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Ventura GC, Dyshliuk N, Dmytriyeva O, Nordsten MJB, Haugaard MM, Christiansen LI, Thymann T, Sangild PT, Pankratova S. Enteral plasma supports brain repair in newborn pigs after birth asphyxia. Brain Behav Immun 2024; 119:693-708. [PMID: 38677626 DOI: 10.1016/j.bbi.2024.04.032] [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: 12/18/2023] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024] Open
Abstract
Newborns exposed to birth asphyxia transiently experience deficient blood flow and a lack of oxygen, potentially inducing hypoxic-ischaemic encephalopathy and subsequent neurological damage. Immunomodulatory components in plasma may dampen these responses. Using caesarean-delivered pigs as a model, we hypothesized that dietary plasma supplementation improves brain outcomes in pigs exposed to birth asphyxia. Mild birth asphyxia was induced by temporary occlusion of the umbilical cord prior to caesarean delivery. Motor development was assessed in asphyxiated (ASP) and control (CON) piglets using neonatal arousal, physical activity and gait test parameters before euthanasia on Day 4. The ASP pigs exhibited increased plasma lactate at birth, deficient motor skills and increased glial fibrillary acidic protein levels in CSF and astrogliosis in the putamen. The expression of genes related to oxidative stress, inflammation and synaptic functions was transiently altered in the motor cortex and caudate nucleus. The number of apoptotic cells among CTIP2-positive neurons in the motor cortex and striatal medium spiny neurons was increased, and maturation of preoligodendrocytes in the internal capsule was delayed. Plasma supplementation improved gait performance in the beam test, attenuated neuronal apoptosis and affected gene expression related to neuroinflammation, neurotransmission and antioxidants (motor cortex, caudate). We present a new clinically relevant animal model of moderate birth asphyxia inducing structural and functional brain damage. The components in plasma that support brain repair remain to be identified but may represent a therapeutic potential for infants and animals after birth asphyxia.
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Affiliation(s)
- Gemma Chavarria Ventura
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nadiya Dyshliuk
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; National University of Life and Environmental Sciences of Ukraine, Kyiv, Ukraine
| | - Oksana Dmytriyeva
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Jacob Bagi Nordsten
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria Mathilde Haugaard
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Line Iadsatian Christiansen
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Thymann
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Torp Sangild
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics, Odense University Hospital, Odense, Denmark
| | - Stanislava Pankratova
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Fall C, Baer R, Lee H, Chambers C, Bandoli G. Changes in the Treatment and Outcomes of Different Severities of Neonatal Hypoxic Ischemic Encephalopathy in California: A Retrospective Cohort Study. RESEARCH SQUARE 2024:rs.3.rs-4505263. [PMID: 38946954 PMCID: PMC11213227 DOI: 10.21203/rs.3.rs-4505263/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
OBJECTIVE Evaluate the changes in management and outcomes of Californian infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Infants with HIE were identified from a California administrative birth cohort using ICD codes and divided into two epochs, Epoch 1 (2010-2015) and Epoch 2 (2016-2019). Risk ratios (RR) for therapeutic hypothermia (TH) in each epoch and their outcomes were calculated using log-linear regression. RESULTS In this cohort, 4779 infants with HIE were identified. Incidence of HIE in California increased yearly from 0.5/1,000 California births to a peak of 1.5/1,000 births in 2018. The use of TH in infants with mild HIE increased in Epoch 2 compared to Epoch 1. There was no significant difference in outcomes between epochs for infants with mild HIE that received TH. CONCLUSION Significantly more infants with mild HIE received TH since 2015 in California, but no difference in outcomes was found for these patients.
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Proietti J, Boylan GB, Walsh BH. Regional variability in therapeutic hypothermia eligibility criteria for neonatal hypoxic-ischemic encephalopathy. Pediatr Res 2024:10.1038/s41390-024-03184-6. [PMID: 38649726 DOI: 10.1038/s41390-024-03184-6] [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: 12/31/2023] [Revised: 03/13/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
Early induced therapeutic hypothermia represents the cornerstone treatment in neonates with probable hypoxic-ischemic encephalopathy. The selection of patients for treatment usually involves meeting criteria indicating evidence of perinatal hypoxia-ischemia and the presence of moderate or severe encephalopathy. In this review, we highlight the variability that exists between some of the different regional and national eligibility guidelines. Determining the potential presence of perinatal hypoxia-ischemia may require either one, two or three signs amongst history of acute perinatal event, prolonged resuscitation at delivery, abnormal blood gases and low Apgar score, with a range of cutoff values. Clinical neurological exams often define the severity of encephalopathy differently, with varying number of domains required for determining eligibility and blurred interpretation of findings assigned to different severity grades in different systems. The role of early electrophysiological assessment is weighted differently. A clinical implication is that infants may receive different care depending on the location in which they are born. This could also impact epidemiological data, as inference of rates of moderate-severe encephalopathy based on therapeutic hypothermia rates are misleading and influenced by different eligibility methods used. We would advocate that a universally endorsed single severity staging of encephalopathy is vital for standardizing management and neonatal outcome. IMPACT: Variability exists between regional and national therapeutic hypothermia eligibility guidelines for neonates with probable hypoxic-ischemic encephalopathy. Differences are common in both criteria indicating perinatal hypoxia-ischemia and criteria defining moderate or severe encephalopathy. The role of early electrophysiological assessment is also weighted unequally. This reflects in different individual care and impacts research data. A universally endorsed single severity staging of encephalopathy would be crucial for standardizing management.
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Affiliation(s)
- Jacopo Proietti
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Engineering for Innovation Medicine, Innovation Biomedicine section, University of Verona, Verona, Italy
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Brian H Walsh
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
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El-Dib M, El-Shibiny H, Walsh B, Cherkerzian S, Boulanger J, Bates SV, Culic I, Gupta M, Hansen A, Herzberg E, Joung K, Keohane C, Patrizi S, Soul JS, Inder T. Establishing a regional registry for neonatal encephalopathy: impact on identification of gaps in practice. Pediatr Res 2024; 95:213-222. [PMID: 37553453 DOI: 10.1038/s41390-023-02763-3] [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: 01/21/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of a malpractice insurance patient safety organization. A NE registry was also established to include 14 centers representing around 50% of deliveries in the state of Massachusetts. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects. METHODS This manuscript reports on the establishment of the registry and the primary findings to date. RESULTS From 2018 to 2020, 502 newborns with NE were evaluated for Therapeutic Hypothermia (TH), of which 246 (49%) received TH, representing a mean of 2.91 per 1000 live births. The study reports on prenatal characteristics, delivery room resuscitation, TH eligibility screening, and post-natal management of newborns with NE who did and did not receive TH. CONCLUSIONS The registry has allowed for the identification of areas of variation in clinical practices, which have guided ongoing quality improvement projects. The authors advocate for the establishment of local and regional registries to standardize and improve NE patient care. They have made the registry data collection tools freely available for other centers to replicate this work. IMPACT Malpractice insurance companies can take an active role in supporting clinicians in establishing clinical practice guidelines and regional registries. Establishing a collaborative regional neonatal encephalopathy (NE) registry is feasible. Data Collection tools for a NE registry have been made publicly available to be adopted and replicated by other groups. Establishing a regional NE registry allowed for the identification of gaps in knowledge, variations in practice, and the opportunity to advance care through quality improvement projects.
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Affiliation(s)
- Mohamed El-Dib
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Hoda El-Shibiny
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian Walsh
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Sara Cherkerzian
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jason Boulanger
- Department of Patient Safety, CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, MA, USA
| | - Sara V Bates
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
| | - Ivana Culic
- Department of Neonatology, Beth Israel Hospital, Boston, MA, USA
- Department of Pediatrics, Beverley Hospital, Boston, MA, USA
| | - Munish Gupta
- Harvard Medical School, Boston, MA, USA
- Department of Neonatology, Beth Israel Hospital, Boston, MA, USA
| | - Anne Hansen
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Emily Herzberg
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
| | - Kyoung Joung
- Division of Newborn Medicine, Mass General Hospital for Children, Boston, MA, USA
- Department of Pediatrics, St. Elizabeth Medical Center, Brighton, MA, USA
| | - Carol Keohane
- Senior Vice President, Chief Quality and Safety Officer, South Shore Health, South Weymouth, MA, USA
| | - Silvia Patrizi
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Newton Wellesley Hospital, Wellesley, MA, USA
| | - Janet S Soul
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Terrie Inder
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Center for Neonatal Research, Children's Hospital of Orange County, Orange County, CA, USA
- University of California, Irvine - College of Medicine, Irvine, CA, USA
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5
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Molloy EJ, Branagan A, Hurley T, Quirke F, Devane D, Taneri PE, El-Dib M, Bloomfield FH, Maeso B, Pilon B, Bonifacio SL, Wusthoff CJ, Chalak L, Bearer C, Murray DM, Badawi N, Campbell S, Mulkey S, Gressens P, Ferriero DM, de Vries LS, Walker K, Kay S, Boylan G, Gale C, Robertson NJ, D'Alton M, Gunn A, Nelson KB. Neonatal encephalopathy and hypoxic-ischemic encephalopathy: moving from controversy to consensus definitions and subclassification. Pediatr Res 2023; 94:1860-1863. [PMID: 37573378 DOI: 10.1038/s41390-023-02775-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 08/14/2023]
Affiliation(s)
- Eleanor J Molloy
- Discipline of Paediatrics, Trinity College Dublin, the University of Dublin, Dublin, Ireland.
- Trinity Translational Medicine Institute (TTMI), St James Hospital & Trinity Research in Childhood Centre (TRiCC), Dublin, Ireland.
- Neurodisability, Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Paediatrics, The Coombe Hospital, Dublin, Ireland.
| | - Aoife Branagan
- Discipline of Paediatrics, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Trinity Translational Medicine Institute (TTMI), St James Hospital & Trinity Research in Childhood Centre (TRiCC), Dublin, Ireland
- Paediatrics, The Coombe Hospital, Dublin, Ireland
- Health Research Board Neonatal Encephalopathy PhD Training Network (NEPTuNE), Dublin, Ireland
| | - Tim Hurley
- Discipline of Paediatrics, Trinity College Dublin, the University of Dublin, Dublin, Ireland
- Trinity Translational Medicine Institute (TTMI), St James Hospital & Trinity Research in Childhood Centre (TRiCC), Dublin, Ireland
- Health Research Board Neonatal Encephalopathy PhD Training Network (NEPTuNE), Dublin, Ireland
| | - Fiona Quirke
- Health Research Board Neonatal Encephalopathy PhD Training Network (NEPTuNE), Dublin, Ireland
- Health Research Board-Trials Methodology Research Network (HRB-TMRN), University of Galway, Galway, Ireland
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Declan Devane
- Health Research Board-Trials Methodology Research Network (HRB-TMRN), University of Galway, Galway, Ireland
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
- Evidence Synthesis Ireland, University of Galway, Galway, Ireland
- Cochrane Ireland, University of Galway, Galway, Ireland
| | - Petek E Taneri
- Health Research Board-Trials Methodology Research Network (HRB-TMRN), University of Galway, Galway, Ireland
- School of Nursing and Midwifery, University of Galway, Galway, Ireland
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Beccy Maeso
- James Lind Alliance, School of Healthcare Enterprise and Innovation, University of Southampton, Southampton, UK
| | | | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Lina Chalak
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Deirdre M Murray
- INFANT Research Centre, Cork, Ireland
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
- Grace Centre for Newborn Intensive Care, Sydney Children's Hospital Network, The University of Sydney, Westmead, NSW, Australia
| | - Suzann Campbell
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Sarah Mulkey
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Pierre Gressens
- Université Paris Cité, NeuroDiderot, Inserm, F-75019, Paris, France
| | - Donna M Ferriero
- Department of Pediatrics and Neurology, University of California San Francisco, Weill Institute for Neurosciences, San Francisco, CA, 94158, USA
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karen Walker
- Department of Newborn Care, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | | | - Geraldine Boylan
- INFANT Research Centre, Cork, Ireland
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Chelsea and Westminster Campus, Imperial College London, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Alistair Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Karin B Nelson
- National Institutes of Health, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
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Wang Z, Zhang D, Zhang P, Zhou W, Hu L, Wang L, Cheng G. Safety and efficacy of therapeutic hypothermia in neonates with mild hypoxic-ischemic encephalopathy. BMC Pediatr 2023; 23:530. [PMID: 37884911 PMCID: PMC10601291 DOI: 10.1186/s12887-023-04365-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Though there has been an increase in the number of neonates with hypoxic-ischemic encephalopathy (HIE) treated by therapeutic hypothermia (TH) in recent years, the effect of therapeutic hypothermia on mild HIE neonates is still uncertain. OBJECTIVES This study aims to explore the safety and efficacy of therapeutic hypothermia in neonates with mild HIE. METHODS Retrospectively collected between January 2010 to December 2022 at Children's Hospital of Fudan University, neonates with mild HIE were divided into TH and non-TH groups. Clinical data of the mild HIE neonates and their mothers' general information during pregnancy were collected. SPSS 23.0 was used to compare the general condition, the incidence of adverse events, and efficacy in the two groups. RESULTS A total of 71 neonates with mild HIE were included, including 31 in the TH group and 40 in the non-TH group. Compared with the non-TH group, the TH group had significantly lower 5-minute Apgar scores [6 (5-7) points vs. 7 (5-8) points, p = 0.033 ], but a higher rate of tracheal intubation at birth (68%, 21/31 vs. 40%, 16/40, p = 0.02), a higher rate of chest compressions > 30 s (39%, 12/31 vs. 15%, 6/40, p = 0.023), the later initiation enteral feeding [4 (3-4) days vs. 1 (1-2) days, p < 0.001], a higher usage rate of analgesic and sedative drugs (45%, 14/31 vs. 18%, 7/40, p = 0.011) and the longer hospital stay [12.5 (11-14) days vs. 9 (7-13.9) days, p = 0.003]. There was no death in 71 mild HIE neonates. TH group had lower incidence of brain injury (16%, 5/31 vs. 43%, 17/40, p = 0.017) and encephalopathy progression (10%, 3/31 vs. 45%, 18/40, p = 0.001) than the non-TH group. There was no statistical significance in the incidence of adverse events between the two groups. CONCLUSION Therapeutic hypothermia can reduce the incidence of brain injury in neonates with mild HIE.
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Affiliation(s)
- Zheng Wang
- Department of Neonatology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201600, China
| | - Dan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Liyuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Guoqiang Cheng
- Department of Fujian Key Laboratory of Neonatal Diseases, Xiamen Key Laboratory of Neonatal Diseases, Fujian, 361000, China.
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7
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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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8
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Sutin J, Vyas R, Feldman HA, Ferradal S, Hsiao CH, Zampolli L, Pierce LJ, Nelson CA, Morton SU, Hay S, El-Dib M, Soul JS, Lin PY, Grant PE. Association of cerebral metabolic rate following therapeutic hypothermia with 18-month neurodevelopmental outcomes after neonatal hypoxic ischemic encephalopathy. EBioMedicine 2023; 94:104673. [PMID: 37392599 PMCID: PMC10338207 DOI: 10.1016/j.ebiom.2023.104673] [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: 01/12/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is standard of care for moderate to severe neonatal hypoxic ischemic encephalopathy (HIE) but many survivors still suffer lifelong disabilities and benefits of TH for mild HIE are under active debate. Development of objective diagnostics, with sensitivity to mild HIE, are needed to select, guide, and assess response to treatment. The objective of this study was to determine if cerebral oxygen metabolism (CMRO2) in the days after TH is associated with 18-month neurodevelopmental outcomes as the first step in evaluating CMRO2's potential as a diagnostic for HIE. Secondary objectives were to compare associations with clinical exams and characterise the relationship between CMRO2 and temperature during TH. METHODS This was a prospective, multicentre, observational, cohort study of neonates clinically diagnosed with HIE and treated with TH recruited from the tertiary neonatal intensive care units (NICUs) of Boston Children's Hospital, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center between December 2015 and October 2019 with follow-up to 18 months. In total, 329 neonates ≥34 weeks gestational age admitted with perinatal asphyxia and suspected HIE were identified. 179 were approached, 103 enrolled, 73 received TH, and 64 were included. CMRO2 was measured at the NICU bedside by frequency-domain near-infrared and diffuse correlation spectroscopies (FDNIRS-DCS) during the late phases of hypothermia (C), rewarming (RW) and after return to normothermia (NT). Additional variables were body temperature and clinical neonatal encephalopathy (NE) scores, as well as findings from magnetic resonance imaging (MRI) and spectroscopy (MRS). Primary outcome was the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) at 18 months, normed (SD) to 100 (15). FINDINGS Data quality for 58 neonates was sufficient for analysis. CMRO2 changed by 14.4% per °C (95% CI, 14.2-14.6) relative to its baseline at NT while cerebral tissue oxygen extraction fraction (cFTOE) changed by only 2.2% per °C (95% CI, 2.1-2.4) for net changes from C to NT of 91% and 8%, respectively. Follow-up data for 2 were incomplete, 33 declined and 1 died, leaving 22 participants (mean [SD] postnatal age, 19.1 [1.2] month; 11 female) with mild to moderate HIE (median [IQR] NE score, 4 [3-6]) and 21 (95%) with BSID-III scores >85 at 18 months. CMRO2 at NT was positively associated with cognitive and motor composite scores (β (SE) = 4.49 (1.55) and 2.77 (1.00) BSID-III points per 10-10 moL/dl × mm2/s, P = 0.009 and P = 0.01 respectively; linear regression); none of the other measures were associated with the neurodevelopmental outcomes. INTERPRETATION Point of care measures of CMRO2 in the NICU during C and RW showed dramatic changes and potential to assess individual response to TH. CMRO2 following TH outperformed conventional clinical evaluations (NE score, cFTOE, and MRI/MRS) at predicting cognitive and motor outcomes at 18 months for mild to moderate HIE, providing a promising objective, physiologically-based diagnostic for HIE. FUNDING This clinical study was funded by an NIH grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, United States (R01HD076258).
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Affiliation(s)
- Jason Sutin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
| | - Rutvi Vyas
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Henry A Feldman
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Pediatrics, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Silvina Ferradal
- Department of Intelligent Systems Engineering, Indiana University Bloomington, 107 S Indiana Ave., Bloomington, IN 47405, USA
| | - Chuan-Heng Hsiao
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Lucca Zampolli
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Lara J Pierce
- Department of Psychology, York University, 198 York Blvd., North York, ON M3J 2S5, Canada
| | - Charles A Nelson
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Sarah U Morton
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Susanne Hay
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Neonatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA
| | - Mohamed El-Dib
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, USA
| | - Janet S Soul
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Neurology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Pei-Yi Lin
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Patricia E Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA; Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
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9
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Thiim KR, Garvey AA, Singh E, Walsh B, Inder TE, El-Dib M. Brain Injury in Infants Evaluated for, But Not Treated with, Therapeutic Hypothermia. J Pediatr 2023; 253:304-309. [PMID: 36179889 DOI: 10.1016/j.jpeds.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/30/2022]
Abstract
Defining neonatal encephalopathy clinically to qualify for therapeutic hypothermia is challenging. This study examines magnetic resonance imaging outcomes of 39 infants who were evaluated and not cooled using criteria inclusive of mild encephalopathy. Infants evaluated for therapeutic hypothermia are at risk for brain injury and may benefit from neuroimaging and follow-up.
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Affiliation(s)
- Kirsten R Thiim
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aisling A Garvey
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Harvard Medical School, Boston, MA
| | - Elizabeth Singh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA
| | - Brian Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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10
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Beck J, Debillon T, Guellec I, Vilotitch A, Loron G, Bednarek N, Ancel PY, Pierrat V, Ego A. Healthcare organizational factors associated with delayed therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: the LyTONEPAL cohort. Eur J Pediatr 2023; 182:181-190. [PMID: 36269426 DOI: 10.1007/s00431-022-04666-7] [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: 09/01/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 01/12/2023]
Abstract
Initiation of therapeutic hypothermia (TH) within 6 h of life is a major concern for treating neonatal hypoxic ischemic encephalopathy (HIE). We aimed to determine clinical and healthcare organizational factors associated with delayed TH in a French population-based cohort of neonates with moderate/severe HIE. Time to reach a rectal temperature of 34 °C defines optimal and delayed (within and over 6 h, respectively) TH. Clinical and healthcare organizational factors associated with delayed TH were analysed among neonates born in cooling centres (CCs) and non-cooling centres (non-CCs). Among 629 neonates eligible for TH, 574 received treatment (91.3%). TH was delayed in 29.8% neonates and in 20.3% and 36.2% of those born in CCs and non-CCs, respectively. Neonates with moderate HIE were more exposed to delayed TH in both CCs and non-CCs. After adjustment for HIE severity, maternal and neonatal characteristics and circumstances of birth were not associated with increased risk of delayed TH. However, this risk was 2 to 5 times higher in maternities with < 1999 annual births, when the delay between birth and call for transfer (adjusted odds ratio [aOR] 2.47, 95% confidence interval [CI] [1.03 to 5.96]) or between call for transfer and admission (aOR 6.06, 95%CI [2.60 to 14.12]) was > 3 h and when an undesirable event occurred during transfer (aOR 2.66, 95%CI [1.11 to 6.37]. Conclusion: Increasing early identification of neonates who could benefit from TH and access to TH in non-CCs before transfer are modifiable factors that could improve care of neonates with HIE. Trial registration: The trial was registered at ClinicalTrials.gov (NCT02676063). What is Known: • International recommendations are to initiate therapeutic hypothermia before 6 h of life in neonates with moderate or severe hypoxic ischemic encephalopathy. What is New: •In this French population-based cohort of infants with hypoxic ischemic encephalopathy, nearly one-third of neonates eligible for treatment did not have access to hypothermia in the therapeutic window of 6 h of life. . • Among infants born in non-cooling centres, healthcare organizational factors involved in delayed care were the small size of maternities (1999 annual births), a time interval of more than 3 h between birth and call for transfer and between call for transfer and admission in neonatology, and the occurrence of an undesirable event during transfer.
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Affiliation(s)
- Jonathan Beck
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, 75004, Paris, France.
- Department of Neonatology, Reims University Hospital Alix de Champagne, Reims, France.
| | - Thierry Debillon
- Univ. Grenoble Alpes, CNRS, Neonatal Intensive Care Unit Grenoble Alpes University Hospital, Grenoble INP Institute of Engineering Univ. Grenoble Alpes, TIMC-IMAG, 38000, Grenoble, France
| | - Isabelle Guellec
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, 75004, Paris, France
- Neonatal Intensive Care Unit, Nice University Hospital, Côte d'Azur University, Nice, France
| | - Antoine Vilotitch
- Center for Clinical Investigation U1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Gauthier Loron
- Department of Neonatology, Reims University Hospital Alix de Champagne, Reims, France
- Université de Reims Champagne Ardenne, 3804, 51097, Reims, CReSTIC EA, France
| | - Nathalie Bednarek
- Department of Neonatology, Reims University Hospital Alix de Champagne, Reims, France
- Université de Reims Champagne Ardenne, 3804, 51097, Reims, CReSTIC EA, France
| | - Pierre-Yves Ancel
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, 75004, Paris, France
- Center for Clinical Investigation P1419, APHP, APHP Centre-Université Paris Cité, 75014, Paris, France
| | - Véronique Pierrat
- Université Paris Cité, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, 75004, Paris, France
- Department of Neonatology, CHI Créteil, Créteil, France
| | - Anne Ego
- Center for Clinical Investigation U1406, Grenoble Alpes University Hospital, Grenoble, France
- Public Health Department, Univ. Grenoble Alpes, CNRS, Grenoble Alpes University Hospital, Grenoble INP Institute of Engineering Univ. Grenoble Alpes, TIMC-IMAG, 38000, Grenoble, France
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11
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Chalak L, Pilon B, Byrne R, Maitre N. Stakeholder engagement in neonatal clinical trials: an opportunity for mild neonatal encephalopathy research. Pediatr Res 2023; 93:4-6. [PMID: 35477747 DOI: 10.1038/s41390-022-02067-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Betsy Pilon
- Hope for HIE, PO Box 250472, West Bloomfield, MI, USA
| | - Rachel Byrne
- CP Foundation West Bloomfield, West Bloomfield, MI, USA
| | - Nathalie Maitre
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
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12
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Glucose-to-lactate ratio and neurodevelopment in infants with hypoxic-ischemic encephalopathy: an observational study. Eur J Pediatr 2023; 182:837-844. [PMID: 36484862 PMCID: PMC9899169 DOI: 10.1007/s00431-022-04694-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/24/2022] [Accepted: 11/05/2022] [Indexed: 12/13/2022]
Abstract
UNLABELLED We aimed to assess the glucose and lactate kinetics during therapeutic hypothermia (TH) in infants with hypoxic-ischemic encephalopathy and its relationship with longitudinal neurodevelopment. We measured glucose and lactate concentrations before TH and on days 2 and 3 in infants with mild, moderate, and severe hypoxic-ischemic encephalopathy (HIE). Neurodevelopment was assessed at 2 years. Participants were grouped according to the neurodevelopmental outcome into favorable (FO) or unfavorable (UFO). Eighty-eight infants were evaluated at follow-up, 34 for the FO and 54 for the UFO group. Severe hypo- (< 2.6 mmol/L) and hyperglycemia (> 10 mmol/L) occurred in 18% and 36% from the FO and UFO groups, respectively. Glucose-to-lactate ratio on day 1 was the strongest predictor of unfavorable metabolic outcome (OR 3.27 [Formula: see text] 1.81, p = 0.032) when adjusted for other clinical and metabolic variables, including Sarnat score. CONCLUSION Glucose-to-lactate ratio on day 1 may represent a new risk marker for infants with HIE undergoing TH. WHAT IS KNOWN • Glucose and lactate are key metabolic fuels during neonatal hypoglycemia. This suggests that their concentrations may influence the neurodevelopmental outcome of neonates experiencing hypoxic-hischemic encephalopathy (HIE). WHAT IS NEW • We describe the relative availbility of glucose and lactate before and during theraputic hypothermia in neonates with HIE.
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13
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Acun C, Karnati S, Padiyar S, Puthuraya S, Aly H, Mohamed M. Trends of neonatal hypoxic-ischemic encephalopathy prevalence and associated risk factors in the United States, 2010 to 2018. Am J Obstet Gynecol 2022; 227:751.e1-751.e10. [PMID: 35690081 DOI: 10.1016/j.ajog.2022.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Despite recent advances in perinatal care, neonatal hypoxic-ischemic encephalopathy remains one of the most common causes of neonatal morbidity and mortality. The trends for prevalence and mortality of neonatal hypoxic-ischemic encephalopathy have not been examined in the era of therapeutic hypothermia in the United States. OBJECTIVE This study aimed to determine (1) the overall and gestational age-specific (35-36, ≥37, and >42 weeks) trends of hypoxic-ischemic encephalopathy prevalence and use of therapeutic hypothermia, (2) the trends of mortality in association with hypoxic-ischemic encephalopathy, (3) the confounding variables associated with hypoxic-ischemic encephalopathy, and (4) the clinical outcomes of neonates with hypoxic-ischemic encephalopathy. STUDY DESIGN This study used National Inpatient Sample datasets from 2010 to 2018. Moreover, the study included infants with a gestational age of ≥35 weeks with a documented hypoxic-ischemic encephalopathy diagnosis (mild, moderate, severe, or unspecified). We calculated trends in hypoxic-ischemic encephalopathy prevalence and the use of therapeutic hypothermia using chi-squared testing. Furthermore, this study used logistic regression models to control for confounders. RESULTS A total of 32,180,617 infants were included, of which 31,249,100 were term (gestational age of ≥37 weeks) and 931,517 were late preterm (gestational age of 35-36 weeks). Hypoxic-ischemic encephalopathy prevalence slightly increased from 0.093% in 2010-2012 to 0.097% in 2016-2018 (P=.01) in term infants and did not significantly change in late preterm infants (P=.20). There were 6235 term infants (20.8%) and 449 late preterm infants (21.1%) with hypoxic-ischemic encephalopathy who were managed with therapeutic hypothermia. The use of therapeutic hypothermia in both term and late preterm infants has increased over the years (P<.01). The mortality rate with hypoxic-ischemic encephalopathy decreased over time from 11.5% to 12.3% between 2010 to 2012, and from 8.3% to 10.6% betweenn 2016 to 2018 (P<.01). The factors with the strongest association with hypoxic-ischemic encephalopathy were placental infarction or insufficiency (odds ratio, 144; 95% confidence interval, 134-157), placental abruption (odds ratio, 101; 95% confidence interval, 91-112), cord prolapse (odds ratio, 74; 95% confidence interval, 65-84), and maternal anemia (odds ratio, 26; 95% confidence interval, 20-37). CONCLUSION Hypoxic-ischemic encephalopathy prevalence in neonates essentially remained the same at 1 per 1000 live births. The use of therapeutic hypothermia increased, and the mortality rate decreased in infants with hypoxic-ischemic encephalopathy. The identification of hypoxic-ischemic encephalopathy-associated factors should promote increased vigilance to optimize newborn outcomes.
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Affiliation(s)
- Ceyda Acun
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH.
| | - Sreenivas Karnati
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Swetha Padiyar
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Subhash Puthuraya
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Mohamed Mohamed
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
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14
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Mahdi Z, Marandyuk B, Desnous B, Liet AS, Chowdhury RA, Birca V, Décarie JC, Tremblay S, Lodygensky GA, Birca A, Pinchefsky EF, Dehaes M. Opioid analgesia and temperature regulation are associated with EEG background activity and MRI outcomes in neonates with mild-to-moderate hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. Eur J Paediatr Neurol 2022; 39:11-18. [PMID: 35598572 DOI: 10.1016/j.ejpn.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/23/2022] [Accepted: 04/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) without sedation may lead to discomfort, which may be associated with adverse consequences in neonates with hypoxic-ischemic encephalopathy (HIE). The aim of this study was to assess the association between level of exposure to opioids and temperature, with electroencephalography (EEG) background activity post-TH and magnetic resonance imaging (MRI) brain injury in neonates with HIE. METHODS Thirty-one neonates with mild-to-moderate HIE who underwent TH were identified. MRIs were reviewed for presence of brain injury. Quantitative EEG background features including EEG discontinuity index and spectral power densities were calculated during rewarming and post-rewarming periods. Dose of opioids administered during TH and temperatures were collected from the medical charts. Multivariable linear and logistic regression analyses were conducted to assess the associations between cumulative dose of opioids and temperature with EEG background and MRI while adjusting for markers of HIE severity. RESULTS Higher opioid doses (β = -0.21, p = 0.02) and reduced skin temperature (β = 0.14, p < 0.01) were associated with lower EEG discontinuity index recorded post-TH. Higher opioid doses (β = 0.75, p = 0.01) and reduced skin temperature (β = -0.39, p = 0.02) were also associated with higher EEG Delta power post-TH. MRI brain injury was observed in 14 patients (45%). In adjusted regression analyses, higher opioid doses (OR = 0.00; 95%CI: 0-0.19; p = 0.01), reduced skin temperature (OR = 41.19; 95%CI: 2.27-747.86; p = 0.01) and reduced cooling device output temperature (OR = 1.91; 95%CI: 1.05-3.48; p = 0.04) showed an association with lower odds of brain injury. CONCLUSIONS Higher level of exposure to opioids and reduced skin temperature during TH in mild-to-moderate HIE were associated with improved EEG background activity post-TH. Moreover, higher exposure to opioids, reduced skin temperature and reduced device output temperature were associated with lower odds of brain injury on MRI.
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Affiliation(s)
- Zamzam Mahdi
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Beatrice Desnous
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Anne-Sophie Liet
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Rasheda Arman Chowdhury
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Veronica Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Jean-Claude Décarie
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Sophie Tremblay
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Gregory Anton Lodygensky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Mathieu Dehaes
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada; Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada.
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15
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Szakmar E, Munster C, El-Shibiny H, Jermendy A, Inder T, El-Dib M. Hypocapnia in early hours of life is associated with brain injury in moderate to severe neonatal encephalopathy. J Perinatol 2022; 42:892-897. [PMID: 35461333 DOI: 10.1038/s41372-022-01398-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the association between hypocapnia within the first 24 h of life and brain injury assessed by a detailed MRI scoring system in infants receiving therapeutic hypothermia (TH) for neonatal encephalopathy (NE) stratified by the stage of NE. STUDY DESIGN This retrospective cohort study included infants who received TH for mild to severe NE. RESULTS 188 infants were included in the study with 48% having mild and 52% moderate-severe NE. Infants with moderate-severe NE spent more time in hypocapnia (PCO2 ≤ 35 mmHg) and presented with more severe brain injury on MRI compared to mild cases. The MRI injury score increased by 6% for each extra hour spent in hypocapnic range in infants with moderate-severe NE. There was no association between hypocapnia and injury scores in mild cases. CONCLUSION In infants with moderate-severe NE, the hours spent in hypocapnia was an independent predictor of brain injury.
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Affiliation(s)
- Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Chelsea Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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16
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McDouall A, Zhou KQ, Bennet L, Green CR, Gunn AJ, Davidson JO. Connexins, Pannexins and Gap Junctions in Perinatal Brain Injury. Biomedicines 2022; 10:biomedicines10061445. [PMID: 35740466 PMCID: PMC9220888 DOI: 10.3390/biomedicines10061445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 11/18/2022] Open
Abstract
Perinatal brain injury secondary to hypoxia-ischemia and/or infection/inflammation remains a major cause of disability. Therapeutic hypothermia significantly improves outcomes, but in randomized controlled trials nearly half of infants still died or survived with disability, showing that additional interventions are needed. There is growing evidence that brain injury spreads over time from injured to previously uninjured regions of the brain. At least in part, this spread is related to opening of connexin hemichannels and pannexin channels, both of which are large conductance membrane channels found in many brain cells. Opening of these membrane channels releases adenosine triphosphate (ATP), and other neuroactive molecules, into the extracellular space. ATP has an important role in normal signaling, but pathologically can trigger the assembly of the multi-protein inflammasome complex. The inflammasome complex promotes activation of inflammatory caspases, and release of inflammatory cytokines. Overall, the connexin hemichannel appears to play a primary role in propagation of injury and chronic disease, and connexin hemichannel blockade has been shown to be neuroprotective in multiple animal models. Thus, there is potential for some blockers of connexin or pannexin channels to be developed into targeted interventions that could be used in conjunction with or separate to therapeutic hypothermia.
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Affiliation(s)
- Alice McDouall
- U1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand; (A.M.); (K.Q.Z.); (L.B.); (A.J.G.)
| | - Kelly Q. Zhou
- U1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand; (A.M.); (K.Q.Z.); (L.B.); (A.J.G.)
| | - Laura Bennet
- U1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand; (A.M.); (K.Q.Z.); (L.B.); (A.J.G.)
| | - Colin R. Green
- Department of Ophthalmology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand;
| | - Alistair J. Gunn
- U1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand; (A.M.); (K.Q.Z.); (L.B.); (A.J.G.)
| | - Joanne O. Davidson
- U1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1023, New Zealand; (A.M.); (K.Q.Z.); (L.B.); (A.J.G.)
- Correspondence:
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17
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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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18
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Jackson TC, Herrmann JR, Garman RH, Kang RD, Vagni VA, Gorse K, Janesko-Feldman K, Stezoski J, Kochanek PM. Hypoxia-ischemia-mediated effects on neurodevelopmentally regulated cold-shock proteins in neonatal mice under strict temperature control. Pediatr Res 2022:10.1038/s41390-022-01990-4. [PMID: 35184138 PMCID: PMC9388702 DOI: 10.1038/s41390-022-01990-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/18/2021] [Accepted: 01/17/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neonates have high levels of cold-shock proteins (CSPs) in the normothermic brain for a limited period following birth. Hypoxic-ischemic (HI) insults in term infants produce neonatal encephalopathy (NE), and it remains unclear whether HI-induced pathology alters baseline CSP expression in the normothermic brain. METHODS Here we established a version of the Rice-Vannucci model in PND 10 mice that incorporates rigorous temperature control. RESULTS Common carotid artery (CCA)-ligation plus 25 min hypoxia (8% O2) in pups with targeted normothermia resulted in classic histopathological changes including increased hippocampal degeneration, astrogliosis, microgliosis, white matter changes, and cell signaling perturbations. Serial assessment of cortical, thalamic, and hippocampal RNA-binding motif 3 (RBM3), cold-inducible RNA binding protein (CIRBP), and reticulon-3 (RTN3) revealed a rapid age-dependent decrease in levels in sham and injured pups. CSPs were minimally affected by HI and the age point of lowest expression (PND 18) coincided with the timing at which heat-generating mechanisms mature in mice. CONCLUSIONS The findings suggest the need to determine whether optimized therapeutic hypothermia (depth and duration) can prevent the age-related decline in neuroprotective CSPs like RBM3 in the brain, and improve outcomes during critical phases of secondary injury and recovery after NE. IMPACT The rapid decrease in endogenous neuroprotective cold-shock proteins (CSPs) in the normothermic cortex, thalamus, and hippocampus from postnatal day (PND) 11-18, coincides with the timing of thermogenesis maturation in neonatal mice. Hypoxia-ischemia (HI) has a minor impact on the normal age-dependent decline in brain CSP levels in neonates maintained normothermic post-injury. HI robustly disrupts the expected correlation in RNA-binding motif 3 (RBM3) and reticulon-3 (RTN3). The potent neuroprotectant RBM3 is not increased 1-4 days after HI in a mouse model of neonatal encephalopathy (NE) in the term newborn and in which rigorous temperature control prevents the manifestation of endogenous post-insult hypothermia.
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Affiliation(s)
- Travis C Jackson
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA.
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA.
| | - Jeremy R Herrmann
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Robert H Garman
- Division of Neuropathology, University of Pittsburgh, 3550 Terrrace Street, Pittsburgh, PA, 15261, USA
| | - Richard D Kang
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA
| | - Vincent A Vagni
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Kiersten Gorse
- University of South Florida Morsani College of Medicine, USF Health Heart Institute, MDD 0630, 560 Channelside Drive, Tampa, FL, 33602, USA
- Department of Molecular Pharmacology & Physiology, University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612-4799, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Jason Stezoski
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center-6th floor, Pittsburgh, PA, 15224, USA
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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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Seitz M, Köster C, Dzietko M, Sabir H, Serdar M, Felderhoff-Müser U, Bendix I, Herz J. Hypothermia modulates myeloid cell polarization in neonatal hypoxic-ischemic brain injury. J Neuroinflammation 2021; 18:266. [PMID: 34772426 PMCID: PMC8590301 DOI: 10.1186/s12974-021-02314-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/01/2021] [Indexed: 01/10/2023] Open
Abstract
Background Neonatal encephalopathy due to hypoxia–ischemia (HI) is a leading cause of death and disability in term newborns. Therapeutic hypothermia (HT) is the only recommended therapy. However, 30% still suffer from neurological deficits. Inflammation is a major hallmark of HI pathophysiology with myeloid cells being key players, participating either in progression or in resolution of injury-induced inflammation. In the present study, we investigated the impact of HT on the temporal and spatial dynamics of microglia/macrophage polarization after neonatal HI in newborn mice. Methods Nine-day-old C57BL/6 mice were exposed to HI through occlusion of the right common carotid artery followed by 1 h hypoxia. Immediately after HI, animals were cooled for 4 h or kept at physiological body core temperature. Analyses were performed at 1, 3 and 7 days post HI. Brain injury, neuronal cell loss, apoptosis and microglia activation were assessed by immunohistochemistry. A broad set of typical genes associated with classical (M1) and alternative (M2) myeloid cell activation was analyzed by real time PCR in ex vivo isolated CD11b+ microglia/macrophages. Purity and composition of isolated cells was determined by flow cytometry. Results Immediate HT significantly reduced HI-induced brain injury and neuronal loss 7 days post HI, whereas only mild non-significant protection from HI-induced apoptosis and neuronal loss were observed 1 and 3 days after HI. Microglia activation, i.e., Iba-1 immunoreactivity peaked 3 days after HI and was not modulated by HT. However, ex vivo isolated CD11b+ cells revealed a strong upregulation of the majority of M1 but also M2 marker genes at day 1, which was significantly reduced by HT and rapidly declined at day 3. HI induced a significant increase in the frequency of peripheral macrophages in sorted CD11b+ cells at day 1, which deteriorated until day 7 and was significantly decreased by HT. Conclusion Our data demonstrate that HT-induced neuroprotection is preceded by acute suppression of HI-induced upregulation of inflammatory genes in myeloid cells and decreased infiltration of peripheral macrophages, both representing potential important effector mechanisms of HT. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-021-02314-9.
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Affiliation(s)
- Marina Seitz
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christian Köster
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Mark Dzietko
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany.,German Centre for Neurodegenerative Diseases, Bonn, Germany
| | - Meray Serdar
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ivo Bendix
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany. .,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Josephine Herz
- Department of Pediatrics I, Neonatology & Experimental Perinatal Neurosciences, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany. .,Center for Translational Neuro-and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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Natique KR, Das Y, Maxey MN, Sepulveda P, Brown LS, Chalak LF. Early Use of Transcranial Doppler Ultrasonography to Stratify Neonatal Encephalopathy. Pediatr Neurol 2021; 124:33-39. [PMID: 34509001 DOI: 10.1016/j.pediatrneurol.2021.07.004] [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: 02/23/2021] [Revised: 06/28/2021] [Accepted: 07/03/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The dynamic nature of neonatal hypoxic-ischemic encephalopathy (HIE) after birth necessitates reliable biomarkers to identify infants with evolving brain injury. This prospective cohort aims to use serial Doppler ultrasonography (US) to measure cerebral blood flow velocity and resistance index (RI) to help detect the time and evolution of the clinical encephalopathy. METHODS A total of 60 neonates were enrolled all ≥36 weeks' gestation with perinatal acidemia, defined as a blood gas pH ≤ 7.0 or base deficit ≥16 mmol/L and encephalopathy including a matched control group without encephalopathy. Each neonate received one to three serial Doppler recordings starting at six to 24 hours of life. Mean RI ≤ 0.55 was considered abnormal. RESULTS Mean RIs obtained shortly after birth were significantly lower with increasing severity of encephalopathy. On the first Doppler recordings, abnormal mean RIs were seen in 11 of 18 (61%) neonates with mild, 13 of 17 (76%) with moderate, and two of two (100%) with severe HIE. Of the neonates with mild HIE and abnormal mean RIs, congruity abnormal amplitude electroencephalography (45%), brain magnetic resonance imaging (45%), and abnormal head ultrasound (44%) are here reported. CONCLUSIONS Doppler measurements can provide bedside adjunct biomarkers indicating the time and severity of neonatal HIE.
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Affiliation(s)
- Kiran R Natique
- Neonatal-Perinatal Medicine, University of Texas Southwestern, Dallas, Texas
| | - Yudhajit Das
- Department of Biomedical Engineering, University of Texas, Arlington, Texas
| | | | | | | | - Lina F Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern, Dallas, Texas.
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22
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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23
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Marlow N, Shankaran S, Rogers EE, Maitre NL, Smyser CD. Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101274. [PMID: 34330680 DOI: 10.1016/j.siny.2021.101274] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.
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Affiliation(s)
| | | | | | - Nathalie L Maitre
- Nationwide Children's Hospital, Columbus, OH, USA; Vanderbilt University, Nashville, TN, USA
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Sabir H, Bonifacio SL, Gunn AJ, Thoresen M, Chalak LF. Unanswered questions regarding therapeutic hypothermia for neonates with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101257. [PMID: 34144931 DOI: 10.1016/j.siny.2021.101257] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Therapeutic hypothermia (TH) is now well established to improve intact survival after neonatal encephalopathy (NE). However, many questions could not be addressed by the randomized controlled trials. Should late preterm newborns with NE be cooled? Is cooling beneficial for mild NE? Is the current therapeutic time window optimal, or could it be shortened or prolonged? Will either milder or deeper hypothermia be effective? Does infection/inflammation exposure in the perinatal period in combination with NE offer potentially beneficial preconditioning or might it obviate hypothermic neuroprotection? In the present review, we dissect the evidence, for whom, when and how can TH best be delivered, and highlight areas that need further research.
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Affiliation(s)
- Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University of Bonn, Bonn, Germany; German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | | | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
| | - Marianne Thoresen
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Neonatal Neuroscience, Translational Medicine, University of Bristol, Bristol, United Kingdom.
| | - Lina F Chalak
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA.
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Hage L, Jeyakumaran D, Dorling J, Ojha S, Sharkey D, Longford N, Modi N, Battersby C, Gale C. Changing clinical characteristics of infants treated for hypoxic-ischaemic encephalopathy in England, Wales and Scotland: a population-based study using the National Neonatal Research Database. Arch Dis Child Fetal Neonatal Ed 2021; 106:501-508. [PMID: 33541916 DOI: 10.1136/archdischild-2020-319685] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/20/2020] [Accepted: 01/09/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Therapeutic hypothermia is standard of care for babies with moderate/severe hypoxic-ischaemic encephalopathy and is increasingly used for mild encephalopathy. OBJECTIVE Describe temporal trends in the clinical condition of babies diagnosed with hypoxic-ischaemic encephalopathy who received therapeutic hypothermia. DESIGN Retrospective cohort study using data held in the National Neonatal Research Database. SETTING National Health Service neonatal units in England, Wales and Scotland. PATIENTS Infants born from 1 January 2010 to 31 December 2017 with a recorded diagnosis of hypoxic-ischaemic encephalopathy who received therapeutic hypothermia for at least 3 days or died in this period. MAIN OUTCOMES Primary outcomes: recorded clinical characteristics including umbilical cord pH; Apgar score; newborn resuscitation; seizures and treatment on day 1. SECONDARY OUTCOMES recorded hypoxic-ischaemic encephalopathy grade. RESULTS 5201 babies with a diagnosis of hypoxic-ischaemic encephalopathy received therapeutic hypothermia or died; annual numbers increased over the study period. A decreasing proportion had clinical characteristics of severe hypoxia ischaemia or a diagnosis of moderate or severe hypoxic-ischaemic encephalopathy, trends were statistically significant and consistent across multiple clinical characteristics used as markers of severity. CONCLUSIONS Treatment with therapeutic hypothermia for hypoxic-ischaemic encephalopathy has increased in England, Scotland and Wales. An increasing proportion of treated infants have a diagnosis of mild hypoxic-ischaemic encephalopathy or have less severe clinical markers of hypoxia. This highlights the importance of determining the role of hypothermia in mild hypoxic-ischaemic encephalopathy. Receipt of therapeutic hypothermia is unlikely to be a useful marker for assessing changes in the incidence of brain injury over time.
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Affiliation(s)
- Lory Hage
- Department of Medicine, Imperial College London, London, UK
| | - Dusha Jeyakumaran
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Shalini Ojha
- Division of Academic Child Health, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Division of Academic Child Health, University of Nottingham, Nottingham, UK
| | - Nicholas Longford
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Neena Modi
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London Faculty of Medicine, London, UK
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26
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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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Relationship Between Umbilical Cord Gas Values and Neonatal Outcomes: Implications for Electronic Fetal Heart Rate Monitoring. Obstet Gynecol 2021; 138:366-373. [PMID: 34352847 DOI: 10.1097/aog.0000000000004515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the relationship between umbilical artery cord gas values and fetal tolerance of labor, as reflected by Apgar score. We hypothesized the existence of wide biological variability in fetal tolerance of metabolic acidemia, which, if present, would weaken one fundamental assumption underlying the use of electronic fetal heart rate (FHR) monitoring. METHODS We conducted a retrospective cohort study of term, singleton, nonanomalous fetuses delivered in our institution between March 2012 and July 2020. Universally obtained umbilical cord gas values and Apgar scores were extracted. We calculated Spearman correlation coefficients and receiver operating characteristic curves for various levels of umbilical artery pH, base excess, and Apgar scores. RESULTS We analyzed data from 29,787 deliveries. The statistical correlation between umbilical artery pH and base excess and both 1- and 5-minute Apgar scores was weak or nonexistent in all pH range subgroups (range 0.064-0.213). Receiver operating characteristic curve analysis suggested umbilical artery pH value of 7.22 yields the best discrimination for prediction of a severely depressed newborn (5-minute Apgar score less than 4), but sensitivity and specificity for this predictive value remains poor to moderate. CONCLUSION The use of electronic FHR monitoring is predicated on a documented relationship between FHR patterns and umbilical artery pH, and an assumed correlation between pH and fetal outcomes, reflecting fetal tolerance of labor and delivery. Our data demonstrate a weak-to-absent correlation between metabolic acidemia and even short-term fetal condition, thus significantly weakening this latter assumption. No amount of future modification of FHR pattern interpretation to better predict newborn pH is likely to lead to improved newborn outcomes, given this weakness in a fundamental assumption on which FHR monitoring is based.
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28
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Selvanathan T, Miller SP. Early EEG in neonates with mild hypoxic-ischemic encephalopathy: more than meets the eye. Pediatr Res 2021; 90:18-19. [PMID: 33824445 DOI: 10.1038/s41390-021-01514-6] [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: 03/17/2021] [Accepted: 03/21/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Thiviya Selvanathan
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Steven P Miller
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
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Thoresen M, Jary S, Walløe L, Karlsson M, Martinez-Biarge M, Chakkarapani E, Cowan FM. MRI combined with early clinical variables are excellent outcome predictors for newborn infants undergoing therapeutic hypothermia after perinatal asphyxia. EClinicalMedicine 2021; 36:100885. [PMID: 34308304 PMCID: PMC8257962 DOI: 10.1016/j.eclinm.2021.100885] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Binary prediction-models for outcome [death, cognition, presence and severity of cerebral palsy (CP)], using MRI and early clinical data applicable for individual outcome prediction have not been developed. METHODS From Dec 1st 2006 until Dec 31st 2013, we recruited 178 infants into a population-based cohort with moderate or severe hypoxic-ischaemic encephalopathy (HIE) including postnatal collapse (PNC, n = 12) and additional diagnoses (n = 12) using CoolCap/TOBY-trial entry-criteria including depressed amplitude-integrated EEG (aEEG). Early clinical/biochemical variables and MRI scans (median day 8) were obtained in 168 infants. Injury severity was scored for cortex, basal ganglia/thalami (BGT), white matter (WM) and posterior limb of the internal capsule, summating to a total injury score (TIS, range 0-11). Outcome was categorized as adverse or favourable at 18-24 months from Bayley-III domains (cut-off 85) and neurological examination including CP classification. FINDINGS HIE and entry-aEEG severity were stable throughout the study. Outcome was favourable in 133/178 infants and adverse in 45/178: 17 died, 28 had low Cognition/Language scores, (including 9 with severe CP and 6 mild); seven had mild CP with favourable cognitive outcome. WMxBGT product scores and TIS were strong outcome predictors, and prediction improved when clinical/biochemical variables were added in binary logistic regression. The Positive Predictive Value for adverse outcome was 88%, increasing to 95% after excluding infants with PNC and additional diagnoses. Using WMxBGT in the regression predicted 8 of the 9 children with severe CP. INTERPRETATION Binary logistic regression with WMxBGT or TIS and clinical variables gave excellent outcome prediction being 12% better than single variable cross-tabulation. Our MRI scoring and regression models are readily accessible and deserve investigation in other cohorts for group and individual prediction. FUNDING We thank the National Health Service (NHS) and our Universities and funders in UK and Norway: SPARKS, The Moulton Foundation, The Norwegian Research Council, The Lærdal Foundation for Acute Medicine and charitable donations for their support for cooling therapy.
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Key Words
- BGT, Basal ganglia/thalami
- BIC, Bayesian information criterion
- Basal ganglia and thalamus
- Bayley-III
- Bayley-III, Bayley Scales of Infant & Toddler Development 3rd edition
- CLC, Cognitive and Language Composite from the Bayley-III scales
- CP, Cerebral palsy
- CX, Cortex
- Cerebral palsy
- Cortex
- DWI, Diffusion-weighted imaging
- GA, Gestational age
- GMFCS, Gross Motor Function Classification System
- HIE, Hypoxic-ischaemic encephalopathy
- Hypoxic-ischaemic encephalopathy
- ILEA, International League Against Epilepsy
- IQR, Interquartile range
- LDH72h, Lactate dehydrogenase close to 72h post-asphyxial event
- LDHpeak, Highest LDH in the first 3 days
- Logistic regression
- MRI
- MRI, Magnetic Resonance Imaging
- Moderate or severe perinatal asphyxia
- NPV, Negative Predictive Value
- Neonatal seizures
- Neurodevelopmental outcome
- Outcome prediction
- PA, Predictive Accuracy
- PLIC, Posterior limb of the internal capsule
- PNC, Postnatal collapse
- PPV, Positive Predictive Value
- Posterior limb of the internal capsule
- RCT, Randomised controlled trial
- Se, Sensitivity
- Sp, Specificity
- T1 and T2
- TH, Therapeutic hypothermia
- TIS, Total injury score
- Therapeutic hypothermia
- WMxBGT, Product of white matter and basal ganglia/thalami scores
- White matter
- aEEG, amplitude integrated electroencephalography
- h, hours
- lactatehrs<5mmol, plasma lactate recovery time
- m, months
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Affiliation(s)
- Marianne Thoresen
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Sally Jary
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Lars Walløe
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Mathias Karlsson
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Medical Sciences, Biomedical Structure and Function, Uppsala University, Uppsala, Sweden
| | - Miriam Martinez-Biarge
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Ela Chakkarapani
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Frances M Cowan
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
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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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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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32
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Association between cerebral oxygen saturation and brain injury in neonates receiving therapeutic hypothermia for neonatal encephalopathy. J Perinatol 2021; 41:269-277. [PMID: 33462339 DOI: 10.1038/s41372-020-00910-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/16/2020] [Accepted: 12/01/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the association of cerebral oxygen saturation (CrSO2) collected by near infrared spectroscopy (NIRS) during therapeutic hypothermia (TH) and rewarming with evidence of brain injury on post-rewarming MRI. STUDY DESIGN This retrospective cohort study included 49 infants, who received TH for mild to severe neonatal encephalopathy. Of those, 26 presented with brain injury assessed by a novel MRI grading system, whereas 23 had normal MRI scans. RESULTS CrSO2 increased significantly from the first to the second day of TH in infants with brain injury, whereas it remained stable in patients with normal MRI. Increasing mean CrSO2 values during rewarming was associated with brain injury (aOR 1.14; 95% CI 1.00-1.28), specifically with gray matter (GM) injury (aOR 1.23; 95% CI 1.02-1.49). The area under the ROC curve showed an excellent discrimination for GM involvement. CONCLUSION Clinically applied NIRS during TH and rewarming can assist in identifying the risk for brain injury.
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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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Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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35
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Scherer J, Whybra-Trümpler C, Mildenberger E. Ergebnisse des Hypothermienetzwerks des Universitätsklinikums Dresden von 2010–2017. Entwicklung der Hypothermietherapie bei Neugeborenen in Deutschland. Z Geburtshilfe Neonatol 2020; 224:367-373. [DOI: 10.1055/a-1164-7174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
ZusammenfassungEinleitung Die Hypothermiebehandlung (TH) verbessert bei Neugeborenen mit hypoxisch-ischämischer Enzephalopathie (HIE) das Outcome und sollte bei Hinweisen für eine perinatale Asphyxie und Zeichen einer moderaten oder schweren HIE angewendet werden.Material/Methode Die Häufigkeit der HIE und der Anwendung der TH wurde aus den Daten der Neonatalerhebung und den Daten des 2010 etablierten Hypothermieregisters extrahiert. Letztere wurden darüber hinaus zur Analyse des kurzfristigen Outcomes herangezogen.Ergebnisse Zwischen 2010 und 2017 schlossen sich 106 der 213 (Stand März 2020) deutschen Perinatalzentren dem Register an. Die Rückantwortquote lag zwischen 22 und 60%. Im Register wurden pro Jahr im Median 164 (IQR 115–224) TH bei Neugeborenen mit HIE erfasst, in der Neonatalerhebung 517 (382–664) bei 543 (432–583) Fällen von HIE. Seit 2014 lag die Zahl der TH über den berichteten Fällen von HIE. Nach TH bei klassischer Indikationsstellung verstarben 10,4% (8–13%) der Neugeborenen. 81% (78–82%) der Neugeborenen wurden nach Hause entlassen, 3,6% (3–5%) in eine Rehabilitationseinrichtung bzw. 5,4% (5–7%) in eine andere Klinik verlegt. Bei Entlassung wurden 89% (87–89%) der Patienten ausschließlich oral ernährt.Diskussion Nach Etablierung der TH in die klinische Routine stieg die Zahl der behandelten Neugeborenen kontinuierlich an. Aktuell liegt die Zahl der TH über der Anzahl der Neugeborenen mit HIE, was nur schwer zu erklären ist, da das Vorliegen einer moderaten oder schweren HIE Voraussetzung für die TH ist. Die Daten des Hypothermieregisters zeigen für den untersuchten Zeitraum keine deutlichen Veränderungen bezüglich Mortalität oder neurologischem Outcome.
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Affiliation(s)
- Jonas Scherer
- Neonatologie, Universitätsmedizin Zentrum für Kinder- und Jugendmedizin, Johannes Gutenberg-Universität Mainz, Mainz
| | - Catharina Whybra-Trümpler
- Neonatologie, Universitätsmedizin Zentrum für Kinder- und Jugendmedizin, Johannes Gutenberg-Universität Mainz, Mainz
| | - Eva Mildenberger
- Neonatologie, Universitätsmedizin Zentrum für Kinder- und Jugendmedizin, Johannes Gutenberg-Universität Mainz, Mainz
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36
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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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Lee JK, Liu D, Raven EP, Jiang D, Liu P, Qin Q, Kulikowicz E, Santos PT, Adams S, Zhang J, Koehler RC, Martin LJ, Tekes A. Mean Diffusivity in Striatum Correlates With Acute Neuronal Death but Not Lesser Neuronal Injury in a Pilot Study of Neonatal Piglets With Encephalopathy. J Magn Reson Imaging 2020; 52:1216-1226. [PMID: 32396711 DOI: 10.1002/jmri.27181] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Diffusion MRI is routinely used to evaluate brain injury in neonatal encephalopathy. Although abnormal mean diffusivity (MD) is often attributed to cytotoxic edema, the specific contribution from neuronal pathology is unclear. PURPOSE To determine whether MD from high-resolution diffusion tensor imaging (DTI) can detect variable degrees of neuronal degeneration and pathology in piglets with brain injury induced by excitotoxicity or global hypoxia-ischemia (HI) with or without overt infarction. STUDY TYPE Prospective. ANIMAL MODEL Excitotoxic brain injury was induced in six neonatal piglets by intrastriatal stereotaxic injection of the glutamate receptor agonist quinolinic acid (QA). Three piglets underwent global HI or a sham procedure. Piglets recovered for 20-96 hours before undergoing MRI (n = 9). FIELD STRENGTH/SEQUENCE 3.0T MRI with DTI, T1 - and T2 -weighted imaging. ASSESSMENT MD, fractional anisotropy (FA), and qualitative T2 injury were assessed in the putamen and caudate. The cell bodies of normal neurons, degenerating neurons (excitotoxic necrosis, ischemic necrosis, or necrosis-apoptosis cell death continuum), and injured neurons with equivocal degeneration were counted by histopathology. STATISTICAL TESTS Spearman correlations were used to compare MD and FA to normal, degenerating, and injured neurons. T2 injury and neuron counts were evaluated by descriptive analysis. RESULTS The QA insult generated titratable levels of neuronal pathology. In QA, HI, and sham piglets, lower MD correlated with higher ratios of degenerating-to-total neurons (P < 0.05), lower ratios of normal-to-total neurons (P < 0.05), and greater numbers of degenerating neurons (P < 0.05). MD did not correlate with abnormal neurons exhibiting nascent injury (P > 0.99). Neuron counts were not related to FA (P > 0.30) or to qualitative injury from T2 -weighted MRI. DATA CONCLUSION MD is more accurate than FA for detecting neuronal degeneration and loss during acute recovery from neonatal excitotoxic and HI brain injury. MD does not reliably detect nonfulminant, nascent, and potentially reversible neuronal injury. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2 J. Magn. Reson. Imaging 2020;52:1216-1226.
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Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, Maryland, USA
| | - Dapeng Liu
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Erika P Raven
- Department of Radiology, New York University (NYU), New York, New York, USA
| | - Dengrong Jiang
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Peiying Liu
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qin Qin
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, Maryland, USA
| | - Polan T Santos
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, Maryland, USA
| | - Shawn Adams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, Maryland, USA
| | - Jiangyang Zhang
- Department of Radiology, New York University (NYU), New York, New York, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, Maryland, USA
| | - Lee J Martin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland, USA
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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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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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40
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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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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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Parmentier CEJ, de Vries LS, Toet MC, van Haastert IC, Koopman C, Weeke LC, Groenendaal F. Increased Use of Therapeutic Hypothermia in Infants with Milder Neonatal Encephalopathy due to Presumed Perinatal Asphyxia. Neonatology 2020; 117:488-494. [PMID: 32814327 DOI: 10.1159/000508710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/06/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Adverse outcomes have been reported in infants with mild neonatal encephalopathy (NE). Increasing clinical experience with the application of therapeutic hypothermia (TH) may have resulted in the treatment of newborns with milder NE during recent years. OBJECTIVE To determine whether infants treated with TH in the initial years following implementation had a higher degree of NE than infants treated during subsequent years. METHODS Infants with NE treated with TH from February 2008 until July 2017 were included. Thompson and Sarnat scores, amplitude-integrated electroencephalography (aEEG) background patterns before the start of TH, and neurodevelopmental outcome at 2 years were compared between infants treated from February 2008 until October 2012 (period 1) and infants treated from November 2012 until July 2017 (period 2). RESULTS 211 newborns with NE were treated with TH (period 1: n = 109, period 2: n = 102). Sarnat scores in period 1 and 2 were mild in 7.3 vs. 28.4%, moderate in 66.1 vs. 44.1%, and severe in 26.6 vs. 22.5%, respectively (p = 0.008). Thompson scores were lower in period 2 (median = 9, IQR 7-12) than in period 1 (median = 10, IQR 8.5-13.5, p = 0.018). The aEEGs and neurodevelopmental outcomes were comparable between the periods. CONCLUSIONS Based on Thompson and Sarnat scores, but not aEEG background patterns, infants treated during the second period had milder NE than infants treated during the first years following implementation of TH. There was no difference in 2 years neurodevelopmental outcome. Further research is necessary to evaluate the value of TH for infants with clinically mild NE.
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Affiliation(s)
- Corline E J Parmentier
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Utrecht, The Netherlands
| | - Mona C Toet
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Utrecht, The Netherlands
| | - Ingrid C van Haastert
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Utrecht, The Netherlands
| | - Corine Koopman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Utrecht, The Netherlands
| | - Lauren C Weeke
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands, .,UMC Utrecht Brain Center, Utrecht, The Netherlands,
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Parga-Belinkie J, Foglia EE, Flibotte J. Caveats of Cooling: Available Evidence and Ongoing Investigations of Therapeutic Hypothermia. Neoreviews 2019; 20:e513-e519. [PMID: 31477599 DOI: 10.1542/neo.20-9-e513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Therapeutic hypothermia (TH) mitigates the long-term effects of neuronal excitotoxicity and cell death seen in hypoxic-ischemic encephalopathy (HIE). It remains the most evidence-based therapy for HIE, but it is not without clinical controversy. The literature abounds with questions, such as "When should we start cooling-as early as the delivery room?" "Given the efficacy of TH for moderate to severe HIE when started within 6 hours of birth, can we expand the therapy to infants with mild HIE?" "What should the target temperature be?" "What is the optimal duration of treatment?" "Is early discontinuation acceptable if the examination findings normalize?" These questions about TH, its incomplete neurologic rescue, and variations in the delivery of this therapy have prompted this review. This article summarizes changing procedural considerations for TH, the level of neuromonitoring available, the use of sedation, and considerations for neuroimaging during and after TH.
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Affiliation(s)
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
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Walløe L, Hjort NL, Thoresen M. Why results from Bayesian statistical analyses of clinical trials with a strong prior and small sample sizes may be misleading The case of the NICHD Neonatal Research Network Late Hypothermia Trial. Acta Paediatr 2019; 108:1190-1191. [PMID: 30924564 PMCID: PMC6618074 DOI: 10.1111/apa.14800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Lars Walløe
- Division of PhysiologyInstitute of Basic Medical SciencesUniversity of OsloOsloNorway
| | - Nils Lid Hjort
- Division of Statistics and BiostatisticsDepartment of MathematicsUniversity of OsloOsloNorway
| | - Marianne Thoresen
- Division of PhysiologyInstitute of Basic Medical SciencesUniversity of OsloOsloNorway
- Neonatal Neuroscience, Translational Health SciencesUniversity of BristolBristolUK
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