24 months from Bayley-III domains (cut-off 85) and neurological examination including CP classification. FINDINGS HIE and entry-aEEG severity were stable throughout the study. Outcome was favourable in 133/178 infants and adverse in 45/178: 17 died, 28 had low Cognition/Language scores, (including 9 with severe CP and 6 mild); seven had mild CP with favourable cognitive outcome. WMxBGT product scores and TIS were strong outcome predictors, and prediction improved when clinical/biochemical variables were added in binary logistic regression. The Positive Predictive Value for adverse outcome was 88%, increasing to 95% after excluding infants with PNC and additional diagnoses. Using WMxBGT in the regression predicted 8 of the 9 children with severe CP. INTERPRETATION Binary logistic regression with WMxBGT or TIS and clinical variables gave excellent outcome prediction being 12% better than single variable cross-tabulation. Our MRI scoring and regression models are readily accessible and deserve investigation in other cohorts for group and individual prediction. FUNDING We thank the National Health Service (NHS) and our Universities and funders in UK and Norway: SPARKS, The Moulton Foundation, The Norwegian Research Council, The Lærdal Foundation for Acute Medicine and charitable donations for their support for cooling therapy.
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Key Words
- BGT, Basal ganglia/thalami
- BIC, Bayesian information criterion
- Basal ganglia and thalamus
- Bayley-III
- Bayley-III, Bayley Scales of Infant & Toddler Development 3rd edition
- CLC, Cognitive and Language Composite from the Bayley-III scales
- CP, Cerebral palsy
- CX, Cortex
- Cerebral palsy
- Cortex
- DWI, Diffusion-weighted imaging
- GA, Gestational age
- GMFCS, Gross Motor Function Classification System
- HIE, Hypoxic-ischaemic encephalopathy
- Hypoxic-ischaemic encephalopathy
- ILEA, International League Against Epilepsy
- IQR, Interquartile range
- LDH72h, Lactate dehydrogenase close to 72h post-asphyxial event
- LDHpeak, Highest LDH in the first 3 days
- Logistic regression
- MRI
- MRI, Magnetic Resonance Imaging
- Moderate or severe perinatal asphyxia
- NPV, Negative Predictive Value
- Neonatal seizures
- Neurodevelopmental outcome
- Outcome prediction
- PA, Predictive Accuracy
- PLIC, Posterior limb of the internal capsule
- PNC, Postnatal collapse
- PPV, Positive Predictive Value
- Posterior limb of the internal capsule
- RCT, Randomised controlled trial
- Se, Sensitivity
- Sp, Specificity
- T1 and T2
- TH, Therapeutic hypothermia
- TIS, Total injury score
- Therapeutic hypothermia
- WMxBGT, Product of white matter and basal ganglia/thalami scores
- White matter
- aEEG, amplitude integrated electroencephalography
- h, hours
- lactatehrs<5mmol, plasma lactate recovery time
- m, months
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Affiliation(s)
- Marianne Thoresen
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Sally Jary
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Lars Walløe
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Mathias Karlsson
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Medical Sciences, Biomedical Structure and Function, Uppsala University, Uppsala, Sweden
| | - Miriam Martinez-Biarge
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Ela Chakkarapani
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Frances M Cowan
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
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25
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Schreiner C, Hammerl M, Neubauer V, Kiechl-Kohlendorfer U, Griesmaier E. Amplitude-integrated electroencephalography signals in preterm infants with cerebral hemorrhage. Early Hum Dev 2021; 154:105309. [PMID: 33465672 DOI: 10.1016/j.earlhumdev.2021.105309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate whether preterm infants with cerebral hemorrhage show alterations of aEEG signals in the first four weeks of life. STUDY DESIGN Preterm infants (n = 536) born before 32 completed weeks of pregnancy at Innsbruck Medical University Hospital were included in the study. AEEG recordings were evaluated for the Burdjalov score and cerebral hemorrhage was diagnosed by cerebral ultrasound. RESULTS Eighty preterm infants with cerebral hemorrhage (median gestational age 28.9 weeks, median birth weight 1157 g) and 456 preterm infants without cerebral hemorrhage (median gestational age 30.0 weeks, median birth weight 1300 g) were investigated. Burdjalov total scores were significantly lower in infants with cerebral hemorrhage. Infants with mild cerebral hemorrhage showed higher Burdjalov total scores compared to infants with severe cerebral hemorrhage in the first days of life. A Burdjalov total score of seven or more was predictive for no development of a cerebral hemorrhage, with a highest area under the curve (0.613) at postnatal day three. CONCLUSION Preterm infants with cerebral hemorrhage show alterations in aEEG signals in the newborn period. In future aEEG could be used as a supplemental method to monitor preterm infants at risk for cerebral hemorrhage. The use of aEEG in early life could reduce the number of ultrasound examinations and limit cumulative stress and discomfort in preterm infants.
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Affiliation(s)
- Christina Schreiner
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Marlene Hammerl
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Vera Neubauer
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elke Griesmaier
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria.
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26
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Spencer APC, Brooks JCW, Masuda N, Byrne H, Lee-Kelland R, Jary S, Thoresen M, Tonks J, Goodfellow M, Cowan FM, Chakkarapani E. Disrupted brain connectivity in children treated with therapeutic hypothermia for neonatal encephalopathy. Neuroimage Clin 2021; 30:102582. [PMID: 33636541 PMCID: PMC7906894 DOI: 10.1016/j.nicl.2021.102582] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/18/2021] [Accepted: 01/28/2021] [Indexed: 11/27/2022]
Abstract
Therapeutic hypothermia following neonatal encephalopathy due to birth asphyxia reduces death and cerebral palsy. However, school-age children without cerebral palsy treated with therapeutic hypothermia for neonatal encephalopathy still have reduced performance on cognitive and motor tests, attention difficulties, slower reaction times and reduced visuo-spatial processing abilities compared to typically developing controls. We acquired diffusion-weighted imaging data from school-age children without cerebral palsy treated with therapeutic hypothermia for neonatal encephalopathy at birth, and a matched control group. Voxelwise analysis (33 cases, 36 controls) confirmed reduced fractional anisotropy in widespread areas of white matter in cases, particularly in the fornix, corpus callosum, anterior and posterior limbs of the internal capsule bilaterally and cingulum bilaterally. In structural brain networks constructed using probabilistic tractography (22 cases, 32 controls), graph-theoretic measures of strength, local and global efficiency, clustering coefficient and characteristic path length were found to correlate with IQ in cases but not controls. Network-based statistic analysis implicated brain regions involved in visuo-spatial processing and attention, aligning with previous behavioural findings. These included the precuneus, thalamus, left superior parietal gyrus and left inferior temporal gyrus. Our findings demonstrate that, despite the manifest successes of therapeutic hypothermia, brain development is impaired in these children.
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Affiliation(s)
- Arthur P C Spencer
- Clinical Research and Imaging Centre, University of Bristol, Bristol, United Kingdom
| | - Jonathan C W Brooks
- Clinical Research and Imaging Centre, University of Bristol, Bristol, United Kingdom; School of Psychological Science, University of Bristol, Bristol, United Kingdom
| | - Naoki Masuda
- Department of Mathematics, State University of New York at Buffalo, Buffalo, NY, United States; Computational and Data-Enabled Science and Engineering Program, State University of New York at Buffalo, Buffalo, NY, United States
| | - Hollie Byrne
- Clinical Research and Imaging Centre, University of Bristol, Bristol, United Kingdom
| | - Richard Lee-Kelland
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marianne Thoresen
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - James Tonks
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; University of Exeter Medical School, Exeter, United Kingdom
| | - Marc Goodfellow
- Living Systems Institute, University of Exeter, Exeter, United Kingdom; Wellcome Trust Centre for Biomedical Modelling and Analysis, University of Exeter, Exeter, United Kingdom; EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter, Exeter, United Kingdom; College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Frances M Cowan
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom.
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27
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Trollmann R. Neuromonitoring in Neonatal-Onset Epileptic Encephalopathies. Front Neurol 2021; 12:623625. [PMID: 33603712 PMCID: PMC7884638 DOI: 10.3389/fneur.2021.623625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/12/2021] [Indexed: 12/31/2022] Open
Abstract
Considering the wide spectrum of etiologies of neonatal-onset epileptic encephalopathies (EE) and their unfavorable consequences for neurodevelopmental prognoses, neuromonitoring at-risk neonates is increasingly important. EEG is highly sensitive for early identification of electrographic seizures and abnormal background activity. Amplitude-integrated EEG (aEEG) is recommended as a useful bedside monitoring method but as a complementary tool because of methodical limitations. It is of special significance in monitoring neonates with acute symptomatic as well as structural, metabolic and genetic neonatal-onset EE, being at high risk of electrographic-only and prolonged seizures. EEG/aEEG monitoring is established as an adjunctive tool to confirm perinatal hypoxic-ischemic encephalopathy (HIE). In neonates with HIE undergoing therapeutic hypothermia, burst suppression pattern is associated with good outcomes in about 40% of the patients. The prognostic specificity of EEG/aEEG is lower compared to cMRI. As infants with HIE may develop seizures after cessation of hypothermia, recording for at least 24 h after the last seizure is recommended. Progress in the identification of genetic etiology of neonatal EE constantly increases. However, presently, no specific EEG changes indicative of a genetic variant have been characterized, except for individual variants associated with typical EEG patterns (e.g., KCNQ2, KCNT1). Long-term monitoring studies are necessary to define and classify electro-clinical patterns of neonatal-onset EE.
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Affiliation(s)
- Regina Trollmann
- Department of Pediatrics and Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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28
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Peeples ES, Rao R, Dizon MLV, Johnson YR, Joe P, Flibotte J, Hossain T, Smith D, Hamrick S, DiGeronimo R, Natarajan G, Lee KS, Yanowitz TD, Mietzsch U, Wu TW, Maitre NL, Pallotto EK, Speziale M, Mathur AM, Zaniletti I, Massaro A. Predictive Models of Neurodevelopmental Outcomes After Neonatal Hypoxic-Ischemic Encephalopathy. Pediatrics 2021; 147:peds.2020-022962. [PMID: 33452064 DOI: 10.1542/peds.2020-022962] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop predictive models for death or neurodevelopmental impairment (NDI) after neonatal hypoxic-ischemic encephalopathy (HIE) from data readily available at the time of NICU admission ("early") or discharge ("cumulative"). METHODS In this retrospective cohort analysis, we used data from the Children's Hospitals Neonatal Consortium Database (2010-2016). Infants born at ≥35 weeks' gestation and treated with therapeutic hypothermia for HIE at 11 participating sites were included; infants without Bayley Scales of Infant Development scores documented after 11 months of age were excluded. The primary outcome was death or NDI. Multivariable models were generated with 80% of the cohort; validation was performed in the remaining 20%. RESULTS The primary outcome occurred in 242 of 486 infants; 180 died and 62 infants surviving to follow-up had NDI. HIE severity, epinephrine administration in the delivery room, and respiratory support and fraction of inspired oxygen of 0.21 at admission were significant in the early model. Severity of EEG findings was combined with HIE severity for the cumulative model, and additional significant variables included the use of steroids for blood pressure management and significant brain injury on MRI. Discovery models revealed areas under the curve of 0.852 for the early model and of 0.861 for the cumulative model, and both models performed well in the validation cohort (goodness-of-fit χ2: P = .24 and .06, respectively). CONCLUSIONS Establishing reliable predictive models will enable clinicians to more accurately evaluate HIE severity and may allow for more targeted early therapies for those at highest risk of death or NDI.
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Affiliation(s)
- Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska;
| | - Rakesh Rao
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Maria L V Dizon
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, Illinois
| | - Yvette R Johnson
- Department of Pediatrics, Cook Children's Medical Center, Fort Worth, Texas.,Department of Pediatrics, Texas Christian University and University of North Texas Health Science Center, Fort Worth, Texas
| | - Priscilla Joe
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, Oakland, California
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tanzeema Hossain
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle Smith
- Department of Pediatrics, University of Colorado Denver, Denver, Colorado
| | - Shannon Hamrick
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Kyong-Soon Lee
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Toby D Yanowitz
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ulrike Mietzsch
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Tai-Wei Wu
- Department of Pediatrics, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
| | - Nathalie L Maitre
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Eugenia K Pallotto
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Mark Speziale
- Department of Pediatrics, Rady Children's Hospital-San Diego and University of California, San Diego, San Diego, California
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University, St Louis, Missouri
| | - Isabella Zaniletti
- Department of Pediatrics, Children's Hospital Association, Lenexa, Kansas; and
| | - An Massaro
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia
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Benninger KL, Inder TE, Goodman AM, Cotten CM, Nordli DR, Shah TA, Slaughter JC, Maitre NL. Perspectives from the Society for Pediatric Research. Neonatal encephalopathy clinical trials: developing the future. Pediatr Res 2021; 89:74-84. [PMID: 32221474 PMCID: PMC7529683 DOI: 10.1038/s41390-020-0859-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Abstract
The next phase of clinical trials in neonatal encephalopathy (NE) focuses on hypothermia adjuvant therapies targeting alternative recovery mechanisms during the process of hypoxic brain injury. Identifying infants eligible for neuroprotective therapies begins with the clinical detection of brain injury and classification of severity. Combining a variety of biomarkers (serum, clinical exam, EEG, movement patterns) with innovative clinical trial design and analyses will help target infants with the most appropriate and timely treatments. The timing of magnetic resonance imaging (MRI) and MR spectroscopy after NE both assists in identifying the acute perinatal nature of the injury (days 3-7) and evaluates the full extent and evolution of the injury (days 10-21). Early, intermediate outcome of neuroprotective interventions may be best defined by the 21-day neuroimaging, with recognition that the full neurodevelopmental trajectory is not yet defined. An initial evaluation of each new therapy at this time point may allow higher-throughput selection of promising therapies for more extensive investigation. Functional recovery can be assessed using a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action. As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow safe, efficient, and targeted therapeutics. IMPACT: As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow faster development of safe, effective, and targeted therapeutics. This article provides a multidisciplinary perspective on the future of clinical trials in NE; novel trial design; study management and oversight; biostatistical methods; and a combination of serum, imaging, and neurodevelopmental biomarkers can advance the field and improve outcomes for infants affected by NE. Innovative clinical trial designs, new intermediate trial end points, and a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action can help address common challenges in NE clinical trials and allow for faster selection and validation of promising therapies for more extensive investigation.
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MESH Headings
- Biomarkers/blood
- Biomedical Research/trends
- Brain Diseases/diagnostic imaging
- Brain Diseases/etiology
- Brain Diseases/physiopathology
- Brain Diseases/therapy
- Clinical Trials as Topic
- Consensus
- Delphi Technique
- Diffusion of Innovation
- Forecasting
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/physiopathology
- Infant, Newborn, Diseases/therapy
- Neonatology/trends
- Neuroimaging
- Research Design/trends
- Societies, Medical
- Societies, Scientific
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Kristen L Benninger
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Amy M Goodman
- Division of Child Neurology, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas R Nordli
- Section of Child Neurology, Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Tushar A Shah
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk, VA, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathalie L Maitre
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
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Seizures severity during rewarming can predict seizure outcomes of infants with neonatal hypoxic-ischemic encephalopathy following therapeutic hypothermia. Biomed J 2020; 43:285-292. [PMID: 32684487 PMCID: PMC7424086 DOI: 10.1016/j.bj.2020.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/14/2023] Open
Abstract
Background The aim of this study was to examine the predictive value of amplitude-integrated electroencephalography (aEEG) on 12-month seizure outcomes of infants with neonatal hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Methods We conducted this retrospective cohort study in a tertiary neonatal intensive care unit between May 2012 and September 2017. Neonates with HIE who received both therapeutic hypothermia (TH) and aEEG were enrolled. Results A total of 23 infants (14 boys, nine girls) with a mean gestational age of 38.9 weeks were enrolled. Fifteen (65%) infants had moderate HIE and eight (35%) had severe HIE according to modified Sarnat staging. The mean aEEG recording time was 107.5 h. Twenty (86.9%) infants had seizure activity during the first 24 h after cooling and 14 (60.8%) had seizure activity during the first 24 h after rewarming. At 12 months, five (21.7%) infants had poor seizure outcomes. Repetitive seizures or status epilepticus pattern during the first 24 h after rewarming, but not the first 24 h after cooling, were associated with the presence of epilepsy at 12 months (p = 0.037). Conclusions We identified a high incidence of electrographic seizures in infants with neonatal HIE treated with therapeutic hypothermia, and post-neonatal epilepsy in the children who survived after HIE. Repetitive seizures or status epilepticus pattern during the first 24 h after rewarming, but not in the first 24 h after cooling, were associated with the presence of epilepsy at 12 months.
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31
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Holistic approach of the care of the infant with hypoxic-ischaemic encephalopathy in Spain. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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32
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Arnaez J, Herranz-Rubia N, Garcia-Alix A, Diez-Delgado J, Benavente-Fernández I, Tofé I, Jerez A, Hurtado J, Ceballos J, Millán M, Esquivel M, Ruiz C, Baca M, Tapia E, Losada M, Torres E, Pavón A, Jiménez P, Jiménez F, Ventura M, Rite S, González T, Arias R, Balliu P, Lloreda-García J, Alcaráz J, Tapia C, de la Morena A, Centelles I, Güemes I, Estañ J, Alberola A, Aparici S, López R, Beceiro J, García B, Martínez L, González E, Arruza L, Blanco M, Moral M, Arias B, Mar F, Jiménez J, Romera G, Cuñarro A, Muñóz C, Cabañas F, Valverde E, Montero R, Tejedor J, Santana C, Reyes B, Romero S, Orizaola A, Baquero M, Hernández D, Pantoja A, Vega-del-Val C, Castañón L, Gutiérrez E, Benito M, Caserío S, Arca G, García M, López-Vílchez M, Castells L, Domingo M, Coroleu W, Boix H, Porta R, García-Alix A, Martínez-Nadal S, Jiménez E, Sole E, Albújar M, Fernández E, Barrio A, Piñán E, Avila-Alvarez A, Vázquez M, Balado N, Crespo P, Couce M, Concheiro-Guisán A, Esteban I, Lavilla A, Alzina V, Aguirre A, Loureiro B, Echániz I, Elorza M, Euba A. Atención integral del neonato con encefalopatía hipóxico-isquémica en España. An Pediatr (Barc) 2020; 92:286-296. [DOI: 10.1016/j.anpedi.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022] Open
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Chawla S, Bates SV, Shankaran S. Is It Time for a Randomized Controlled Trial of Hypothermia for Mild Hypoxic-Ischemic Encephalopathy? J Pediatr 2020; 220:241-244. [PMID: 31952851 PMCID: PMC8462395 DOI: 10.1016/j.jpeds.2019.11.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/04/2019] [Accepted: 11/20/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Sara V. Bates
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI.
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Rakshasbhuvankar AA, Wagh D, Athikarisamy SE, Davis J, Nathan EA, Palumbo L, Ghosh S, Nagarajan L, Rao SC. Inter-rater reliability of amplitude-integrated EEG for the detection of neonatal seizures. Early Hum Dev 2020; 143:105011. [PMID: 32145502 DOI: 10.1016/j.earlhumdev.2020.105011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/29/2020] [Accepted: 02/27/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Amplitude-integrated electroencephalogram (aEEG) is being used increasingly for seizure detection in neonates. However, data regarding inter-rater reliability among neonatologists for the use of aEEG for the detection of neonatal seizures is lacking. METHODS Term and late-preterm infants at risk of seizures were monitored simultaneously with 24-h video-electroencephalography (vEEG) and aEEG. vEEG was interpreted by an experienced neurologist. Five neonatologists with experience in aEEG interpretation from four different neonatal units interpreted aEEG recordings independently. The Brennan and Prediger kappa coefficient and Intra-class Correlation Coefficients (ICC) were used to assess inter-rater reliability between the neonatologists. RESULTS Thirty-five infants at risk of seizure with gestational age at birth 35-42 weeks were recruited for the study after informed parental consent. vEEG detected seizures in seven infants with a total of 169 individual seizure episodes. Neonatologists detected seizures in 10 to 15 infants on aEEG. The sensitivities for the detection of individual seizures by neonatologists ranged from 18% to 38%. The inter-rater reliability for detection of: individual seizure was "fair" (kappa = 0.37; 95% CI: 0.32-0.42), infant with seizure was "moderate" (kappa = 0.60; 95% CI: 0.44-0.75), duration of individual seizure (ICC: 0.22; 95% CI: 0.18-0.28) and total duration of seizures in an infant (ICC: 0.46; 95% CI: 0.30-0.63) was "poor". The neonatologists missed 77-90% of the duration of seizures. CONCLUSION The inter-rater reliability of aEEG for the detection of neonatal seizures was suboptimal. Even when interpreted by experienced and trained clinicians, seizure detection with aEEG has limitations and can miss large number and duration of seizures.
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Affiliation(s)
- Abhijeet A Rakshasbhuvankar
- Neonatal Clinical Care Unit, King Edward Memorial Hospital and Perth Children's Hospital, Perth, Australia; Centre for Neonatal Research and Education, Medical School, University of Western Australia, Australia.
| | - Deepika Wagh
- Neonatal Clinical Care Unit, King Edward Memorial Hospital and Perth Children's Hospital, Perth, Australia; Centre for Neonatal Research and Education, Medical School, University of Western Australia, Australia
| | - Sam E Athikarisamy
- Neonatal Clinical Care Unit, King Edward Memorial Hospital and Perth Children's Hospital, Perth, Australia; Centre for Neonatal Research and Education, Medical School, University of Western Australia, Australia
| | - Jonathan Davis
- Neonatal Clinical Care Unit, King Edward Memorial Hospital and Perth Children's Hospital, Perth, Australia; Centre for Neonatal Research and Education, Medical School, University of Western Australia, Australia
| | - Elizabeth A Nathan
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Australia; Division of Obstetrics and Gynaecology, University of Western Australia, Perth, Australia
| | - Linda Palumbo
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Australia
| | - Soumya Ghosh
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Australia; Centre for Neuromuscular and Neurological Disorders, Perron Institute, University of Western Australia, Perth, Australia
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Perth, Australia; Division of Paediatrics and Child Health, Medical School, University of Western Australia, Perth, Australia
| | - Shripada C Rao
- Neonatal Clinical Care Unit, King Edward Memorial Hospital and Perth Children's Hospital, Perth, Australia; Centre for Neonatal Research and Education, Medical School, University of Western Australia, Australia
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35
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Cawley P, Chakkarapani E. Fifteen-minute consultation: Therapeutic hypothermia for infants with hypoxic ischaemic encephalopathy-translating jargon, prognosis and uncertainty for parents. Arch Dis Child Educ Pract Ed 2020; 105:75-83. [PMID: 31292147 DOI: 10.1136/archdischild-2017-314116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 03/09/2019] [Accepted: 06/18/2019] [Indexed: 11/03/2022]
Abstract
Hypoxic ischaemic encephalopathy may lead to death or severe long-term morbidity. Therapeutic hypothermia (TH) increases survival without impairments in childhood, but prognostic uncertainty may remain for years after birth. Clear and accurate communication is imperative but challenging. This article explores the predictive value of routinely performed assessments during TH, as well as the qualitative research relating to parental experience. This article will benefit paediatric trainees, consultants and nurse practitioners in providing: (1) the background information needed for initiating a conversation with parents regarding outcome and (2) optimising their communication with parents in translating jargon, prognosis and uncertainty.
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Affiliation(s)
- Paul Cawley
- Neonatal Intensive Care Unit, Southmead Hospital, Bristol, UK.,Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Liu W, Yang Q, Wei H, Dong W, Fan Y, Hua Z. Prognostic Value of Clinical Tests in Neonates With Hypoxic-Ischemic Encephalopathy Treated With Therapeutic Hypothermia: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:133. [PMID: 32161566 PMCID: PMC7052385 DOI: 10.3389/fneur.2020.00133] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/05/2020] [Indexed: 12/17/2022] Open
Abstract
Background and Objective: There remains an unmet clinical need for markers that predict outcomes in the hypothermia-treated (HT) infants with HIE. The aim of this meta-analysis was to investigate the prognostic accuracy of currently available clinical tests performed in the immediate post-natal period for predicting neurological outcomes between 18 months and 3 years of age in HT near-term and term infants with perinatal asphyxia and HIE. Methods: A comprehensive review of the Embase, Cochrane library, and PubMed databases was performed to identify studies that evaluated the prognostic value of clinical tests for neurological outcomes in HT near-term and term infants with perinatal asphyxia and hypoxic-ischemic encephalopathy. Pooled sensitivity and specificity with corresponding 95% confidence intervals and area under the receiver operating characteristic (ROC) curve (AUC) were calculated. Results: Of the 1,144 relevant studies, 26 studies describing four clinical tests conducted in 1458 HT near-term or term infants were included. For predicting an unfavorable neurological outcome, of the imaging techniques, MRI within 2 weeks of birth performed best on sensitivity 0.85 (95% CI 0.79–0.89), specificity 0.72 (95% CI 0.66–0.77), and AUC 0.88; among the neurophysiological tests, multichannel EEG (Electroencephalogram) demonstrated the sensitivity 0.63 (95% CI 0.49–0.76), specificity 0.82 (95% CI 0.70–0.91), and AUC 0.88, and for aEEG (amplitude-integrated electroencephalography) background pattern pooled sensitivity, specificity and AUC were 0.90 (95% CI 0.86–0.94), 0.46 (95% CI 0.42–0.51), and 0.78 whereas for SEPs (Somatosensory evoked potentials), pooled sensitivity and specificity were 0.52 (95% CI 0.34–0.69), 0.76 (95% CI 0.63–0.87), and AUC 0.84, respectively. Conclusions: In the wake of the era of TH, MRI and neurophysiological tests (aEEG or EEG) were promising predictors of adverse outcomes, while SEPs need high-quality studies to confirm the findings. Continued follow-up of the children and well-designed large prospective studies are essential to determine whether these benefits are maintained in later childhood.
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Affiliation(s)
- Weiqin Liu
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Qifen Yang
- School of Life Sciences, SouthWest University, Chongqing, China
| | - Hong Wei
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhui Dong
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Fan
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Ziyu Hua
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
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Feldmann M, Rousson V, Nguyen TD, Bernet V, Hagmann C, Latal B, Natalucci G. Cognitive outcome of early school-aged children born very preterm is not predicted by early short-term amplitude-integrated electroencephalography. Acta Paediatr 2020; 109:78-84. [PMID: 31254357 DOI: 10.1111/apa.14919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 02/06/2023]
Abstract
AIM We investigated the association between early amplitude-integrated electroencephalography (aEEG) and cognitive outcome in very preterm infants at early school-age. METHODS This prospective cohort study, conducted in the Department of Neonatology, University Hospital Zurich, Switzerland, from 2009 to 2012, comprised of infants born at <32 weeks of gestation, who underwent continuous aEEG recording during the first 4 days of life. Cognitive outcome was assessed with the Kaufman-Assessment Battery for Children at 5 years. Univariate and multivariate logistic regressions were calculated between aEEG parameters and normal cognitive outcome, defined as an intelligence quotient (IQ) of at least 85. RESULTS The 118 (52.5% male) infants were born at a mean gestational age of 29.9 weeks and a mean birth weight of 1235 ± 363 g. We followed up 89 children at the age of five, and they had a mean IQ of 97.8 ± 12.7 with 21.3% under 85-and 2.2% had cerebral palsy. Univariate analyses found associations between aEEG measures and normal cognitive outcome, but these were no longer significant after adjustment for confounders. Socioeconomic status and neonatal morbidity were independent predictors of cognitive outcome. CONCLUSION Early short-term aEEG did not predict later cognitive outcome in our cohort of very preterm infants.
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Affiliation(s)
- Maria Feldmann
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
| | - Valentin Rousson
- Institute for Social and Preventive Medicine, Statistical Unit Lausanne University Hospital Lausanne Switzerland
| | - Thi Dao Nguyen
- Department of Neonatology University of Zurich and University Hospital Zurich Zurich Switzerland
| | - Vera Bernet
- Department of Neonatology and Paediatric Intensive care University Children's Hospital Zurich Zurich Switzerland
| | - Cornelia Hagmann
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
- Department of Neonatology and Paediatric Intensive care University Children's Hospital Zurich Zurich Switzerland
| | - Beatrice Latal
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Children's Research Centre University Children's Hospital Zurich Zurich Switzerland
| | - Giancarlo Natalucci
- Child Development Centre University Children's Hospital Zurich Zurich Switzerland
- Department of Neonatology University of Zurich and University Hospital Zurich Zurich Switzerland
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38
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Ouwehand S, Smidt LCA, Dudink J, Benders MJNL, de Vries LS, Groenendaal F, van der Aa NE. Predictors of Outcomes in Hypoxic-Ischemic Encephalopathy following Hypothermia: A Meta-Analysis. Neonatology 2020; 117:411-427. [PMID: 32235122 DOI: 10.1159/000505519] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/18/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Prediction of neurodevelopmental outcome in infants with hypoxic-ischemic encephalopathy remains an important challenge. Various studies have shown that the predictive ability of different modalities changed after the introduction of therapeutic hypothermia. This paper reviews the diagnostic test accuracy of the different modalities that are being used to predict neurodevelopmental outcomes following therapeutic hypothermia. METHODS A systematic literature search was performed using Embase and PubMed. Two reviewers independently included eligible studies and extracted data. The quality of the studies was assessed using the Quality in Prognosis Studies Tool. Meta-analyses were performed where possible. RESULTS Forty-seven articles and 3 conference abstracts were included, reporting on 3,072infants of whom 39% died or had an adverse neurodevelopmental outcome. A meta-analysis could be performed using 37 articles on (amplitude-integrated) electroencephalography (EEG), conventional magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and proton magnetic resonance spectroscopy (1H-MRS). Amplitude-integrated EEG (aEEG) at 24 and 72 h showed similar high diagnostic OR, while aEEG at 6 h and EEG performed less, both due to a low specificity. For MRI, most studies reported scoring systems in which early (<8 days) MRI performed better than late (≥8 days) MRI. Injury to the posterior limb of the internal capsule on MRI or to the thalami on DWI were strong individual predictors, as was an increased lactate/N-acetylaspartate peak on 1H-MRS. CONCLUSIONS In the era of therapeutic hypothermia, the different modalities remain good predictors of neurodevelopmental outcome. However, timing should be taken into account. aEEG may initially be false positive and gets more reliable after 24 h. In contrast, MRI should be used during the first week, as its predictive value decreases afterwards.
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Affiliation(s)
- Sabine Ouwehand
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisanne C A Smidt
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands, .,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands,
| | - Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Lee-Kelland R, Jary S, Tonks J, Cowan FM, Thoresen M, Chakkarapani E. School-age outcomes of children without cerebral palsy cooled for neonatal hypoxic-ischaemic encephalopathy in 2008-2010. Arch Dis Child Fetal Neonatal Ed 2020; 105:8-13. [PMID: 31036702 DOI: 10.1136/archdischild-2018-316509] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 02/26/2019] [Accepted: 03/08/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Since therapeutic hypothermia became standard care for neonatal hypoxic-ischaemic encephalopathy (HIE), even fewer infants die or have disability at 18-month assessment than in the clinical trials. However, longer term follow-up of apparently unimpaired children is lacking. We investigated the cognitive, motor and behavioural performances of survivors without cerebral palsy (CP) cooled for HIE, in comparison with matched non-HIE control children at 6-8 years. DESIGN Case-control study. PARTICIPANTS 29 case children without CP, cooled in 2008-2010 and 20 age-matched, sex-matched and social class-matched term-born controls. MEASURES Wechsler Intelligence Scales for Children, Fourth UK Edition, Movement Assessment Battery for Children, Second Edition (MABC-2) and Strengths and Difficulties Questionnaire. RESULTS Cases compared with controls had significantly lower mean (SD) full-scale IQ (91 [10.37]vs105[13.41]; mean difference (MD): -13.62, 95% CI -20.53 to -6.71) and total MABC-2 scores (7.9 [3.26]vs10.2[2.86]; MD: -2.12, 95% CI -3.93 to -0.3). Mean differences were significant between cases and controls for verbal comprehension (-8.8, 95% CI -14.25 to -3.34), perceptual reasoning (-13.9, 95% CI-20.78 to -7.09), working memory (-8.2, 95% CI-16.29 to -0.17), processing speed (-11.6, 95% CI-20.69 to -2.47), aiming and catching (-1.6, 95% CI-3.26 to -0.10) and manual dexterity (-2.8, 95% CI-4.64 to -0.85). The case group reported significantly higher median (IQR) total (12 [6.5-13.5] vs 6 [2.25-10], p=0.005) and emotional behavioural difficulties (2 [1-4.5] vs 0.5 [0-2.75], p=0.03) and more case children needed extra support in school (34%vs5%, p=0.02) than the control group. CONCLUSIONS School-age children without CP cooled for HIE still have reduced cognitive and motor performance and more emotional difficulties than their peers, strongly supporting the need for school-age assessments.
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Affiliation(s)
- Richard Lee-Kelland
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sally Jary
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Tonks
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Psychology, University of Exeter, Exeter, UK
| | - Frances M Cowan
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Paediatrics, Imperial College London, London, UK
| | - Marianne Thoresen
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Faculty of Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Ela Chakkarapani
- Faculty of Health Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Rao R, Trivedi S, Distler A, Liao S, Vesoulis Z, Smyser C, Mathur AM. Neurodevelopmental Outcomes in Neonates with Mild Hypoxic Ischemic Encephalopathy Treated with Therapeutic Hypothermia. Am J Perinatol 2019; 36:1337-1343. [PMID: 30609430 PMCID: PMC6609494 DOI: 10.1055/s-0038-1676973] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To review developmental outcomes of neonates with mild hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). STUDY DESIGN Neonates ≥35 weeks' gestation with mild HIE/TH (TH group, n = 30) were matched with healthy term-born infants (control group, n = 30) and reviewed for the presence and severity of magnetic resonance imaging (MRI)-detected neurological injury. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant Development (BSID). RESULTS MRI injury was present in 13/30 (43.3%) neonates (11 mild, 1 moderate, and 1 severe injuries) in the TH group. The mean (standard deviation [SD]) corrected age at BSID III was 29.3 (3.9) months in the controls compared with 14.7 (3.9) months in the TH group (p < 0.01). The mean (SD) cognitive, language, and motor composite scores in neonates in the TH group (n = 16, 53.3%) and control groups (n = 30, 100%) were 99.4 (17.1) versus 93.0 (12.3), (p = 0.15), 89.5 (15.5) versus 100.2 (18.4), (p = 0.054), and 93.1 (15.4) versus 100.8 (16.3) (p = 0.13), respectively. CONCLUSION Developmental outcomes of neonates with mild HIE/TH were similar to healthy, term-born neonates.
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Affiliation(s)
- Rakesh Rao
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Shamik Trivedi
- Division of Newborn Medicine, Ann and Robert Laurie School of Medicine, Chicago, Illinois
| | - Amy Distler
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Steve Liao
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Zachary Vesoulis
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Christopher Smyser
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
| | - Amit M. Mathur
- Department of Pediatrics, Washington University in St Louis, St. Louis, Missouri
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Rana D, Pollard L, Rowland J, Dhanireddy R, Pourcyrous M. Amplitude-integrated EEG in infants with neonatal abstinence syndrome. J Neonatal Perinatal Med 2019; 12:391-397. [PMID: 31356218 DOI: 10.3233/npm-1834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To describe amplitude-integrated encephalogram (aEEG) characteristics of neonates with neonatal abstinence syndrome (NAS). METHODS This is a prospective observational study. Newborns exposed to prenatal opioids and their gestational matched controls were included. A single-channel aEEG was obtained using Olympic 6000 CFM monitor. The background activity (continuous/discontinuous), the amplitudes (μV) and the presence of sleep-wake cycle (SWC) were documented. RESULTS A total of 59 infants, 23 with NAS and 36 controls were enrolled. All aEEG were completed within 48 hours of life prior to initiation of treatment. Birth weight and gestational age were similar in both groups. An aEEG was abnormal (discontinuous pattern and/or absent SWC) in 78 % (18/23) of infants with NAS versus only 25% in control group (9/36), [OR 10.8, CI (2.7-46.5) P < 0.001]. 61% of infants with NAS had discontinuous pattern [OR 7.8, CI (2-32) P = 0.001] and 39% had absence of sleep-wake cycle [OR 7.1, CI (1.4-39.4) P = 0.007]. CONCLUSIONS A majority of infants with NAS have abnormal aEEG activity.
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Affiliation(s)
- Divya Rana
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leann Pollard
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jonathan Rowland
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Massroor Pourcyrous
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
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Abstract
Hypoxic-ischemic encephalopathy is a subtype of neonatal encephalopathy and a major contributor to global neonatal morbidity and mortality. Despite advances in obstetric and neonatal care there are still challenges in accurate determination of etiology of neonatal encephalopathy. Thus, identification of intrapartum risk factors and comprehensive evaluation of the neonate is important to determine the etiology and severity of neonatal encephalopathy. In developed countries, therapeutic hypothermia as a standard of care therapy for neonates with hypoxic-ischemic encephalopathy has proven to decrease incidence of death and neurodevelopmental disabilities, including cerebral palsy in surviving children. Advances in neuroimaging, brain monitoring modalities, and biomarkers of brain injury have improved the ability to diagnose, monitor, and treat newborns with encephalopathy. However, challenges remain in early identification of neonates at risk for hypoxic-ischemic brain injury, and determination of the timing and extent of brain injury. Using imaging studies such as Neonatal MRI and MR spectroscopy have proven to be most useful in predicting outcomes in infants with encephalopathy within the first week of life, although comprehensive neurodevelopmental assessments still remains the gold standard for determining long term outcomes. Future studies are needed to identify other newborns with encephalopathy that might benefit from therapeutic hypothermia and to determine the efficacy of other adjunctive neuroprotective strategies. This review focuses on newer evidence and advances in diagnoses and management of infants with neonatal encephalopathy, including novel therapies, as well as prognostication of outcomes to childhood.
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Saw CL, Rakshasbhuvankar A, Rao S, Bulsara M, Patole S. Current Practice of Therapeutic Hypothermia for Mild Hypoxic Ischemic Encephalopathy. J Child Neurol 2019; 34:402-409. [PMID: 30898007 DOI: 10.1177/0883073819828625] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
CONTEXT Therapeutic hypothermia is the recommended treatment for neonates with moderate or severe hypoxic ischemic encephalopathy (HIE). There is an increasing trend to use therapeutic hypothermia even in infants with mild hypoxic ischemic encephalopathy, even though there is little evidence to support/refute this. OBJECTIVE To estimate the incidences of mild hypoxic ischemic encephalopathy among infants who received therapeutic hypothermia, and its short- and long-term outcomes. DATA SOURCES AND STUDY SELECTION PubMed, Embase, CINAHL, and Cochrane library were searched to identify observational studies reporting on therapeutic hypothermia in term and near-term infants with mild hypoxic ischemic encephalopathy. The JBI (Joanna Briggs Institute) tools were used to assess the risk of bias in the included studies. Random effects meta-analysis was conducted to find out the percentage of cooled infants who had only mild hypoxic ischemic encephalopathy. RESULTS A total of 3590 citations were screened, of which 13 were included. Of the 2783 infants who received therapeutic hypothermia, 573 had mild hypoxic ischemic encephalopathy. Meta-analysis found that 22% of the infants who underwent therapeutic hypothermia had only mild hypoxic ischemic encephalopathy (95% confidence interval: 16%-27%; I2 statistic = 90.5%). Five studies provided information on adverse effects of therapeutic hypothermia in mild hypoxic ischemic encephalopathy. The reported adverse effects were extreme hypothermia, bradycardia, hypoglycemia, sepsis, skin necrosis, pulmonary hypertension, and systemic hypotension. Limitation: The limitations included relatively small sample size and the lack of data for short- and long-term neurodevelopmental outcome. CONCLUSIONS A significant proportion of infants who received therapeutic hypothermia had mild hypoxic ischemic encephalopathy. Randomized trials are urgently needed to evaluate the efficacy and safety of therapeutic hypothermia in infants with mild hypoxic ischemic encephalopathy.
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Affiliation(s)
- Chia L Saw
- 1 Department of Neonatology, Princess Margaret and King Edward Hospitals, Perth, Australia
| | - Abhijeet Rakshasbhuvankar
- 1 Department of Neonatology, Princess Margaret and King Edward Hospitals, Perth, Australia
- 2 Centre for Neonatal Research and Education, University of Western Australia, Australia
| | - Shripada Rao
- 1 Department of Neonatology, Princess Margaret and King Edward Hospitals, Perth, Australia
- 2 Centre for Neonatal Research and Education, University of Western Australia, Australia
| | - M Bulsara
- 3 Institute for Health Research, University of Notre Dame, Perth, Australia
| | - Sanjay Patole
- 1 Department of Neonatology, Princess Margaret and King Edward Hospitals, Perth, Australia
- 2 Centre for Neonatal Research and Education, University of Western Australia, Australia
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Pinchefsky EF, Hahn CD, Kamino D, Chau V, Brant R, Moore AM, Tam EWY. Hyperglycemia and Glucose Variability Are Associated with Worse Brain Function and Seizures in Neonatal Encephalopathy: A Prospective Cohort Study. J Pediatr 2019; 209:23-32. [PMID: 30982528 DOI: 10.1016/j.jpeds.2019.02.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/17/2019] [Accepted: 02/15/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To investigate how glucose abnormalities correlate with brain function on amplitude-integrated electroencephalography (aEEG) in infants with neonatal encephalopathy. STUDY DESIGN Neonates born at full term with encephalopathy were enrolled within 6 hours of birth in a prospective cohort study at a pediatric academic referral hospital. Continuous interstitial glucose monitors and aEEG were placed soon after birth and continued for 3 days. Episodes of hypoglycemia (≤50 mg/dL; ≤2.8 mmol/L) and hyperglycemia (>144 mg/dL; >8.0 mmol/L) were identified. aEEG was classified in 6-hour epochs for 3 domains (background, sleep-wake cycling, electrographic seizures). Generalized estimating equations assessed the relationship of hypo- or hyperglycemia with aEEG findings, adjusting for clinical markers of hypoxia-ischemia (Apgar scores, umbilical artery pH, and base deficit). RESULTS Forty-five infants (gestational age 39.5 ± 1.4 weeks) were included (24 males). During aEEG monitoring, 16 episodes of hypoglycemia were detected (9 infants, median duration 77.5, maximum 220 minutes) and 18 episodes of hyperglycemia (13 infants, median duration 237.5, maximum 3125 minutes). Epochs of hypoglycemia were not associated with aEEG changes. Compared with epochs of normoglycemia, epochs of hyperglycemia were associated with worse aEEG background scores (B 1.120, 95% CI 0.501-1.738, P < .001), less sleep-wake cycling (B 0.587, 95% CI 0.417-0.757, P < .001) and more electrographic seizures (B 0.433, 95% CI 0.185-0.681, P = .001), after adjusting for hypoxia-ischemia severity. CONCLUSIONS In neonates with encephalopathy, epochs of hyperglycemia were temporally associated with worse global brain function and seizures, even after we adjusted for hypoxia-ischemia severity. Whether hyperglycemia causes neuronal injury or is simply a marker of severe brain injury requires further study.
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Affiliation(s)
- Elana F Pinchefsky
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada.
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Daphne Kamino
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vann Chau
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada; BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Rollin Brant
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada; Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Aideen M Moore
- Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Emily W Y Tam
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada; Program in Neurosciences and Mental Health, SickKids Research Institute, Toronto, Ontario, Canada
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Han Y, Fu N, Chen W, Liang J, Cui Y, Zhang Y, Qin J. Prognostic Value of Electroencephalography in Hypothermia-Treated Neonates With Hypoxic-Ischemic Encephalopathy: A Meta-Analysis. Pediatr Neurol 2019; 93:3-10. [PMID: 30691779 DOI: 10.1016/j.pediatrneurol.2018.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/05/2018] [Accepted: 12/24/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Electroencephalography (EEG) background activity is associated with neurological outcome in neonates with hypoxic-ischemic encephalopathy. There is uncertainty about the prognostic value of EEG background activity after hypothermia was introduced. METHODS Searches were made on Pubmed, Embase, and the Cochrane Library, from inception to March 1, 2018. Pooled sensitivities and specificities were calculated to assess the diagnostic power of burst suppression, low voltage, and flat trace background activities in the prediction of an adverse neurological outcome in the follow-up period in hypothermia-treated neonates with hypoxic-ischemic encephalopathy. I2 was used to assess heterogeneity, and meta-regression was done to explore the source of heterogeneity. RESULTS Eighteen studies with 940 neonates were included. Pooled sensitivities and specificities in predicting the combination of death and neurodevelopmental impairment were burst suppression (sensitivity 0.87 [95% confidence interval (CI) 0.79 to 0.93], specificity 0.60 [95% CI 0.44 to 0.74]), low voltage (sensitivity 0.84 [0.75 to 0.90], specificity 0.80 [0.58 to 0.92]), and flat trace (sensitivity 0.85 [0.75 to 0.92], specificity 0.94 [0.77 to 0.99]). Subgroup analysis revealed the sensitivities of background patterns obtained after 24 hours of life were higher than those within age 24 hours, whereas the specificities were just the reverse. Flat trace performed best on sensitivity 0.93 (0.60 to 0.99) and specificity 0.90 (0.64 to 0.98) in predicting death. Burst suppression demonstrated the highest sensitivity 0.87 (0.58 to 0.97) and flat trace performed best on specificity 0.85 (0.60 to 0.96) in predicting neurodevelopmental impairment. CONCLUSIONS EEG background activity is predictive of long-term neurological outcome in hypothermia-treated neonates with hypoxic-ischemic encephalopathy. Burst suppression, low voltage, and flat trace are potential predictors of death or neurodevelopmental impairment.
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Affiliation(s)
- Ye Han
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Na Fu
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Wenjie Chen
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Jingjing Liang
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Yanan Cui
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Ying Zhang
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Jiong Qin
- Department of Pediatrics, Peking University People's Hospital, Beijing, China.
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Should therapeutic hypothermia be offered to babies with mild neonatal encephalopathy in the first 6 h after birth? Pediatr Res 2019; 85:442-448. [PMID: 30733613 DOI: 10.1038/s41390-019-0291-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/20/2018] [Accepted: 12/30/2018] [Indexed: 12/11/2022]
Abstract
Infants with moderate to severe neonatal encephalopathy (NE) benefit significantly from therapeutic hypothermia, with reduced risk of death or disability. However, the need for therapeutic hypothermia for infants with milder NE remains unclear. It has been suggested that these infants should not be offered therapeutic hypothermia as they may not be at risk for adverse neurodevelopmental outcome and that the balance of risk against potential benefit is unknown. Several key questions need to be answered including first, whether one can define NE in the first 6 h after birth so as to accurately distinguish infants with brain injury who may be at risk for adverse neurodevelopmental consequences. Second, will treatment of infants with mild NE with therapeutic hypothermia improve or even worsen neurological outcomes? Although alternate treatment protocols for mild NE may be feasible, the use of the current approach combined with rigorous avoidance of hyperthermia and initiation of hypothermia as early as possible after birth may promote optimal outcomes. Animal experimental data support the potential for greater benefit for mild HIE compared with moderate to severe HIE. This review will summarize current knowledge of mild NE and the challenges to a trial in this population.
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Dempsey EM, Kooi EMW, Boylan G. It's All About the Brain-Neuromonitoring During Newborn Transition. Semin Pediatr Neurol 2018; 28:48-59. [PMID: 30522728 DOI: 10.1016/j.spen.2018.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - E M W Kooi
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Geraldine Boylan
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland; INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland.
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Arnaez J, Garcia-Alix A, Calvo S, Lubián-López S, Diez-Delgado J, Benavente I, Tofé I, Jerez A, Hurtado J, Ceballos J, Millán M, Esquivel M, Ruiz C, Baca M, Tapia E, Losada M, Torres E, Pavón A, Jiménez P, Jiménez F, Ventura M, Rite S, González T, Arias R, Balliu P, Lloreda-García J, Alcaráz J, Tapia C, de la Morena A, Centelles I, Güemes I, Estañ J, Alberola A, Aparici S, López R, Beceiro J, García B, Martínez L, González E, Arruza L, Blanco M, Moral M, Arias B, Mar F, Jiménez J, Romera G, Cuñarro A, Muñóz C, Cabañas F, Valverde E, Montero R, Tejedor J, Santana C, Reyes B, Romero S, Orizaola A, Baquero M, Hernández D, Pantoja A, Vega C, Castañón L, Gutiérrez E, Benito M, Caserío S, Arca G, García M, López-Vílchez M, Castells L, Domingo M, Coroleu W, Boix H, Porta R, García-Alix A, Martínez-Nadal S, Jiménez E, Sole E, Albújar M, Fernández E, Barrio A, Piñán E, Avila-Alvarez A, Vázquez M, Balado N, Crespo P, Couce M, Concheiro-Guisán A, Esteban I, Lavilla A, Alzina V, Aguirre A, Loureiro B, Echániz I, Euba MEA. Care of the newborn with perinatal asphyxia candidate for therapeutic hypothermia during the first six hours of life in Spain. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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[Care of the newborn with perinatal asphyxia candidate for therapeutic hypothermia during the first six hours of life in Spain]. An Pediatr (Barc) 2017; 89:211-221. [PMID: 29241628 DOI: 10.1016/j.anpedi.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/24/2017] [Accepted: 11/09/2017] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The process of care and assistance from birth to the starting of therapeutic hypothermia (TH) is crucial in order to improve its effectiveness and prevent the worsening of hypoxic-ischaemic injury. METHODS A national cross-sectional study carried out in 2015 by use of a questionnaire sent to all level iii units on the care of the newborn≥35 weeks gestation within the first hours of life after a perinatal asphyxia event. According to clinical practice guidelines, the quality of care was compared between the hospitals that carried out or did not carry out TH, and according to the level of care. RESULTS A total of 89/90 hospitals participated, of which 57/90 performed TH. They all used resuscitation protocols and turned off the radiant warmer after stabilisation. All of them performed glucose and blood gas analysis, monitored the central temperature, put the newborn on a diet, and performed at least two examinations for the diagnosis of hypoxic-ischaemic encephalopathy. Greater than one-third (35%) of hospitals did not have amplitude-integrated electroencephalogram, and 6/57 were TH-hospitals. The quality of care among hospitals with and without TH was similar, childbirth being better in those that performed TH, and those with a higher level of care. Level IIIc hospitals had higher scores than the others. The TH-hospitals mentioned not always having neonatologists with experience in neurological assessment and interpretation of amplitude-integrated electroencephalogram (25%), or in brain ultrasound (62%). CONCLUSIONS In response to the recommendations of the asphyxiated newborn, there is a proper national health care standard with differences according to the level of care and whether TH is offered. More amplitude-integrated electroencephalogram devices are necessary, as well as more neonatologists trained in the evaluations that will be require by the newborn with hypoxic-ischaemic encephalopathy.
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Liu X, Jary S, Cowan F, Thoresen M. Reduced infancy and childhood epilepsy following hypothermia-treated neonatal encephalopathy. Epilepsia 2017; 58:1902-1911. [PMID: 28961316 DOI: 10.1111/epi.13914] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate what proportion of a regional cohort of cooled infants with neonatal encephalopathy develop epilepsy (determined by the International League Against Epilepsy [ILAE] definition and the number of antiepileptic drugs [AEDs]) up to 8 years of age. METHODS From 2006-2013, 151 infants with perinatal asphyxia underwent 72 h cooling. Clinical and amplitude-integrated electroencepalography (aEEG) with single-channel EEG-verified neonatal seizures were treated with AEDs. Brain magnetic resonance imaging (MRI) was assessed using a 0-11 severity score. Postneonatal seizures, epilepsy rates, and AED treatments were documented. One hundred thirty-four survivors were assessed at 18-24 months; adverse outcome was defined as death or Bayley III composite Cognition/Language or Motor scores <85 and/or severe cerebral palsy or severely reduced vision/hearing. Epilepsy rates in 103 children age 4-8 years were also documented. RESULTS aEEG confirmed seizures occurred precooling in 77 (57%) 151 of neonates; 48% had seizures during and/or after cooling and received AEDs. Only one infant was discharged on AEDs. At 18-24 months, one third of infants had an adverse outcome including 11% mortality. At 2 years, 8 (6%) infants had an epilepsy diagnosis (ILAE definition), of whom 3 (2%) received AEDs. Of the 103 4- to 8-year-olds, 14 (13%) had developed epilepsy, with 7 (7%) receiving AEDs. Infants/children on AEDs had higher MRI scores than those not on AEDs (median [interquartile range] 9 [8-11] vs. 2 [0-4]) and poorer outcomes. Nine (64%) of 14 children with epilepsy had cerebral palsy compared to 13 (11%) of 120 without epilepsy, and 10 (71%) of 14 children with epilepsy had adverse outcomes versus 23 (19%) of 120 survivors without epilepsy. The number of different AEDs given to control neonatal seizures, aEEG severity precooling, and MRI scores predicted childhood epilepsy. SIGNIFICANCE We report, in a regional cohort of infants cooled for perinatal asphyxia, 6% with epilepsy at 2 years (2% on AEDs) increasing to 13% (7% on AEDs) at early school age. These AED rates are much lower than those reported in the cooling trials, even with adjusting for our cohort's milder asphyxia. Long-term follow-up is needed to document final epilepsy rates.
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Affiliation(s)
- Xun Liu
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Frances Cowan
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marianne Thoresen
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.,Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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