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Faingold R, Prempunpong C, Garfinkle J, St Martin C, Menegotto F, Boyle R, Aguilera JM, Nguyen KA, Sant'Anna GM. Association between Early Basal Ganglia and Thalami Perfusion Assessed by Color Doppler Ultrasonography and Brain Injury in Infants with Hypoxic-Ischemic Encephalopathy: A Prospective Cohort Study. J Pediatr 2024; 271:114086. [PMID: 38705232 DOI: 10.1016/j.jpeds.2024.114086] [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: 12/04/2023] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To evaluate associations between neurologic outcomes and early measurements of basal ganglia (BG) and thalamic (Th) perfusion using color Doppler ultrasonography (CDUS) in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN Prospective study of infants with mild (n = 18), moderate (n = 17), and severe HIE (n = 14) and controls (n = 17). Infants with moderate-severe HIE received therapeutic hypothermia (TH). CDUS was performed at 24-36 hours and brain magnetic resonance imaging (MRI) at a median of 10 days. Development was followed through 2.5-5 years. The primary outcome was the association between BG and Th perfusion and brain MRI injury. Secondary analyses focused on associations between perfusion measurements and admission neurologic examinations, MRI scores in infants treated with TH, and motor and sensory disability, or death. An exploratory analysis assessed the accuracy of BG and Th perfusion to predict brain MRI injury in infants treated with TH. RESULTS Increased BG and Th perfusion on CDUS was observed in infants with severe MRI scores and those with significant motor and neurosensory disability or death through 2.5-5 years (P < .05). Infants with severe HIE showed increased BG and Th perfusion (P < .005) compared with infants with moderate HIE. No differences were identified between the between the control and mild HIE groups. Th perfusion ≥0.237 cm/second (Area under the curve of 0.824) correctly classified 80% of infants with severe MRI scores. CONCLUSIONS Early dynamic CDUS of the BG and Th is a potential biomarker of severe brain injury in infants with HIE and may be a useful adjunct to currently used assessments.
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Affiliation(s)
- Ricardo Faingold
- Pediatric Radiology, Hospital for Sick Children, University of Toronto, Toronto, ON
| | | | - Jarred Garfinkle
- Pediatrics, Neonatal Division, McGill University Health Center, Montreal, Canada
| | - Christine St Martin
- Pediatric Radiology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada
| | - Flavia Menegotto
- Pediatric Radiology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, United Kingdom
| | - Rose Boyle
- Neonatal Division, University of Alberta, Edmonton, Canada
| | | | - Kim-Anh Nguyen
- Pediatrics, Neonatal Follow-Up Division, Jewish General Hospital, McGill University Health Center, Montreal, Canada
| | - Guilherme M Sant'Anna
- Pediatrics, Neonatal Division, Research Institute and Member of the Experimental Medicine Department, McGill University Health Center, Montreal, Canada.
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Lee KS, Massaro A, Wintermark P, Soul J, Natarajan G, Dizon MLV, Mietzsch U, Mohammad K, Wu TW, Chandel A, Shenberger J, DiGeronimo R, Peeples ES, Hamrick S, Cardona VQ, Rao R. Practice Variations for Therapeutic Hypothermia in Neonates with Hypoxic-ischemic Encephalopathy: An International Survey. J Pediatr 2024; 274:114181. [PMID: 38950817 DOI: 10.1016/j.jpeds.2024.114181] [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] [Received: 02/12/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To evaluate variations in management of therapeutic hypothermia (TH) for neonatal hypoxic-ischemic encephalopathy (HIE) among international clinical sites and to identify areas for harmonization. STUDY DESIGN An electronic survey was sent to Children's Hospitals Neonatal Consortium site sponsors, Canadian Neonatal Network site investigators, members of the Newborn Brain Society, and American Academy of Pediatrics Neonatology chiefs. RESULTS One hundred five sites responded, with most from high-income regions (n = 95). Groupings were adapted from the United Nations regional groups: US (n = 52 sites); Canada (n = 20); Western Europe and other states excluding Canada and US Group (WEOG, n = 18); and non-WEOG (central and eastern Europe, Asia, Africa, Latin America, and Caribbean, n = 15). Regional variations were seen in the eligibility criteria for TH, such as the minimum gestational age, grading of HIE severity, use of electroencephalography, and the frequency of providing TH for mild HIE. Active TH during transport varied among regions and was less likely in smaller volume sites. Amplitude-integrated electroencephalogram and/or continuous electroencephalogram to determine eligibility for TH was used by most sites in WEOG and non-WEOG but infrequently by the US and Canada Groups. For sedation during TH, morphine was most frequently used as first choice but there was relatively high (33%) use of dexmedetomidine in the US Group. Timing of brain magnetic resonance imaging and neurodevelopmental follow-up were variable. Neurodevelopmental follow occurred earlier and more frequently, although for a shorter duration, in the non-WEOG. CONCLUSIONS We found significant variations in practices for TH for HIE across regions internationally. Future guidelines should incorporate resource availability in a global perspective.
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Affiliation(s)
- Kyong-Soon Lee
- Division of Neonatology, the Hospital for Sick Children, Department of Paediatrics, University of Toronto, Canada.
| | - An Massaro
- Division of Neonatology, Children's National Hospital, Department of Pediatrics, The George Washington School of Medicine, Washington, DC
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Girija Natarajan
- Children's Hospital of Michigan/Wayne State University, Detroit, MI
| | - Maria L V Dizon
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Newborn Critical Care, University of Calgary, Cumming School of Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Amit Chandel
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | | | - Robert DiGeronimo
- Division of Neonatology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Eric S Peeples
- Division of Neonatology, Department of Pediatrics, Children's Nebraska, University of Nebraska Medical Center, Omaha, NE
| | - Shannon Hamrick
- Emory University and Children's Healthcare of Atlanta, Atlanta GA
| | | | - Rakesh Rao
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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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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Mohammad K, Molloy E, Scher M. Training in neonatal neurocritical care: A case-based interdisciplinary approach. Semin Fetal Neonatal Med 2024:101530. [PMID: 38670881 DOI: 10.1016/j.siny.2024.101530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.
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Affiliation(s)
| | | | - Mark Scher
- Pediatrics/Neurology, Case Western Reserve University, Cleveland, USA.
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5
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McDouall A, Wassink G, Ranasinghe S, Zhou KQ, Karunasinghe RN, Dean JM, Davidson JO. Blockade of connexin hemichannels with tonabersat protects against mild hypoxic ischemic brain injury in neonatal rats. Exp Neurol 2024; 371:114611. [PMID: 37944882 DOI: 10.1016/j.expneurol.2023.114611] [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: 07/30/2023] [Revised: 10/15/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND PURPOSE There is growing evidence that infants with mild hypoxic-ischemic (HI) encephalopathy have increased risk of brain injury and adverse neurodevelopmental outcomes. Currently, there is no approved treatment for these infants. It was previously shown that blocking connexin 43 hemichannels is neuroprotective in models of moderate to severe HI injury. However, it is yet to be established whether these channels play a role in the evolution of mild HI brain injury, and whether blocking these channels after mild HI is neuroprotective. METHODS HI was induced in postnatal day 10 rats of both sexes by right carotid artery ligation followed by 80 min of hypoxia in 8% oxygen. Pups receiving HI were randomised to receive intraperitoneal injections of either saline, vehicle (2-hydroxypropyl-beta-cyclodextrin polyethylene glycol-400), or tonabersat (2 mg/kg), at 60 min, 24 h, and 48 h after hypoxia. Seven days after HI, brains were harvested for measurement of volume loss and histological analysis. RESULTS HI resulted in a significant reduction in hemispheric, hippocampal, and white matter volumes, which were significantly attenuated after treatment with tonabersat. HI was also associated with a significant reduction in numbers of neurons in the CA1 and CA3 hippocampal regions, a reduction in the numbers of oligodendrocytes in the corpus callosum, and an increase in the number of astrocytes in both regions, which were significantly attenuated by tonabersat treatment. There were no differences in rectal temperatures between tonabersat- and vehicle-treated rat pups. CONCLUSIONS Blockade of connexin hemichannels with tonabersat significantly reduced mild HI injury in the hippocampus and white matter, without causing hypothermia.
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Affiliation(s)
- Alice McDouall
- Department of Physiology, the University of Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, the University of Auckland, New Zealand
| | | | - Kelly Q Zhou
- Department of Physiology, the University of Auckland, New Zealand
| | | | - Justin M Dean
- Department of Physiology, the University of Auckland, New Zealand
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Birkenmaier A, Adams M, Kleber M, Schwendener Scholl K, Rathke V, Hagmann C, Brotschi B, Grass B. Increase in Standardized Management of Neonates with Hypoxic-Ischemic Encephalopathy Since Implementation of a Patient Register. Ther Hypothermia Temp Manag 2023; 13:175-183. [PMID: 36811496 DOI: 10.1089/ther.2022.0055] [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] [Indexed: 02/24/2023] Open
Abstract
The Swiss National Asphyxia and Cooling Register was implemented in 2011. This study assessed quality indicators of the cooling process and (short-term) outcomes of neonates with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH) longitudinally over time in Switzerland. This is a multicenter national retrospective cohort study of prospectively collected register data. Quality indicators were defined for longitudinal comparison (2011-2014 vs. 2015-2018) of processes of TH and (short-term) outcomes of neonates with moderate-to-severe HIE. Five hundred seventy neonates receiving TH in 10 Swiss cooling centers were included (2011-2018). Four hundred forty-nine (449/570; 78.8%) neonates with moderate-to-severe HIE received TH according to the Swiss National Asphyxia and Cooling Register Protocol. Quality indicators of processes of TH improved in 2015-2018 (compared with 2011-2014): less passive cooling (p = 0.013), shorter time to reach target temperature (p = 0.002), and less over- or undercooling (p < 0.001). In 2015-2018, adherence to performing a cranial magnetic resonance imaging after rewarming improved (p < 0.001), whereas less cranial ultrasounds were performed on admission (p = 0.012). With regard to quality indicators of short-term outcomes, persistent pulmonary hypertension of the neonate was reduced (p = 0.003), and there was a trend toward less coagulopathy (p = 0.063) in 2015-2018. There was no statistically significant change in the remaining processes and outcomes. The Swiss National Asphyxia and Cooling Register is well implemented with good overall adherence to the treatment protocol. Management of TH improved longitudinally. Continuous reevaluation of register data is desirable for quality assessment, benchmarking, and maintaining international evidence-based quality standards.
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Affiliation(s)
- André Birkenmaier
- University of Zurich, Faculty of Medicine, Department of Neonatology and Pediatric Intensive Care, Children's Hospital St. Gallen, Neonatal and Pediatric Intensive Care Unit, St. Gallen, Switzerland
| | - Mark Adams
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Kleber
- Clinic of Neonatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | | | - Verena Rathke
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Barbara Brotschi
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beate Grass
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Division of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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Malan R, Van Der Linde J, Kritzinger A, Graham MA, Krüger E, Kollapen K, Lockhat Z. Evolution of swallowing and feeding abilities of neonates with hypoxic-ischaemic encephalopathy during hospitalisation: A case series. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 25:893-902. [PMID: 36444930 DOI: 10.1080/17549507.2022.2147217] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE To describe the evolution of swallowing and feeding abilities of neonates with hypoxic-ischaemic encephalopathy (HIE) during hospitalisation. METHOD A longitudinal cohort study was used. Twenty-nine participants (median age 39.0 weeks [IQR = 2.0 weeks]) with mild (n = 7), moderate (n = 19) and severe (n = 3) HIE were included. Clinical swallowing and feeding assessments were conducted at introduction of oral feeds and at discharge using the Neonatal Feeding Assessment Scale (NFAS). Videofluoroscopic swallow studies (VFSS) supplemented the NFAS before discharge. RESULT Approximately two thirds of participants showed symptoms of oropharyngeal dysphagia (OPD) during initial NFAS and VFSS. Significantly fewer OPD symptoms occurred at discharge NFAS (p = 0.004). Endurance during non-nutritive sucking (p < 0.001) and nutritive sucking (p < 0.001) significantly improved. Nine participants (31.0%) demonstrated penetration or aspiration. Most aspiration events were silent (60%). Instrumental assessment identified pharyngeal phase dysphagia more effectively than bedside evaluation. High proportions of participants displayed OPD symptoms regardless of HIE severity. The correlation between OPD severity and the length of hospitalisation (p = 0.052) was not significant. CONCLUSION All grades of HIE should be considered for early intervention by speech-language pathologists before discharge. Findings may be valuable to neonatal feeding teams.
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Affiliation(s)
- Roxanne Malan
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Jeannie Van Der Linde
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Alta Kritzinger
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Marien A Graham
- Department of Science, Mathematics and Technology Education, University of Pretoria, Pretoria, South Africa
| | - Esedra Krüger
- Department of Speech-Language Pathology and Audiology, University of Pretoria, Pretoria, South Africa
| | - Kumeshnie Kollapen
- Department of Radiology, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Zarina Lockhat
- Department of Radiology, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
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8
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Törn AE, Hesselman S, Johansen K, Ågren J, Wikström AK, Jonsson M. Outcomes in children after mild neonatal hypoxic ischaemic encephalopathy: A population-based cohort study. BJOG 2023; 130:1602-1609. [PMID: 37199188 DOI: 10.1111/1471-0528.17533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/24/2023] [Accepted: 04/26/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To investigate whether mild neonatal hypoxic ischaemic encephalopathy (HIE) in term born infants is associated with cerebral palsy, epilepsy, mental retardation and death up to 6 years of age. DESIGN Population-based cohort study. SETTING Sweden, 2009-2015. POPULATION Live term born infants without congenital malformations or chromosomal abnormalities (n = 505 075). METHODS Birth and health data were retrieved from Swedish national health and quality registers. Mild HIE was identified by diagnosis in either the Swedish Medical Birth Register or the Swedish Neonatal Quality Register. Cox proportional hazards regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). MAIN OUTCOME MEASURES A composite of the outcomes cerebral palsy, epilepsy, mental retardation and death up to 6 years of age. RESULTS Median follow-up time was 3.3 years after birth. Of 414 infants diagnosed with mild HIE, 17 were classified according to the composite outcome and incidence rates were 12.6 and 2.9 per 1000 child-years in infants with and without HIE respectively. Infants with mild HIE was four times as likely to be diagnosed with the composite outcome (HR 4.42, 95% CI 2.75-7.12) compared with infants without HIE. When analysed separately, associations were found with cerebral palsy (HR 21.50, 95% CI 9.59-48.19) and death (HR 19.10, 95% CI 7.90-46.21). HRs remained essentially unchanged after adjustment for covariates. CONCLUSIONS Mild neonatal HIE was associated with neurological morbidity and mortality in childhood. Challenges include identifying infants who may develop morbidity and how to prevent adverse outcomes.
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Affiliation(s)
- Anna E Törn
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanne Hesselman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research, Uppsala University, Falun, Sweden
| | - Kine Johansen
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Shevtsova Y, Eldarov C, Starodubtseva N, Goryunov K, Chagovets V, Ionov O, Plotnikov E, Silachev D. Identification of Metabolomic Signatures for Ischemic Hypoxic Encephalopathy Using a Neonatal Rat Model. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1693. [PMID: 37892356 PMCID: PMC10605414 DOI: 10.3390/children10101693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
A study was performed to determine early metabolomic markers of ischemic hypoxic encephalopathy (HIE) using a Rice-Vannucci model for newborn rats. Dried blood spots from 7-day-old male and female rat pups, including 10 HIE-affected animals and 16 control animals, were analyzed by liquid chromatography coupled with mass spectrometry (HPLC-MS) in positive and negative ion recording modes. Multivariate statistical analysis revealed two distinct clusters of metabolites in both HPLC-MS modes. Subsequent univariate statistical analysis identified 120 positive and 54 negative molecular ions that exhibited statistically significant change in concentration, with more than a 1.5-fold difference after HIE. In the HIE group, the concentrations of steroid hormones, saturated mono- and triglycerides, and phosphatidylcholines (PCs) were significantly decreased in positive mode. On the contrary, the concentration of unsaturated PCs was increased in the HIE group. Among negatively charged molecular ions, the greatest variations were found in the categories of phosphatidylcholines, phosphatidylinositols, and triglycerides. The major metabolic pathways associated with changed metabolites were analyzed for both modes. Metabolic pathways such as steroid biosynthesis and metabolism fatty acids were most affected. These results underscored the central role of glycerophospholipid metabolism in triggering systemic responses in HIE. Therefore, lipid biomarkers' evaluation by targeted HPLC-MS research could be a promising approach for the early diagnosis of HIE.
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Affiliation(s)
- Yulia Shevtsova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Chupalav Eldarov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Natalia Starodubtseva
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
| | - Kirill Goryunov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
| | - Vitaliy Chagovets
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
| | - Oleg Ionov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
| | - Egor Plotnikov
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
| | - Denis Silachev
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of Russian Federation, 117997 Moscow, Russia; (Y.S.); (C.E.); (N.S.); (K.G.); (V.C.); (O.I.); (E.P.)
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119992 Moscow, Russia
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10
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Kieffer H, Carlton K, Adams S, Jozwik J, Cabacungan E, Cohen SS. Quality improvement sustainability to decrease utilization drift for therapeutic hypothermia in the NICU. J Perinat Med 2023; 51:956-961. [PMID: 36976872 DOI: 10.1515/jpm-2022-0421] [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: 08/28/2022] [Accepted: 03/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVES Therapeutic hypothermia (TH) is now standard of care for the neuroprotection of patients with moderate to severe hypoxic-ischemic encephalopathy (HIE). TH misuse results in increased medical complication rates and high health care resource utilization. Quality improvement (QI) methodology can address drift from clinical guidelines. Assessment of sustainability of any intervention over time is an integral part of the QI methodology. METHODS Our prior QI intervention improved medical documentation using an electronic medical record-smart phrase (EMR-SP) and demonstrated special cause variation. This study serves as Epoch 3 and investigates the sustainability of our QI methods to decrease TH misuse. RESULTS A total of 64 patients met the diagnostic criteria for HIE. Over the study period, 50 patients were treated with TH, and 33 cases (66%) used TH appropriately. The number of appropriate TH cases between cases of misuse increased to an average of 9 in Epoch 3 from 1.9 in Epoch 2. Of the 50 cases, 34 (68%) had EMR-SP documentation included. Length of stay and TH complication rates did not vary between cases of TH misuse and appropriate TH use. CONCLUSIONS Our study confirmed a sustained decrease in TH misuse, despite inconsistent use of EMR-SP. We speculate that culture change involving increased awareness of guidelines through education may have contributed more to a lasting change.
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Affiliation(s)
| | - Katherine Carlton
- Medical College of Wisconsin Affiliated Hospitals, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Samuel Adams
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jenna Jozwik
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erwin Cabacungan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan S Cohen
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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11
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Akula VP, Sriram A, Xu S, Walsh E, Van Meurs K, Cranshaw M, Kuzniewicz MW. Adverse short- and long-term outcomes among infants with mild neonatal encephalopathy. Pediatr Res 2023; 94:1003-1010. [PMID: 35999380 DOI: 10.1038/s41390-022-02249-8] [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] [Received: 02/16/2022] [Accepted: 07/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Studies in newborns with mild neonatal encephalopathy (mNE) demonstrated normal outcomes, but recent literature suggests otherwise. METHODS This retrospective cohort study examined inborn infants between 2014 and 2017. Biochemical and clinical characteristics determined the presence of NE and an encephalopathy score categorized infants as Definite or Possible mNE. An Unexposed control group consisted of newborns not meeting the inclusion criteria. Long-term outcomes assessed included cerebral palsy, seizures, developmental disorder, and motor and speech delay. The association of mNE with seizure disorder by 3 years of age was assessed with logistic regression and developmental disorders with Cox proportional hazards models. RESULTS Of the 156,501 births, we identified 130 with Definite mNE and 445 with Possible mNE (0.8 and 2.8 per 1000 births, respectively). Both groups had significantly higher rates of any developmental disorder and motor and speech delay when compared to the Unexposed (p < 0.05, except for p = 0.07 for motor delay in the Possible NE group). The Definite mNE group had higher rates of developmental disorder and motor and speech delay when compared to the Unexposed with hazard ratios (95% CI) 2.0 (1.2-3.2), 3.7 (1.5-8.8), and 2.1 (1.3-3.5), respectively. CONCLUSIONS An estimate of short- and long-term consequences of mNE suggests that there may be a higher risk of adverse outcome. IMPACT Infants with mild NE are at significant risk for adverse short- and long-term outcomes. The risk of having an abnormal long-term outcome at 3 years of age were doubled in the mild NE group compared to the Unexposed group. Randomized clinical trials are needed as neuroprotective strategies may mitigate these.
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Affiliation(s)
- Vishnu-Priya Akula
- Department of Pediatrics, Kaiser Permanente East Bay, Walnut Creek, CA, USA.
| | - Achyuth Sriram
- Kaiser Permanente Northern California Residency Program, Oakland, CA, USA
| | - Sherian Xu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Eileen Walsh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Krisa Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew Cranshaw
- Kaiser Permanente Northern California Residency Program, Oakland, CA, USA
| | - Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Pediatrics, Kaiser Permanente, San Francisco, CA, USA
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12
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Zhuang X, Jin K, Lin H, Li J, Yin Y, Dong X. Can radiomics be used to detect hypoxic-ischemic encephalopathy in neonates without magnetic resonance imaging abnormalities? Pediatr Radiol 2023; 53:1927-1940. [PMID: 37183229 PMCID: PMC10421781 DOI: 10.1007/s00247-023-05680-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND No study has assessed normal magnetic resonance imaging (MRI) findings to predict potential brain injury in neonates with hypoxic-ischemic encephalopathy (HIE). OBJECTIVE We aimed to evaluate the efficacy of MRI-based radiomics models of the basal ganglia, thalami and deep medullary veins to differentiate between HIE and the absence of MRI abnormalities in neonates. MATERIALS AND METHODS In this study, we included 38 full-term neonates with HIE and normal MRI findings and 89 normal neonates. Radiomics features were extracted from T1-weighted images, T2-weighted images, diffusion-weighted imaging and susceptibility-weighted imaging (SWI). The different models were evaluated using receiver operating characteristic curve analysis. Clinical utility was evaluated using decision curve analysis. RESULTS The SWI model exhibited the best performance among the seven single-sequence models. For the training and validation cohorts, the area under the curves (AUCs) of the SWI model were 1.00 and 0.98, respectively. The combined nomogram model incorporating SWI Rad-scores and independent predictors of clinical characteristics was not able to distinguish HIE in patients without MRI abnormalities from the control group (AUC, 1.00). A high degree of fitting and favorable clinical utility was detected using the calibration curve with the Hosmer-Lemeshow test. Decision curve analysis was used for the SWI, clinical and combined nomogram models. The decision curve showed that the SWI and combined nomogram models had better predictive performance than the clinical model. CONCLUSIONS HIE can be detected in patients without MRI abnormalities using an MRI-based radiomics model. The SWI model performed better than the other models.
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Affiliation(s)
- Xiamei Zhuang
- Department of Radiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410007, China
| | - Ke Jin
- Department of Radiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410007, China.
| | - Huashan Lin
- Department of Pharmaceutical Diagnosis, GE Healthcare, Changsha, 410005, China
| | - Junwei Li
- Department of Radiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410007, China
| | - Yan Yin
- Department of Radiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410007, China
| | - Xiao Dong
- Department of Radiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410007, China
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13
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Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and neurodevelopmental impairment in neonates. Therapeutic hypothermia (TH) is the only established effective therapy and randomized trials affirm that TH reduces death and disability in moderate-to-severe HIE. Traditionally, infants with mild HIE were excluded from these trials due to the perceived low risk for impairment. Recently, multiple studies suggest that infants with untreated mild HIE may be at significant risk of abnormal neurodevelopmental outcomes. This review will focus on the changing landscape of TH, the spectrum of HIE presentations and their neurodevelopmental outcomes.
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Affiliation(s)
| | - Gina Milano
- University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, Texas 75390, USA
| | - Lina F Chalak
- University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, Texas 75390, USA.
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14
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Kodidhi A, Riley M, Vesoulis Z. The influence of late prematurity on the encephalopathy exam of infants with neonatal encephalopathy. J Neonatal Perinatal Med 2023; 16:693-700. [PMID: 38073399 PMCID: PMC10753960 DOI: 10.3233/npm-230041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Late preterm (LPT) infants are increasingly treated for hypoxic-ischemic encephalopathy (HIE). However, neurodevelopmental differences of LPT infants may independently influence the neurologic exam and confound care. METHODS Perinatal and outcome characteristics were extracted along with the worst autonomic and state/neuromuscular/reflex Sarnat components in a cross-section of infants with moderate/severe HIE. Infants were classified as late preterm (LPT, 34-36 weeks) or term (>36 weeks). RESULTS 250 infants were identified, 55 were late preterm. LPT infants had lower mean gestational age and birthweight and greater length of stay (LOS). LPT infants had higher median scores for the Moro and respiratory autonomic components, but no difference in total score. CONCLUSIONS LPT infants had increased LOS, worse Moro reflex, and respiratory status, but no clinically or statistically significant differences in total Sarnat scores. Although it is important to note the impact of immaturity on the exam, it is unlikely to independently alter management.
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Affiliation(s)
- A Kodidhi
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - M Riley
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Z Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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15
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Brain injury following mild hypoxic-ischemic encephalopathy in neonates-Ten-year experience in a tertiary perinatal center. J Perinatol 2022; 42:1630-1636. [PMID: 35953534 DOI: 10.1038/s41372-022-01486-3] [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: 03/19/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We aimed to evaluate abnormal magnetic resonance imaging (MRI) findings in neonates with mild hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This was a single-center, retrospective study of mild HIE conducted from 2011 to 2020. Almost all neonates with mild HIE received management targeted to a temperature of 36 ± 0.5°C for 72 h and underwent MRI (135 of 145). We evaluated medical records and assessed amplitude-integrated electroencephalography (aEEG). RESULT All participants survived until discharge. Abnormal MRI findings were present in 23/135 (17%) neonates. The normal versus abnormal MRI-finding groups had similar characteristics, except discontinuous aEEG patterns (p = 0.002) and inotropic drugs (p = 0.035). Regression analyses showed discontinuous aEEG patterns (odds ratio = 19.3, 95% confidence interval=1.88-197, p = 0.013) being associated with higher odds of abnormal MRI findings. CONCLUSION Our study suggests that a discontinuous aEEG pattern is associated with abnormal MRI findings and can be used to discuss the definition of mild HIE.
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16
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Li Y, Wisnowski JL, Chalak L, Mathur AM, McKinstry RC, Licona G, Mayock DE, Chang T, Van Meurs KP, Wu TW, Ahmad KA, Cornet MC, Rao R, Scheffler A, Wu YW. Mild hypoxic-ischemic encephalopathy (HIE): timing and pattern of MRI brain injury. Pediatr Res 2022; 92:1731-1736. [PMID: 35354930 PMCID: PMC9771796 DOI: 10.1038/s41390-022-02026-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mild hypoxic-ischemic encephalopathy (HIE) is increasingly recognized as a risk factor for neonatal brain injury. We examined the timing and pattern of brain injury in mild HIE. METHODS This retrospective cohort study includes infants with mild HIE treated at 9 hospitals. Neonatal brain MRIs were scored by 2 reviewers using a validated classification system, with discrepancies resolved by consensus. Severity and timing of MRI brain injury (i.e., acute, subacute, chronic) was scored on the subset of MRIs that were performed at or before 8 days of age. RESULTS Of 142 infants with mild HIE, 87 (61%) had injury on MRI at median age 5 (IQR 4-6) days. Watershed (23%), deep gray (20%) and punctate white matter (18%) injury were most common. Among the 125 (88%) infants who received a brain MRI at ≤8 days, mild (44%) injury was more common than moderate (11%) or severe (4%) injury. Subacute (37%) lesions were more commonly observed than acute (32%) or chronic lesions (1%). CONCLUSION Subacute brain injury is common in newborn infants with mild HIE. Novel neuroprotective treatments for mild HIE will ideally target both subacute and acute injury mechanisms. IMPACT Almost two-thirds of infants with mild HIE have evidence of brain injury on MRI obtained in the early neonatal period. Subacute brain injury was seen in 37% of infants with mild HIE. Neuroprotective treatments for mild HIE will ideally target both acute and subacute injury mechanisms.
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Affiliation(s)
- Yi Li
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA.
| | - Jessica L Wisnowski
- Department of Radiology and Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Robert C McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Genesis Licona
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington School of Medicine & Health Sciences, Washington, DC, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kaashif A Ahmad
- Pediatrix Medical Group of San Antonio, San Antonio, TX, USA
| | - Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Rakesh Rao
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Aaron Scheffler
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Espinoza ML, Brundler MA, Hasan SU, Mohammad K, Momin S, Al Shaikh B, Yusuf K. Placental pathology as a marker of brain injury in infants with hypoxic ischemic encephalopathy. Early Hum Dev 2022; 174:105683. [PMID: 36215816 DOI: 10.1016/j.earlhumdev.2022.105683] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hypoxic Ischemic Encephalopathy (HIE) can lead to devastating consequences for the affected infant. Although therapeutic cooling benefits infants with moderate and severe HIE, differentiating mild from moderate-severe HIE may be challenging. The placenta reflects the fetal intrauterine environment and may reveal underlying processes that affect brain injury. AIM To describe placental histopathology using the Amsterdam Placental Workshop Group Criteria in different grades of HIE. STUDY DESIGN Retrospective cohort. SUBJECTS Infants admitted to a tertiary care neonatal intensive care unit with a diagnosis of HIE between 2011 and 2016. OUTCOME MEASURE Maternal and neonatal clinical variables and placental histopathology using the Amsterdam Placental Workshop Group Criteria were compared between mild and moderate-severe HIE. Mann-Whitney or t-test or ꭓ2 were performed for bivariate associations as appropriate. To explain the relationship between placental pathology and severity of HIE odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using logistic regression models. RESULTS Of the 73 infants in the study, 23 had mild and 50 moderate-sever HIE. There was no difference in maternal and neonatal characteristics except for sentinel events which were higher in the moderate- severe group. On placental histopathology, acute inflammation, including fetal inflammatory reaction (FIR) were significantly higher in the moderate-severe group. After adjusting for confounders, FIR remained significantly associated with moderate-severe HIE, ORs 6.29, 95 % CI 1.5-25. CONCLUSION Our study demonstrates FIR in the placenta is associated with severity of HIE.
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Affiliation(s)
- Maria Liza Espinoza
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada
| | - Marie-Anne Brundler
- Department of Pathology & Laboratory Medicine and Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Shabih U Hasan
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada
| | - Sarfaraz Momin
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada
| | - Belal Al Shaikh
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada
| | - Kamran Yusuf
- Department of Pediatrics, University of Calgary, Section of Neonatology, Calgary, AB, Canada.
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Natarajan N, Benedetti G, Perez FA, Wood TR, German KR, Lockrow JP, Puia-Dumitrescu M, Myers E, Mietzsch U. Association Between Early EEG Background and Outcomes in Infants With Mild HIE Undergoing Therapeutic Hypothermia. Pediatr Neurol 2022; 134:52-58. [PMID: 35835026 DOI: 10.1016/j.pediatrneurol.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/17/2022] [Accepted: 06/09/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) occurs in 1-4:1000 live births. Although neonates with moderate-severe HIE have been studied over several decades, newborns with mild HIE remain understudied, including seizure occurrence, electroencephalography (EEG) characteristics, and outcome. METHODS We conducted a retrospective cohort study of neonates ≥35 weeks of gestation with mild HIE who underwent therapeutic hypothermia to correlate the early EEG background pattern with clinical course and outcomes. RESULTS Of the included 29 neonates, 10 infants had a moderately to severely abnormal EEG background and 19 had either a normal or a mildly abnormal background. Those with moderately to severely abnormal background also had more multiorgan dysfunction (90% vs 42%, P = 0.02) and a higher incidence of subdural and intraventricular hemorrhages (80% vs 26%, P = 0.02). The overall seizure incidence was 20.7% and was significantly higher in newborns with more severely abnormal background compared to neonates with less abnormal background (50% vs 5%; P = 0.01; relative risk, 9.5; 95% confidence interval, 1.28-70.6). Seizure onset was between 11 and 63 hours of life. Regardless of the EEG background pattern, seizures were brief with an overall low seizure burden. None of the newborns with normal or mildly abnormal background had a new onset of seizures after 24 hours of recording or developed epilepsy during infancy. CONCLUSIONS In neonates with mild HIE, early moderately to severely abnormal EEG background is common and strongly associated with an increased risk for seizures.
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Affiliation(s)
- Niranjana Natarajan
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Giulia Benedetti
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Francisco A Perez
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Thomas R Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kendell R German
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jason P Lockrow
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Emily Myers
- Division of Developmental Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington.
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Differences in standardized neonatal encephalopathy exam criteria may impact therapeutic hypothermia eligibility. Pediatr Res 2022; 92:791-798. [PMID: 34754094 DOI: 10.1038/s41390-021-01834-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) is routinely provided to those with moderate or severe neonatal encephalopathy (NE). Subtle differences exist in the standardized exams used to define NE severity. We aimed to assess if an infant's TH eligibility status differed if they were evaluated using either the NICHD/Neonatal Research Network's (NICHD-NRN) or TOBY/British Association of Perinatal Medicine's (TOBY-BAPM) neurological exam. METHODS Encephalopathic infants ≥36 weeks with evidence of perinatal asphyxia and complete documentation of the neurological exam <6 h of age were included. TH eligibility using the NICHD-NRN and TOBY-BAPM criteria was determined based upon the documented exams. RESULTS Ninety-one encephalopathic infants were included. Despite good agreement between the two exams (κ = 0.715, p < 0.001), TH eligibility differed between them (p < 0.001). A total of 47 infants were deemed eligible by at least one method-46 using NICHD-NRN and 35 using TOBY-BAPM. Of the 12 infants eligible per NICHD-NRN, but ineligible per TOBY-BAPM, two developed electrographic seizures and seven demonstrated hypoxic-ischemic cerebral injury. CONCLUSIONS Both the NICHD-NRN and TOBY-BAPM exams are evidence-based. Despite this, there is a significant difference in the number of infants eligible for TH depending on which exam is used. The NICHD-NRN exam identifies a greater proportion as eligible. IMPACT There are subtle differences in the NICHD-NRN and TOBY-BAPM's encephalopathy exams used to determine eligibility for TH. This results in a significant difference in the proportion of infants determined to be eligible for TH depending on which encephalopathy exam is used. The NICHD-NRN encephalopathy exam identifies more infants as being eligible for TH than the TOBY-BAPM encephalopathy exam. This may result in different rates of cooling depending on which evidence-based neurological exam for evaluation of encephalopathy a center uses.
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20
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Garvey AA, O’Toole JM, Livingstone V, Walsh B, Moore M, Pavel AM, Panaite L, Ryan MA, Boylan GB, Murray DM, Dempsey EM. Evolution of Early Cerebral
NIRS
in Hypoxic Ischaemic Encephalopathy. Acta Paediatr 2022; 111:1870-1877. [PMID: 35869794 PMCID: PMC9545024 DOI: 10.1111/apa.16493] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/27/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Aisling A. Garvey
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
| | - John M. O’Toole
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
| | - Vicki Livingstone
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
| | - Brian Walsh
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
| | - Michael Moore
- Department of Radiology Cork University Hospital Cork Ireland
| | - Andreea M. Pavel
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
| | - Lavinia Panaite
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
| | - Mary Anne Ryan
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
| | - Geraldine B. Boylan
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
| | - Deirdre M. Murray
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
| | - Eugene M. Dempsey
- Department of Paediatrics & Child Health University College Cork Cork Ireland
- INFANT Research Centre University College Cork Cork Ireland
- Department of Neonatology Cork University Maternity Hospital Wilton Cork Ireland
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21
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Gaulee P, Yang Z, Sura L, Xu H, Rossignol C, Weiss MD, Bliznyuk N. Concentration of Serum Biomarkers of Brain Injury in Neonates With a Low Cord pH With or Without Mild Hypoxic-Ischemic Encephalopathy. Front Neurol 2022; 13:934755. [PMID: 35873777 PMCID: PMC9301366 DOI: 10.3389/fneur.2022.934755] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To determine the concentrations of four neuroprotein biomarkers and 68 miRNAs in neonates with low cord pH and/or mild hypoxic-ischemic encephalopathy (HIE). Study Design A prospective cohort study enrolled neonates with low cord pH (n = 18), moderate-severe HIE (n = 40), and healthy controls (n = 38). Groups provided serum samples at 0–6 h of life. The concentrations of biomarkers and miRNAs were compared between cohorts. Result The low cord pH and moderate-severe HIE groups had increased concentrations of GFAP, NFL and Tau compared to controls (P < 0.05, P < 0.001, respectively). NFL concentrations in mild HIE was higher than controls (P < 0.05) but less than moderate-severe HIE (P < 0.001). Of 68 miRNAs, 36 in low cord pH group and 40 in moderate-severe HIE were upregulated compared to controls (P < 0.05). Five miRNAs in low cord pH group (P < 0.05) and 3 in moderate-severe HIE were downregulated compared to controls (P < 0.05). Conclusion A biomarker panel in neonates with low cord pH may help clinicians make real-time decisions.
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Affiliation(s)
- Pratima Gaulee
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
- *Correspondence: Pratima Gaulee
| | - Zhihui Yang
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Livia Sura
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Haiyan Xu
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Candace Rossignol
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Michael D. Weiss
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Nikolay Bliznyuk
- Department of Agricultural and Biological Engineering, Biostatistics and Statistics, University of Florida, Gainesville, FL, United States
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22
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Munshi UK, Brown MM, Tauber KA, Horgan MJ. Early Troponin I Levels in Newborns Undergoing Therapeutic Hypothermia for Hypoxic Ischemic Encephalopathy and Residual Encephalopathy at Discharge. Am J Perinatol 2022; 39:1083-1088. [PMID: 33285603 DOI: 10.1055/s-0040-1721497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Elevation of serum troponin I has been reported in newborns with hypoxic ischemic encephalopathy (HIE), but it is diagnostic and prognostic utility for newborn under 6 hours is not clear. Study the predictive value of early serum troponin I levels in newborns with HIE undergoing therapeutic hypothermia (TH) for persistent residual encephalopathy (RE) at discharge. STUDY DESIGN Retrospective chart review of newborns admitted with diagnosis of HIE to neonatal intensive care unit (NICU) for TH over a period of 3 years. Troponin levels were drawn with the initial set of admission laboratories while initiating TH. Newborns were followed up during hospital course and stratified into three groups based on predischarge examination and their electrical encephalography and cranial MRI findings: Group 1: no RE, Group 2: mild-to-moderate RE, and Group 3: severe RE or needing assisted medical technology or death. Demographic and clinical characteristics including troponin I levels were compared in each group. RESULTS Out of 104 newborns who underwent TH, 65 infants were in Group 1, 26 infants in Group 2, and 13 newborns in Group 3. All groups were comparable in demographic characteristics. There was a significant elevation of serum troponin in group 2 (mild-to-moderate RE) and group 3 (severe RE) as compared with group 1 (no RE). Receiver operator curve analysis for any RE (groups 2 and 3) compared with group 1 (no RE as control) had 0.88 (0.81-0.95) area under curve, p < 0.001. A cut-off level of troponin I ≥0.12 µg/L had a sensitivity of 77% and specificity of 78% for diagnosis of any RE, positive predictive value of 68%, and a negative predictive value of 84%. CONCLUSION In newborns undergoing TH for HIE, the elevation of troponin within 6 hours of age predicts high risk of having RE at discharge. KEY POINTS · Troponin I elevation is a biomarker of myocardial ischemia in adults and children.. · Myocardial ischemia may be part of multi-organ injury in neonatal HIE.. · Early elevation of troponin I level may correlate with the severity of neonatal HIE and predict residual encephalopathy in newborn at discharge from initial hospitalization..
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Affiliation(s)
- Upender K Munshi
- Division of Neonatology, Department of Pediatrics, Bernard & Millie Duker Children's Hospital, Albany Medical Center, Albany, New York
| | - Meredith Monaco Brown
- Division of Neonatology, Department of Pediatrics, Bernard & Millie Duker Children's Hospital, Albany Medical Center, Albany, New York
| | - Kate A Tauber
- Division of Neonatology, Department of Pediatrics, Bernard & Millie Duker Children's Hospital, Albany Medical Center, Albany, New York
| | - Michael J Horgan
- Division of Neonatology, Department of Pediatrics, Bernard & Millie Duker Children's Hospital, Albany Medical Center, Albany, New York
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23
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Starodubtseva NL, Eldarov C, Kirtbaya AR, Balashova EN, Gryzunova AS, Ionov OV, Zubkov VV, Silachev DN. Recent advances in diagnostics of neonatal hypoxic ischemic encephalopathy. BULLETIN OF RUSSIAN STATE MEDICAL UNIVERSITY 2022. [DOI: 10.24075/brsmu.2022.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The prognosis in neonatal hypoxic ischemic encephalopathy (HIE) depends on early differential diagnosis for justified administration of emergency therapeutic hypothermia. The moment of therapy initiation directly affects the long-term neurological outcome: the earlier the commencement, the better the prognosis. This review analyzes recent advances in systems biology that facilitate early differential diagnosis of HIE as a pivotal complement to clinical indicators. We discuss the possibilities of clinical translation for proteomic, metabolomic and extracellular vesicle patterns characteristic of HIE and correlations with severity and prognosis. Identification and use of selective biomarkers of brain damage in neonates during the first hours of life is hindered by systemic effects of hypoxia. Chromatography– mass spectrometry blood tests allow analyzing hundreds and thousands of metabolites in a small biological sample to identify characteristic signatures of brain damage. Clinical use of advanced analytical techniques will facilitate the accurate and timely diagnosis of HIE for enhanced management.
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Affiliation(s)
- NL Starodubtseva
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - ChM Eldarov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - AR Kirtbaya
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - EN Balashova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - AS Gryzunova
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - OV Ionov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - VV Zubkov
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - DN Silachev
- Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
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24
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Tarocco A, Morciano G, Perrone M, Cafolla C, Ferrè C, Vacca T, Pistocchi G, Meneghin F, Cocchi I, Lista G, Cetin I, Greco P, Garani G, Stella M, Natile M, Ancora G, Savarese I, Campi F, Bersani I, Dotta A, Tiberi E, Vento G, Chiodin E, Staffler A, Maranella E, Di Fabio S, Wieckowski MR, Giorgi C, Pinton P. Increase of Parkin and ATG5 plasmatic levels following perinatal hypoxic-ischemic encephalopathy. Sci Rep 2022; 12:7795. [PMID: 35551488 PMCID: PMC9098891 DOI: 10.1038/s41598-022-11870-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/18/2022] [Indexed: 11/27/2022] Open
Abstract
Brain injury at birth is an important cause of neurological and behavioral disorders. Hypoxic-ischemic encephalopathy (HIE) is a critical cerebral event occurring acutely or chronically at birth with high mortality and morbidity in newborns. Therapeutic strategies for the prevention of brain damage are still unknown, and the only medical intervention for newborns with moderate-to-severe HIE is therapeutic hypothermia (TH). Although the neurological outcome depends on the severity of the initial insult, emerging evidence suggests that infants with mild HIE who are not treated with TH have an increased risk for neurodevelopmental impairment; in the current clinical setting, there are no specific or validated biomarkers that can be used to both correlate the severity of the hypoxic insult at birth and monitor the trend in the insult over time. The aim of this work was to examine the presence of autophagic and mitophagic proteins in bodily fluids, to increase knowledge of what, early at birth, can inform therapeutic strategies in the first hours of life. This is a prospective multicentric study carried out from April 2019 to April 2020 in eight third-level neonatal intensive care units. All participants have been subjected to the plasma levels quantification of both Parkin (a protein involved in mitophagy) and ATG5 (involved in autophagy). These findings show that Parkin and ATG5 levels are related to hypoxic-ischemic insult and are reliable also at birth. These observations suggest a great potential diagnostic value for Parkin evaluation in the first 6 h of life.
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Affiliation(s)
- Anna Tarocco
- Neonatal Intensive Care Unit and Neonatology, University Hospital S. Anna, 44121, Ferrara, Italy.,Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70, 44121, Ferrara, Italy
| | - Giampaolo Morciano
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70, 44121, Ferrara, Italy.
| | - Mariasole Perrone
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70, 44121, Ferrara, Italy
| | - Claudia Cafolla
- Department of Medical Sciences, Pediatric Unit, University of Ferrara, 44121, Ferrara, Italy
| | - Cristina Ferrè
- Department of Medical Sciences, Pediatric Unit, University of Ferrara, 44121, Ferrara, Italy
| | - Tiziana Vacca
- Neonatal Intensive Care Unit and Neonatology, University Hospital S. Anna, 44121, Ferrara, Italy
| | - Ginevra Pistocchi
- BSC Medical Biosciences Faculty of Medicine, Imperial College, London, SW7 2AZ, UK
| | - Fabio Meneghin
- Neonatal Pathology and Neonatal Intensive Care Unit, Vittore-Buzzi Children Hospital, Milan, Italy
| | - Ilaria Cocchi
- Neonatal Pathology and Neonatal Intensive Care Unit, Vittore-Buzzi Children Hospital, Milan, Italy
| | - Gianluca Lista
- Neonatal Pathology and Neonatal Intensive Care Unit, Vittore-Buzzi Children Hospital, Milan, Italy
| | - Irene Cetin
- Obstetrics and Gynecology Unit, Vittore Buzzi Children Hospital" and University of Milan, 20154, Milan, Italy
| | - Pantaleo Greco
- Department of Medical Sciences, Section of Obstetrics and Gynecology, University Hospital S.Anna, 44121, Ferrara, Italy
| | - Giampaolo Garani
- Neonatal Intensive Care Unit and Neonatology, University Hospital S. Anna, 44121, Ferrara, Italy
| | - Marcello Stella
- Pediatrics Department and Neonatal and Pediatric Intensive Care Unit, Bufalini Hospital, 47521, Cesena, Italy
| | - Miria Natile
- Neonatal Intensive Care Unit, Infermi Hospital Rimini, 47921, Rimini, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Infermi Hospital Rimini, 47921, Rimini, Italy
| | - Immacolata Savarese
- Department of Neonatology, Bambino Gesù Children's Hospital - IRCCS, 00165, Rome, Italy
| | - Francesca Campi
- Department of Neonatology, Bambino Gesù Children's Hospital - IRCCS, 00165, Rome, Italy
| | - Iliana Bersani
- Department of Neonatology, Bambino Gesù Children's Hospital - IRCCS, 00165, Rome, Italy
| | - Andrea Dotta
- Department of Neonatology, Bambino Gesù Children's Hospital - IRCCS, 00165, Rome, Italy
| | - Eloisa Tiberi
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health, Obstetric and Neonatology Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Elisabetta Chiodin
- Division of Neonatology, Central Teaching Hospital of Bolzano, 39100, Bolzano, Italy
| | - Alex Staffler
- Division of Neonatology, Central Teaching Hospital of Bolzano, 39100, Bolzano, Italy
| | - Eugenia Maranella
- Neonatology and Neonatal Intensive Care Unit, San Salvatore Hospital, 67100, L'Aquila, Italy
| | - Sandra Di Fabio
- Neonatology and Neonatal Intensive Care Unit, San Salvatore Hospital, 67100, L'Aquila, Italy
| | - Mariusz R Wieckowski
- Laboratory of Mitochondrial Biology and Metabolism, NenckiInstituteofExperimental Biology, Polish Academy of Sciences, 02-093, Warsaw, Poland
| | - Carlotta Giorgi
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70, 44121, Ferrara, Italy
| | - Paolo Pinton
- Department of Medical Sciences, Laboratory for Technologies of Advanced Therapies (LTTA), University of Ferrara, Via Fossato di Mortara 70, 44121, Ferrara, Italy.
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25
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Yieh L, Lee H, Lu T, Song A, Gong CL, Wu TW, Friedlich P, Lakshmanan A, Dukhovny D, Hay J. Neonates with mild hypoxic-ischaemic encephalopathy receiving supportive care versus therapeutic hypothermia in California. Arch Dis Child Fetal Neonatal Ed 2022; 107:324-328. [PMID: 34462319 DOI: 10.1136/archdischild-2021-322250] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/12/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The use of therapeutic hypothermia (TH) for mild hypoxic-ischaemic encephalopathy (HIE) remains controversial and inconsistent. We analysed trends in TH and maternal and infant characteristics associated with short-term outcomes of infants with mild HIE. DESIGN Retrospective cohort analysis of the California Perinatal Quality Care Collaborative database 2010-2018. E-value analysis was conducted to determine the potential impact of unmeasured confounding. SETTING California neonatal intensive care units. PATIENTS 1364 neonates with mild HIE. INTERVENTIONS Supportive care versus TH. MAIN OUTCOME MEASURES Factors associated with TH and mortality. RESULTS The proportion of infants receiving TH increased from 46% in 2010 to 79% in 2018. TH was more likely in the setting of singleton birth (OR 2.69, 95% CI 1.21 to 5.39), no major birth defects (OR 2.18, 95% CI 1.42 to 3.30), operative vaginal delivery (OR 3.04, 95% CI 1.80 to 5.10) and 5-minute Apgar score ≤5 (OR 3.17, 95% CI 2.43 to 4.13). Mortality was associated with small for gestational age (OR 5.79, 95% CI 1.90 to 18.48), <38 weeks' gestation (OR 7.31 95% CI 2.39 to 24.93), major birth defects (OR 11.62, 95% CI 3.97 to 38.00), inhaled nitric oxide (OR 12.73, 95% CI 4.00 to 44.53) and nosocomial infection (OR 7.98, 95% CI 1.15 to 47.03). E-value analyses suggest that unmeasured confounding may have contributed to some of the observed effects. CONCLUSIONS Variation in management of mild HIE persists, but therapeutic drift has become more prevalent over time. Further studies are needed to assess long-term outcomes alongside resource utilisation to inform evidence-based practice.
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Affiliation(s)
- Leah Yieh
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Henry Lee
- California Perinatal Quality Care Collaborative, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California, USA
| | - Tianyao Lu
- California Perinatal Quality Care Collaborative, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California, USA
| | - Ashley Song
- Department of Preventive Medicine, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cynthia L Gong
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Philippe Friedlich
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ashwini Lakshmanan
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Joel Hay
- Leonard D. Schaeffer Center for Health Policy and Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
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26
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Chalak L. New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care. Clin Perinatol 2022; 49:279-294. [PMID: 35210007 DOI: 10.1016/j.clp.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.
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Affiliation(s)
- Lina Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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27
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Bingham A, Gundogan F, Rand K, Farrar J, Tucker R, Laptook AR. Placental Findings in Infants with Hypoxic-Ischemic Encephalopathy: The Importance of the Comparison Group. J Pediatr 2022; 242:106-112. [PMID: 34848190 DOI: 10.1016/j.jpeds.2021.11.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the effect of 3 distinct comparison groups on associations between placental abnormalities and neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This single-center, prospective case-control study of singletons of gestational age ≥36 weeks with predefined criteria for HIE (n = 30) and 3 control groups was conducted from June 2015 to January 2018. The control groups were infants born by repeat cesarean delivery (n = 60), infants born small for gestational age (SGA; n = 80), and infants receiving positive-pressure ventilation (PPV) at birth (n = 70). One pathologist blinded to infant category reviewed placental sections using the Amsterdam Placental Workshop criteria. Logistic regression with group contrasts relative to HIE was used to analyze primary placental pathologies, and ORs with 95% CIs provided effect sizes. RESULTS The odds of maternal vascular malperfusion were increased among HIE group placentas compared with placentas of the repeat cesarean delivery (OR, 4.50; 95% CI, 1.45-14.00) and PPV (3.88; 1.35-11.16) groups, but not those of the SGA group. The odds of fetal vascular malperfusion were increased in the HIE group compared with the SGA group (OR, 9.75; 95% CI, 1.85-51.51). The odds of acute chorioamnionitis were higher in the HIE group compared only with the repeat cesarean delivery group, reflecting a similar incidence of chorioamnionitis in SGA group and PPV group placentas. The absence of placental findings was lowest in the HIE group (6.7%), followed by the SGA (18.8%), PPV (31.4%), and repeat cesarean delivery (75%) groups. CONCLUSIONS Associations with placental abnormalities among infants with HIE varied based on the specific placental abnormality and the control group. Potentially important associations between placental pathology and HIE may be obscured if control groups are not well designed.
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Affiliation(s)
- Adrienne Bingham
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI
| | - Fusun Gundogan
- Department of Pathology and Laboratory Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI
| | - Katherine Rand
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Jessica Farrar
- Department of Pediatrics, Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Richard Tucker
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI
| | - Abbot R Laptook
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI
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28
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Tuiskula A, Metsäranta M, Toiviainen‐Salo S, Vanhatalo S, Haataja L. Profile of minor neurological findings after perinatal asphyxia. Acta Paediatr 2022; 111:291-299. [PMID: 34599610 PMCID: PMC9299470 DOI: 10.1111/apa.16133] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/20/2021] [Accepted: 09/30/2021] [Indexed: 12/29/2022]
Abstract
Aim To characterise the spectrum of findings in sequential neurological examinations, general movements (GM) assessment and magnetic resonance imaging (MRI) of infants with perinatal asphyxia. Methods The prospective cohort study of term infants with perinatal asphyxia treated at Helsinki University Hospital's neonatal units in 2016–2020 used Hammersmith Neonatal Neurological Examination (HNNE) and brain MRI at 2 weeks and Hammersmith Infant Neurological Examination (HINE) and GM assessment at 3 months of age. Results Analysis included 50 infants: 33 displaying perinatal asphyxia without hypoxic‐ischaemic encephalopathy (HIE), seven with HIE1 and 10 with HIE2. Of the infants with atypical HNNE findings, 24/25 perinatal asphyxia without HIE cases, 5/6 HIE1 cases and all 10 HIE2 cases showed atypical findings in the HINE. The HINE identified atypical spontaneous movements significantly more often in infants with white matter T2 hyperintensity. Conclusion In this cohort, most infants with perinatal asphyxia, with or without HIE, presented atypical neurological findings in sequential examinations. The profile of neurological findings for children with perinatal asphyxia without HIE resembled that of children with HIE. White matter T2 hyperintensity was associated with atypical spontaneous movements in the HINE and was a frequent MRI finding also in perinatal asphyxia without HIE.
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Affiliation(s)
- Anna Tuiskula
- BABA Center Pediatric Research Center Department of Pediatrics, Children's Hospital Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Marjo Metsäranta
- Department of Neonatology, Children's Hospital BABA Center Pediatric Research Center Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Sanna Toiviainen‐Salo
- Department of Pediatric Radiology, Radiology, HUS Diagnostic Center BABA Center Pediatric Research Center Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, Children's Hospital BABA Center Pediatric Research Center Neuroscience Center, Helsinki Institute of Life Science Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Leena Haataja
- Department of Pediatric Neurology, Children's Hospital BABA Center Pediatric Research Center Helsinki University Hospital and University of Helsinki Helsinki Finland
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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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McDouall A, Wassink G, Bennet L, Gunn AJ, Davidson JO. Challenges in developing therapeutic strategies for mild neonatal encephalopathy. Neural Regen Res 2022; 17:277-282. [PMID: 34269188 PMCID: PMC8464003 DOI: 10.4103/1673-5374.317963] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
There is increasing evidence that infants with mild neonatal encephalopathy (NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.
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Affiliation(s)
- Alice McDouall
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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Falsaperla R, Sciuto S, Gioè D, Sciuto L, Pisani F, Pavone P, Ruggieri M. Mild Hypoxic-Ischemic Encephalopathy: Can Neurophysiological Monitoring Predict Unfavorable Neurological Outcome? A Systematic Review and Meta-analysis. Am J Perinatol 2021; 40:833-838. [PMID: 34666398 DOI: 10.1055/s-0041-1736593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Hypoxic-ischemic encephalopathy (HIE) is the second cause of neonatal deaths and one of the main conditions responsible for long-term neurological disability. Contrary to past belief, children with mild HIE can also experience long-term neurological sequelae. The aim of this systematic review is to determine the predictive value of long-term neurological outcome of (electroencephalogram) EEG/amplitude-integrated electroencephalogram (aEEG) in children who complained mild HIE. STUDY DESIGN From a first search on PubMed, Google Scholar, and clinicalTrials.gov databases, only five articles were considered suitable for this study review. A statistical meta-analysis with the evaluation of odds ratio was performed on three of these studies. RESULTS No correlation was found between the characteristics of the electrical activity of the brain obtained through EEG/aEEG in infants with mild HIE and subsequent neurological involvement. CONCLUSION EEG/aEEG monitoring in infants with mild HIE cannot be considered a useful tool in predicting their neurodevelopmental outcome, and its use for this purpose is reported as barely reliable. KEY POINTS · Hypoxic-Ischemic Encephalopathy is responsible for long-term neurological outcome, even in newborns with mild HIE.. · No correlation was found between EEG/aEEG trace in infants with mild HIE and neurological sequelae.. · Neurophysiological monitoring, in mild HIE, cannot predic neurodevelopmental outcome..
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Affiliation(s)
- Raffaele Falsaperla
- Division of Pediatrics and Pediatric Emergency, University Hospital Policlinico "Rodolico-San Marco," Catania, Italy.,Division of Neonatal Intensive Care and Neonatology, University Hospital Policlinico "Rodolico-San Marco," Catania, Italy
| | - Sarah Sciuto
- Division of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, Pediatrics Postgraduate Residency Program, University of Catania, Catania, Italy
| | - Daniela Gioè
- Division of Pediatrics, Hospital of Lentini, Lentini, Italy
| | - Laura Sciuto
- Division of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, Pediatrics Postgraduate Residency Program, University of Catania, Catania, Italy
| | - Francesco Pisani
- Division of Pediatrics, University Hospital of Children "Pietro Barilla," Parma, Italy
| | - Piero Pavone
- Division of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Division of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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Buchiboyina A, Yip CSA, Mehta S. Cooling infants with mild hypoxic ischaemic encephalopathy- Do we have the evidence? J Matern Fetal Neonatal Med 2021; 35:8511-8513. [PMID: 34612151 DOI: 10.1080/14767058.2021.1986481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ashok Buchiboyina
- Department of Neonatology, Fiona Stanley Hospital, Murdoch, Western, Australia.,Curtin Medical School, Curtin University, Bentley, Western, Australia.,School of Medicine, University Notre Dame Australia, Fremantle, Western, Australia
| | - Chi Seong Andrew Yip
- Department of General Paediatrics, Perth Children's Hospital, Nedlands, Western Australia
| | - Shailender Mehta
- Department of Neonatology, Fiona Stanley Hospital, Murdoch, Western, Australia.,Curtin Medical School, Curtin University, Bentley, Western, Australia.,School of Medicine, University Notre Dame Australia, Fremantle, Western, Australia
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Wisnowski JL, Wintermark P, Bonifacio SL, Smyser CD, Barkovich AJ, Edwards AD, de Vries LS, Inder TE, Chau V. Neuroimaging in the term newborn with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101304. [PMID: 34736808 PMCID: PMC9135955 DOI: 10.1016/j.siny.2021.101304] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neuroimaging is widely used to aid in the diagnosis and clinical management of neonates with neonatal encephalopathy (NE). Yet, despite widespread use clinically, there are few published guidelines on neuroimaging for neonates with NE. This review outlines the primary patterns of brain injury associated with hypoxic-ischemic injury in neonates with NE and their frequency, associated neuropathological features, and risk factors. In addition, it provides an overview of neuroimaging methods, including the most widely used scoring systems used to characterize brain injury in these neonates and their utility as predictive biomarkers. Last, recommendations for neuroimaging in neonates with NE are presented.
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Affiliation(s)
- Jessica L. Wisnowski
- Departments of Radiology and Pediatrics (Neonatology), Children’s Hospital Los Angeles, 4650 Sunset Blvd. MS #81, Los Angeles CA 90027, USA
| | - Pia Wintermark
- Department of Pediatrics (Neonatology), McGill University/Montreal Children's Hospital, Division of Newborn Medicine, Research Institute of the McGill University Health Centre, 1001 boul. Décarie, Site Glen Block E, EM0.3244, Montréal, QC H4A 3J1, Canada.
| | - Sonia L. Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics (Neonatology), Lucile Packard Children’s Hospital, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA 94304, USA
| | - Christopher D. Smyser
- Departments of Neurology, Radiology, and Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110-1093, USA
| | - A. James Barkovich
- Department of Radiology, UCSF Benioff Children’s Hospital, University of California San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - A. David Edwards
- Evelina London Children’s Hospital, Centre for Developing Brain, King’s College London, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Linda S. de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Vann Chau
- Department of Pediatrics (Neurology), The Hospital for Sick Children, University of Toronto, 555 University Avenue, Room 6513, Toronto, ON M5G 1X8, Canada.
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Kota S, Jasti K, Liu Y, Liu H, Zhang R, Chalak L. EEG Spectral Power: A Proposed Physiological Biomarker to Classify the Hypoxic-Ischemic Encephalopathy Severity in Real Time. Pediatr Neurol 2021; 122:7-14. [PMID: 34243047 DOI: 10.1016/j.pediatrneurol.2021.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/16/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mild hypoxic-ischemic encephalopathy (HIE) constitutes a large unstudied population with considerable debate on how to define and treat due to the dynamic evolution of the clinical signs of encephalopathy. We propose to address this gap with quantitative physiological biomarkers to aid in stratification of the disease severity. The objectives of this prospective cohort study were to measure the electroencephalographic (EEG) power as an objective biomarker of the evolution of the clinical encephalopathy in newborns with mild to severe HIE. METHODS EEG was collected in infants with HIE using four bipolar electrodes analyzed for the first three hours of the recording. Delta power (DP, 0.5 to 4 Hz) and total power (TP, 0.5 to 20 Hz) were compared between groups with different HIE severity using a univariate ordinal logistic regression model and receiver operating characteristic curves. RESULTS A total of 44 term-born infants with mild to severe HIE were identified within six hours of birth. The DP and TP values were significantly higher for the mild group than for the moderate group for all bipolar electrodes. A one-unit increase in DP was associated with significantly lower odds of encephalopathy. DP best distinguished mild from higher encephalopathy grades by area under the curve. CONCLUSIONS We conclude that DP and TP are sensitive real-time biomarkers for monitoring the dynamic evolution of the encephalopathy severity in the first day of life. The quantitative EEG power may lead to timely recognition of the worsening of the encephalopathy and guide future therapeutic interventions targeting mild HIE.
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Affiliation(s)
- Srinivas Kota
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kaushik Jasti
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
| | - Rong Zhang
- Departments of Neurology and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
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Garcia-Alix A, Arnaez J, Arca G, Agut T, Alarcon A, Martín-Ancel A, Girabent-Farres M, Valverde E, Benavente-Fernández I. Development, Reliability, and Testing of a New Rating Scale for Neonatal Encephalopathy. J Pediatr 2021; 235:83-91.e7. [PMID: 33857465 DOI: 10.1016/j.jpeds.2021.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To develop and test the Neonatal Encephalopathy-Rating Scale (NE-RS), a new rating scale to grade the severity of neonatal encephalopathy (NE) within the first 6 hours after birth. STUDY DESIGN A 3-phase process was conducted: (1) design of a comprehensive scale that would be specific, sensitive, brief, and unsophisticated; (2) evaluation in a cohort of infants with neonatal encephalopathy and healthy controls; and (3) validation with brain magnetic resonance imaging findings and outcome at 2 years of age. RESULTS We evaluated the NE-RS in 54 infants with NE and 28 healthy infants. The NE-RS had excellent internal consistency (Cronbach alpha coefficient: 0.93 [95% CI 0.86-0.94]) and reliability (intraclass correlation coefficient in the NE cohort 0.996 [95% CI 0.993-0.998; P < .001]). Alertness, posture, motor response, and spontaneous activity were the top discriminators for degrees of NE. The cut-off value for mild vs moderate NE was 8 points (area under the curve [AUC] 0.99, 95% CI 0.85-1.00) and for moderate vs severe NE, 30 points (AUC 0.93, 95% CI 0.81-0.99). The NE-RS was significantly correlated with the magnetic resonance imaging score (Spearman Rho 0.77, P < .001) and discriminated infants who had an adverse outcome (AUC 0.91, 95% CI 0.83-0.99, sensitivity 0.82, specificity 0.81, positive predictive value 0.87, negative predictive value 0.74). CONCLUSIONS The NE-RS is reliable and performs well in reflecting the severity of NE within the first 6 hours after birth. This tool could be useful when assessing clinical criteria for therapeutic hypothermia in NE.
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Affiliation(s)
- Alfredo Garcia-Alix
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain; NeNe Foundation, Madrid, Spain.
| | - Juan Arnaez
- NeNe Foundation, Madrid, Spain; Hospital Universitario de Burgos, Burgos, Spain
| | - Gemma Arca
- NeNe Foundation, Madrid, Spain; Hospital Clínic (Maternitat)-IDIBAPS, Barcelona, Spain
| | - Thais Agut
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain; NeNe Foundation, Madrid, Spain
| | - Ana Alarcon
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Ana Martín-Ancel
- Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Montserrat Girabent-Farres
- Department of Physioterapy, School of Health Sciences, TecnoCampus-Pompeu Fabra University, Mataró, Barcelona, Spain
| | - Eva Valverde
- NeNe Foundation, Madrid, Spain; Hospital Universitario La Paz, Madrid, Spain
| | - Isabel Benavente-Fernández
- NeNe Foundation, Madrid, Spain; Hospital Puerta del Mar, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cádiz, Spain
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Kumar V, Singla M, Thayyil S. Cooling in mild encephalopathy: Costs and perils of therapeutic creep. Semin Fetal Neonatal Med 2021; 26:101244. [PMID: 33849797 DOI: 10.1016/j.siny.2021.101244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Increasing confidence in therapeutic hypothermia and ambiguity of cooling guidelines has led to many clinicians extending its use to untested populations like mild encephalopathy, or even no encephalopathy. Poor quality clinical neurological examination for encephalopathy staging coupled with a fear of litigation if a baby with mild encephalopathy progress to moderate or severe encephalopathy appears to be the primary driver for this therapeutic creep. Recent data suggesting increased apoptosis with cooling uninjured brains, and lack of hypothermic neuroprotection in partial prolonged hypoxia, implies that such therapeutic creeps may cause more harm than benefit. Currently available preclinical and clinical data do not support the clinical use of therapeutic hypothermia for mild encephalopathy, although phase II clinical trials are ongoing. We recommend that until further evidence from adequately powered randomised controlled trials are available, cooling in mild encephalopathy need to be considered experimental and parental consent should be obtained before providing this therapy.
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Affiliation(s)
- Vijay Kumar
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, UK
| | - Mani Singla
- Newborn Care Centre, Royal Hospital for Women, Barker Street, Randwick, 2031, NSW, Australia
| | - Sudhin Thayyil
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, UK.
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McAdams RM, Berube MW. Emerging therapies and management for neonatal encephalopathy-controversies and current approaches. J Perinatol 2021; 41:661-674. [PMID: 33712717 DOI: 10.1038/s41372-021-01022-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 01/31/2023]
Abstract
Neonatal encephalopathy (NE) continues to have a major impact on newborn survival and neurodevelopmental outcomes worldwide. In high-income settings, therapeutic hypothermia is the only established standard treatment for neonates with moderate-to-severe NE, with compelling evidence that cooling reduces mortality and major neurodevelopmental impairment in survivors. Despite therapeutic hypothermia, a significant proportion of cooled infants continue to suffer long-term disability from brain injury. Innovative therapies offer the possibility of further improving neurodevelopmental outcomes by working synergistically with therapeutic hypothermia to decrease hypoxia-ischemia-induced excitotoxicity, prevent progression to secondary energy failure, and in some cases, promote neuroregeneration in the developing neonatal brain. This review discusses emerging NE therapies currently under investigation, offers insight into controversies surrounding various approaches to clinical care during therapeutic hypothermia, and identifies ongoing knowledge deficits that hinder attainment of optimal outcomes for neonates with NE.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Megan W Berube
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Does mild hypoxic ischemic encephalopathy adversely affect neurodevelopmental outcome? J Perinatol 2021; 41:901-904. [PMID: 33714978 DOI: 10.1038/s41372-021-01026-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 01/27/2021] [Accepted: 02/17/2021] [Indexed: 11/08/2022]
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Carlton K, Cabacungan E, Adams SJ, Cohen SS. Quality improvement for reducing utilization drift in hypoxic-ischemic encephalopathy management. J Perinat Med 2021; 49:389-395. [PMID: 33141108 DOI: 10.1515/jpm-2020-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/15/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines. METHODS A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied. RESULTS We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score. CONCLUSIONS Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies.
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MESH Headings
- Clinical Reasoning
- Documentation/methods
- Documentation/standards
- Eligibility Determination/methods
- Eligibility Determination/standards
- Female
- Humans
- Hypothermia, Induced/methods
- Hypothermia, Induced/statistics & numerical data
- Hypoxia-Ischemia, Brain/epidemiology
- Hypoxia-Ischemia, Brain/therapy
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/therapy
- Intensive Care Units, Neonatal/standards
- Intensive Care Units, Neonatal/statistics & numerical data
- Male
- Practice Guidelines as Topic
- Procedures and Techniques Utilization/statistics & numerical data
- Quality Improvement/organization & administration
- Retrospective Studies
- United States/epidemiology
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Affiliation(s)
| | - Erwin Cabacungan
- Medical College of Wisconsin, Pediatrics, Milwaukee, Wisconsin, USA
| | - Samuel J Adams
- Medical College of Wisconsin, Neurology, Milwaukee, Wisconsin, USA
| | - Susan S Cohen
- Medical College of Wisconsin, Pediatrics, 999 N. 92nd Street, CCC 410, Milwaukee, 53226-0509, Milwaukee, Wisconsin, USA
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Machie M, Weeke L, de Vries LS, Rollins N, Brown L, Chalak L. MRI Score Ability to Detect Abnormalities in Mild Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2021; 116:32-38. [PMID: 33412459 PMCID: PMC8087244 DOI: 10.1016/j.pediatrneurol.2020.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) scores have been well validated in moderate/severe hypoxic-ischemic encephalopathy (HIE). Infants with mild HIE can have different patterns of injury, yet different scores have not been compared in this group of infants. Our objective was to compare the ability of three = MRI scores to detect abnormalities in infants with mild HIE, and infants with moderate/severe HIE were included for comparison. METHODS This is a single-center prospective cohort study of infants ≥36 weeks' gestation with HIE born at a level III neonatal intensive care unit from 2017 to 2019. All infants with HIE underwent an MRI, but only infants with moderate/severe HIE underwent therapeutic hypothermia. At least two experienced MRI readers who were unaware of all clinical variables independently assigned three scores (Barkovich, NICHD NRN, and Weeke). RESULTS A total of 42 newborns with varying HIE severity underwent MRI on day five of life. In the overall cohort, abnormalities were reported in three (7%) infants using the Barkovich, in 10 (24%) using the NICHD NRN, and in 24 (57%) using the Weeke score. Agreement was excellent for each score: Barkovich score (k = 1.0), NICHD NRN (k = 0.92), and Weeke score (k = 0.9). CONCLUSIONS Subtle injury due to mild HIE was detected with the highest frequency using the Weeke score, while inter-rater reliability was excellent for all three scores. These findings suggest that infants with mild HIE and subtle MRI abnormalities may benefit from detailed scoring systems, which is important for studies investigating the benefit of hypothermia in mild HIE.
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Affiliation(s)
- Michelle Machie
- Division of Pediatric Neurology, UT Southwestern Medical Center, Dallas, Texas.
| | - Lauren Weeke
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda S. de Vries
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nancy Rollins
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Larry Brown
- Division of Biostatistics and Study Design, Parkland hospital, Dallas, Texas
| | - Lina Chalak
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center, Dallas, Texas.
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Debuf MJ, Carkeek K, Piersigilli F. A Metabolomic Approach in Search of Neurobiomarkers of Perinatal Asphyxia: A Review of the Current Literature. Front Pediatr 2021; 9:674585. [PMID: 34249811 PMCID: PMC8267248 DOI: 10.3389/fped.2021.674585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
Perinatal asphyxia and the possible sequelae of hypoxic-ischemic encephalopathy (HIE), are associated with high morbidity and mortality rates. The use of therapeutic hypothermia (TH) commencing within the first 6 h of life-currently the only treatment validated for the management of HIE-has been proven to reduce the mortality rate and disability seen at follow up at 18 months. Although there have been attempts to identify neurobiomarkers assessing the severity levels in HIE; none have been validated in clinical use to date, and the lack thereof limits the optimal treatment for these vulnerable infants. Metabolomics is a promising field of the "omics technologies" that may: identify neurobiomarkers, help improve diagnosis, identify patients prone to developing HIE, and potentially improve targeted neuroprotection interventions. This review focuses on the current evidence of metabolomics, a novel tool which may prove to be a useful in the diagnosis, management and treatment options for this multifactorial complex disease. Some of the most promising metabolites analyzed are the group of acylcarnitines: Hydroxybutyrylcarnitine (Malonylcarnitine) [C3-DC (C4-OH)], Tetradecanoylcarnitine [C14], L-Palmitoylcarnitine [C16], Hexadecenoylcarnitine [C16:1], Stearoylcarnitine [C18], and Oleoylcarnitine [C18:1]. A metabolomic "fingerprint" or "index," made up of 4 metabolites (succinate × glycerol/(β-hydroxybutyrate × O-phosphocholine)), seems promising in identifying neonates at risk of developing severe HIE.
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Affiliation(s)
- Marie Julie Debuf
- Division of Neonatology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Katherine Carkeek
- Division of Neonatology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Fiammetta Piersigilli
- Division of Neonatology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium
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Garvey AA, Pavel AM, O’Toole JM, Walsh BH, Korotchikova I, Livingstone V, Dempsey EM, Murray DM, Boylan GB. Multichannel EEG abnormalities during the first 6 hours in infants with mild hypoxic-ischaemic encephalopathy. Pediatr Res 2021; 90:117-124. [PMID: 33879847 PMCID: PMC8370873 DOI: 10.1038/s41390-021-01412-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Infants with mild HIE are at risk of significant disability at follow-up. In the pre-therapeutic hypothermia (TH) era, electroencephalography (EEG) within 6 hours of birth was most predictive of outcome. This study aims to identify and describe features of early EEG and heart rate variability (HRV) (<6 hours of age) in infants with mild HIE compared to healthy term infants. METHODS Infants >36 weeks with mild HIE, not undergoing TH, with EEG before 6 hours of age were identified from 4 prospective cohort studies conducted in the Cork University Maternity Services, Ireland (2003-2019). Control infants were taken from a contemporaneous study examining brain activity in healthy term infants. EEGs were qualitatively analysed by two neonatal neurophysiologists and quantitatively assessed using multiple features of amplitude, spectral shape and inter-hemispheric connectivity. Quantitative features of HRV were assessed in both the groups. RESULTS Fifty-eight infants with mild HIE and sixteen healthy term infants were included. Seventy-two percent of infants with mild HIE had at least one abnormal EEG feature on qualitative analysis and quantitative EEG analysis revealed significant differences in spectral features between the two groups. HRV analysis did not differentiate between the groups. CONCLUSIONS Qualitative and quantitative analysis of the EEG before 6 hours of age identified abnormal EEG features in mild HIE, which could aid in the objective identification of cases for future TH trials in mild HIE. IMPACT Infants with mild HIE currently do not meet selection criteria for TH yet may be at risk of significant disability at follow-up. In the pre-TH era, EEG within 6 hours of birth was most predictive of outcome; however, TH has delayed this predictive value. 72% of infants with mild HIE had at least one abnormal EEG feature in the first 6 hours on qualitative assessment. Quantitative EEG analysis revealed significant differences in spectral features between infants with mild HIE and healthy term infants. Quantitative EEG features may aid in the objective identification of cases for future TH trials in mild HIE.
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Affiliation(s)
- Aisling A. Garvey
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Andreea M. Pavel
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - John M. O’Toole
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Brian H. Walsh
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Irina Korotchikova
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M. Dempsey
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M. Murray
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Geraldine B. Boylan
- INFANT Research Centre, Cork, Ireland ,grid.7872.a0000000123318773Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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White YN, Grant PE, Soul JS, Inder T, El-Dib M. Early exit from neonatal therapeutic hypothermia: A single institution experience using MRI to guide decision-making. J Neonatal Perinatal Med 2020; 13:441-447. [PMID: 32417801 DOI: 10.3233/npm-200458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To evaluate the feasibility of a protocol using combined magnetic resonance imaging (MRI), clinical data, and electroencephalogram (EEG) to identify neonates with mild neonatal encephalopathy (NE) treated with therapeutic hypothermia (TH) who are eligible for "early exit". METHODS Retrospective chart review of TH cases at a single Level III NICU over a 5-year period was used to describe the demographic, clinical, and outcome data in neonates that received early exit in contrast to 72 hour TH treatment. RESULTS Two hundred and eight TH cases, including 18 early exit cases (9%) and 9 cases (4%) evaluated for early exit with MRI but continued on 72 hours of TH, were identified. Early exit and 72 hour treatment groups did not differ in demographics or cord gas measures, although early exit neonates had a shorter length of stay (p < 0.05). Consistent with the early exit protocol, no early exit infants had evidence of moderate or severe encephalopathy on EEG or evidence of hypoxic ischemic injury on MRI at 24 hours of life. Neurology follow up between age 1 and 18 months was available for 10 early exit infants, 8 of whom had a normal examination. CONCLUSIONS Early MRI at 24 hours of age, alongside clinical and EEG criteria, is feasible as part of a protocol to identify neonates eligible for early exit from therapeutic hypothermia.
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Affiliation(s)
- Y N White
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - P E Grant
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - J S Soul
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - T Inder
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - M El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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O'Dea M, Sweetman D, Bonifacio SL, El-Dib M, Austin T, Molloy EJ. Management of Multi Organ Dysfunction in Neonatal Encephalopathy. Front Pediatr 2020; 8:239. [PMID: 32500050 PMCID: PMC7243796 DOI: 10.3389/fped.2020.00239] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.
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Affiliation(s)
- Mary O'Dea
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
| | - Deirdre Sweetman
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mohamed El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eleanor J. Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
- Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland
- Paediatrics, CHI at Tallaght, Tallaght University Hospital, Dublin, Ireland
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45
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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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46
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Is there a role for therapeutic hypothermia administration in term infants with mild neonatal encephalopathy? J Perinatol 2020; 40:522-529. [PMID: 31767982 DOI: 10.1038/s41372-019-0562-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/29/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Identifying term infants presenting with early mild neonatal encephalopathy (NE) as candidates for therapeutic hypothermia (TH) remains unclear. Study objectives were to characterize the neonatal clinical, magnetic resonance imaging (MRI), and longer-term outcome in infants with mild NE treated with TH. STUDY DESIGN Retrospective cohort study of infants admitted with mild or moderate NE treated with TH. Enrollment criteria included a sentinel event, severe acidosis, DR interventions, and low Apgar scores. RESULTS Infants with mild (n = 11) and moderate NE (n = 37) received TH. Mild NE findings included hyperalertness (64%), hypotonia (73%), high level sensory response (91%); 64% progressed to moderate NE. Infants with mild vs. moderate NE had less severe MRI changes (0 vs. 16%) and no cerebral palsy (CP) (0 vs. 13%). CONCLUSIONS Outcomes were favorable with mild NE whereas four infants with moderate NE developed CP. A potential role for TH in this population requires further study.
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47
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Characteristics and short-term outcomes of neonates with mild hypoxic-ischemic encephalopathy treated with hypothermia. J Perinatol 2020; 40:275-283. [PMID: 31723237 DOI: 10.1038/s41372-019-0551-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/07/2019] [Accepted: 10/28/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare the characteristics and outcomes of neonates with mild hypoxic-ischemic encephalopathy (HIE) who received hypothermia versus standard care. STUDY DESIGN We conducted a retrospective cohort study of neonates ≥35 weeks' gestation and ≥1800 g admitted with a diagnosis of Sarnat stage 1 encephalopathy. We evaluated length of hospital stay, duration of ventilation, evidence of brain injury on MRI, and neonatal morbidities. RESULTS Of 1089 eligible neonates, 393 (36%) received hypothermia and 595 (55%) had neuroimaging. The hypothermia group was more likely to be outborn, born via C-section, had lower Apgar scores, and required extensive resuscitation. They had longer durations of stay (9 vs. 6 days, P < 0.001), respiratory support (3 vs. 2 days, P < 0.001), but lower odds of brain injury on MRI (adjusted odds ratio 0.33, 95% CI: 0.22-0.52) compared with standard care group. CONCLUSION Despite prolongation of hospital stay, hypothermia may be potentially beneficial in neonates with mild HIE; however, selection bias cannot be ruled out.
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48
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Chalak LF, Adams-Huet B, Sant'Anna G. A Total Sarnat Score in Mild Hypoxic-ischemic Encephalopathy Can Detect Infants at Higher Risk of Disability. J Pediatr 2019; 214:217-221.e1. [PMID: 31301853 DOI: 10.1016/j.jpeds.2019.06.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/31/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
Abstract
To define mild hypoxic-ischemic encephalopathy and distinguish infants at risk of disability in the first 6 hours, this study stratified risk of disability by using early neurologic examination findings of infants enrolled in the Prospective Research for Infants with Mild Encephalopathy cohort. A total Sarnat score of ≥5 when performed at <6 hours of age detected future disability. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01747863.
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Affiliation(s)
- Lina F Chalak
- University of Texas Southwestern Medical Center, Dallas, TX.
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49
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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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50
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Wilson LA, Fell DB, Hawken S, Wong CA, Murphy MSQ, Little J, Potter BK, Walker M, Lacaze-Masmonteil T, Juul S, Chakraborty P, Wilson K. Association between newborn screening analytes and hypoxic ischemic encephalopathy. Sci Rep 2019; 9:15704. [PMID: 31673070 PMCID: PMC6823438 DOI: 10.1038/s41598-019-51919-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/10/2019] [Indexed: 01/04/2023] Open
Abstract
Hypoxic ischemic encephalopathy (HIE) is a major cause of neonatal mortality and morbidity. Our study sought to examine whether patterns of newborn screening analytes differed between infants with and without neonatal HIE in order to identify opportunities for potential use of these analytes for diagnosis in routine clinical practice. We linked a population-based newborn screening registry with health databases to identify cases of HIE among term infants (≥37 weeks' gestation) in Ontario from 2010-2015. Correlations between HIE and screening analytes were examined using multivariable logistic regression models containing clinical factors and individual screening analytes (acyl-carnitines, amino acids, fetal-to-adult hemoglobin ratio, endocrine markers, and enzymes). Among 731,841 term infants, 3,010 were diagnosed with HIE during the neonatal period. Multivariable models indicated that clinical variables alone or in combination with hemoglobin values were not associated with HIE diagnosis. Although the model was improved after adding acyl-carnitines and amino acids, the ability of the model to identify infants with HIE was moderate. Our findings indicate that analytes associated with catabolic stress were altered in infants with HIE; however, future research is required to determine whether amino acid and acyl-carnitine profiles could hold clinical utility in the early diagnosis or clinical management of HIE. In particular, further research should examine whether cord blood analyses can be used to identify HIE within a clinically useful timeframe or to guide treatment and predict long-term health outcomes.
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Affiliation(s)
- Lindsay A Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Deshayne B Fell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa Ontario, Canada
- ICES, University of Ottawa, Ottawa Ontario, Canada
| | - Steven Hawken
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada
- ICES, University of Ottawa, Ottawa Ontario, Canada
| | | | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada
| | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada
- ICES, University of Ottawa, Ottawa Ontario, Canada
| | - Mark Walker
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa Ontario, Canada
| | - Thierry Lacaze-Masmonteil
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle Washington, USA
| | - Pranesh Chakraborty
- Department of Pediatrics, University of Ottawa, Ottawa Ontario, Canada
- Newborn Screening Ontario, Children's Hospital of Eastern Ontario, Ottawa Ontario, Canada
| | - Kumanan Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada.
- ICES, University of Ottawa, Ottawa Ontario, Canada.
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