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Chilombe MB, Seydel KB, Hammond CA, Mwanza S, Patel AA, Lungu F, wa Somwe S, Kampondeni S, Potchen MJ, McDermott MP, Birbeck GL. Protocol for a magnetic resonance imaging study of participants in the fever RCT: Does fever control prevent brain injury in malaria? PLoS One 2024; 19:e0294823. [PMID: 38640099 PMCID: PMC11029645 DOI: 10.1371/journal.pone.0294823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Despite eradication efforts, ~135,000 African children sustained brain injuries as a result of central nervous system (CNS) malaria in 2021. Newer antimalarial medications rapidly clear peripheral parasitemia and improve survival, but mortality remains high with no associated decline in post-malaria neurologic injury. A randomized controlled trial of aggressive antipyretic therapy with acetaminophen and ibuprofen (Fever RCT) for malarial fevers being conducted in Malawi and Zambia began enrollment in 2019. We propose to use neuroimaging in the context of the RCT to further evaluate neuroprotective effects of aggressive antipyretic therapy. METHODS This observational magnetic resonance imaging (MRI) ancillary study will obtain neuroimaging and neurodevelopmental and behavioral outcomes in children previously enrolled in the Fever RCT at 1- and 12-months post discharge. Analysis will compare the odds of any brain injury between the aggressive antipyretic therapy and usual care groups based upon MRI structural abnormalities. For children unable to undergo imaging without deep sedation, neurodevelopmental and behavioral outcomes will be used to identify brain injury. DISCUSSION Neuroimaging is a well-established, valid proxy for neurological outcomes after brain injury in pediatric CNS malaria. This MRI ancillary study will add value to the Fever RCT by determining if treatment with aggressive antipyretic therapy is neuroprotective in CNS malaria. It may also help elucidate the underlying mechanism(s) of neuroprotection and expand upon FEVER RCT safety assessments.
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Affiliation(s)
- Moses B. Chilombe
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, United States of America
| | - Colleen A. Hammond
- Department of Radiology, Michigan State University, East Lansing, Michigan, United States of America
| | - Suzanna Mwanza
- Department of Pediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
| | - Archana A. Patel
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Frank Lungu
- Neurology Research Office, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Somwe wa Somwe
- Neurology Research Office, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | - Sam Kampondeni
- Mpingwe Clinic, Limbe, Malawi
- Department of Imaging Sciences, University of Rochester, Rochester, New York, United States of America
| | - Michael J. Potchen
- Department of Imaging Sciences, University of Rochester, Rochester, New York, United States of America
- Zambia College of Medicine and Surgery, Lusaka, Zambia
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, United States of America
- Department of Neurology, University of Rochester, Rochester, New York, United States of America
| | - Gretchen L. Birbeck
- Neurology Research Office, University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
- Department of Neurology, University of Rochester, Rochester, New York, United States of America
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Chilombe MB, Seydel KB, Hammond C, Mwanza S, Patel AA, Lungu F, Somwe SW, Kampondeni S, Potchen MJ, McDermott MP, Birbeck GL. Protocol for a Magnetic Resonance Imaging (MRI) Study of Participants in the Fever Randomized Controlled Trial: Does fever control prevent brain injury in malaria? MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.10.23298374. [PMID: 37986869 PMCID: PMC10659499 DOI: 10.1101/2023.11.10.23298374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Despite eradication efforts, ~135,000 African children sustained brain injuries as a result of central nervous system (CNS) malaria in 2021. Newer antimalarial medications rapidly clear peripheral parasitemia and improve survival, but mortality remains high with no associated decline in post-malaria neurologic injury. A randomized controlled trial of aggressive antipyretic therapy with acetaminophen and ibuprofen (Fever RCT) for malarial fevers being conducted in Malawi and Zambia began enrollment in 2019. We propose to use neuroimaging in the context of the RCT to further evaluate neuroprotective effects of aggressive antipyretic therapy. Methods This observational magnetic resonance imaging (MRI) ancillary study will obtain neuroimaging and neurodevelopmental and behavioral outcomes in children previously enrolled in the Fever RCT at 1- and 12-months post discharge. Analysis will compare the odds of any brain injury between the aggressive antipyretic therapy and usual care groups based upon MRI structural abnormalities. For children unable to undergo imaging without deep sedation, neurodevelopmental and behavioral outcomes will be used to identify brain injury. Discussion Neuroimaging is a well-established, valid proxy for neurological outcomes after brain injury in pediatric CNS malaria. This MRI ancillary study will add value to the Fever RCT by determining if treatment with aggressive antipyretic therapy is neuroprotective in CNS malaria. It may also help elucidate the underlying mechanism(s) of neuroprotection and expand upon FEVER RCT safety assessments.
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Affiliation(s)
- Moses B. Chilombe
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, USA
| | - Colleen Hammond
- Department of Radiology, Michigan State University, East Lansing, Michigan, USA
| | - Suzanna Mwanza
- Department of Pediatrics and Child Health, Chipata Central Hospital, Chipata, Zambia
| | - Archana A. Patel
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Frank Lungu
- University Teaching Hospitals Children’s Hospital, Neurology Research Office, Lusaka, Zambia
| | - Somwe wa Somwe
- University Teaching Hospitals Children’s Hospital, Neurology Research Office, Lusaka, Zambia
| | - Sam Kampondeni
- Mpingwe Clinic, Limbe, Malawi
- Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
| | - Michael J. Potchen
- Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
- Zambia College of Medicine and Surgery, Lusaka, Zambia
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
- Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Gretchen L. Birbeck
- University Teaching Hospitals Children’s Hospital, Neurology Research Office, Lusaka, Zambia
- Department of Neurology, University of Rochester, Rochester, New York, USA
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Momin S, Thomas S, Zein H, Scott JN, Leijser LM, Vayalthrikovil S, Yusuf K, Paul R, Howlett A, Mohammad K. Comparing Three Methods of Therapeutic Hypothermia Among Transported Neonates with Hypoxic-Ischemic Encephalopathy. Ther Hypothermia Temp Manag 2023; 13:141-148. [PMID: 36961391 DOI: 10.1089/ther.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) and associated multiorgan injury are significant causes of morbidity and mortality in term and near-term neonates. Therapeutic hypothermia (TH) is the current standard of care for neuroprotection in neonates with HIE. In our experience, the majority of babies born with HIE were found in nontertiary care facilities in our region, where effective methods of cooling during transport to tertiary care centers are desirable. Most centers initiate passive TH at referral hospitals, while active cooling is typically initiated during transport. The objective of this study was to evaluate the effectiveness of three methods of cooling during transport of neonates with HIE in southern Alberta. In this prospective cohort study, 186 neonates with HIE were transported between January 2013 and December 2021. Among the 186 neonates, 47 were passively cooled, 36 actively cooled with gel packs, and 103 cooled with a servo-controlled cooling device. The clinical characteristics were comparable for the three groups, with no difference in adverse events. Fifteen neonates (8%) died and 54 neonates (29%) suffered radiologically determined brain injury. Servo-controlled cooling was found to be superior to other methods in maintaining a target temperature without significant fluctuation during transport and with temperature in the target range on arrival at tertiary care facilities. The rate of overcooling was also lower in the servo-controlled group compared with other groups. There were no statistically significant differences between the groups in relation to mortality and brain MRI changes associated with HIE. Adjusting for GA, 10-minute Apgar score, base excess, HIE stage, and need for intubation during transport, passive cooling increased the odds of temperature fluctuation outside the range by 12-fold and gel pack cooling by 13-fold compared with servo-controlled cooling. The use of servo-controlled TH devices should be the preferred practice wherever feasible. (REB17-1334_REN3).
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Affiliation(s)
- Sarfaraz Momin
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - James N Scott
- Department of Diagnostic Imaging, Division of Neuroradiology, University of Calgary, Calgary, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Sakeer Vayalthrikovil
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Kamran Yusuf
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Renee Paul
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Alexandra Howlett
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, Canada
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Chilombe MB, McDermott MP, Seydel KB, Mathews M, Mwenechanya M, Birbeck GL. Aggressive antipyretics in central nervous system malaria: Study protocol of a randomized-controlled trial assessing antipyretic efficacy and parasite clearance effects (Malaria FEVER study). PLoS One 2022; 17:e0268414. [PMID: 36206262 PMCID: PMC9543763 DOI: 10.1371/journal.pone.0268414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022] Open
Abstract
Background Malaria remains a major public health challenge in Africa where annually, ~250,000 children with malaria experience a neurologic injury with subsequent neuro-disability. Evidence indicates that a higher temperature during the acute illness is a risk factor for post-infectious neurologic sequelae. As such, aggressive antipyretic therapy may be warranted among children with complicated malaria at substantial risk of brain injury. Previous clinical trials conducted primarily in children with uncomplicated malaria and using only a single antipyretic medication have shown limited benefits in terms of fever reduction; however, no studies to date have examined malaria fever management using dual therapies. In this clinical trial of aggressive antipyretic therapy, children hospitalized with central nervous system (CNS) malaria will be randomized to usual care (acetaminophen every 6 hours for a temperature ≥ 38.5°C) vs. prophylactic acetaminophen and ibuprofen every 6 hours for 72 hours. Methods In this double-blinded, placebo controlled, two-armed clinical trial, we will enroll 284 participants from three settings at Queen Elizabeth Central Hospital in Blantyre, Malawi; at the University Teaching Hospitals Children’s Hospital in Lusaka, Zambia and at Chipata Central Hospital, Chipata, Zambia. Parents or guardians must provide written informed consent. Eligible participants are 2–11 years with evidence of P. falciparum malaria infection by peripheral blood smear or rapid diagnostic test with CNS symptoms associated with malaria. Eligible children will receive treatment allocation randomization either to standard of care for fever management or to prophylactic, scheduled treatment every 6 hours for 72 hours with dual antipyretic therapies using acetaminophen and ibuprofen. Assignment to treatment groups will be with 1:1 allocation using blocked randomization. The primary outcome will be maximum temperature in the 72 hours after enrolment. Secondary outcomes include parasite clearance as determined by quantitative Histidine Rich Protein II and seizures through 72 hours after enrolment. Discussion This clinical trial seeks to challenge the practice paradigm of limited fever treatment based upon hyperpyrexia by evaluating the fever-reduction efficacy of more aggressive antipyretic using two antipyretics and prophylactic administration and will elucidate the impact of antipyretics on parasite clearance and acute symptomatic seizures. If aggressive antipyretic therapy is shown to safely reduce the maximum temperature, a clinical trial evaluating the neuroprotective effects of temperature reduction in CNS malaria is warranted.
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Affiliation(s)
- Moses B. Chilombe
- Blantyre Malaria Project, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, United States of America
| | - Karl B. Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
| | - Manoj Mathews
- University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
| | | | - Gretchen L. Birbeck
- University Teaching Hospitals Children’s Hospital, Lusaka, Zambia
- University of Zambia School of Medicine, Lusaka, Zambia
- Department of Neurology, University of Rochester, Rochester, New York, United States of America
- * E-mail:
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Mathew JL, Kaur N, Dsouza JM. Therapeutic hypothermia in neonatal hypoxic encephalopathy: A systematic review and meta-analysis. J Glob Health 2022; 12:04030. [PMID: 35444799 PMCID: PMC8994481 DOI: 10.7189/jogh.12.04030] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is regarded as the most efficacious therapy for neonatal hypoxic encephalopathy. However, limitations in previous systematic reviews and the publication of new data necessitate updating the evidence. We conducted this up-to-date systematic review to evaluate the effects of TH in neonatal encephalopathy on clinical outcomes. Methods In this systematic review and meta-analysis, we searched Medline, Cochrane Library, Embase, LIVIVO, Web of Science, Scopus, CINAHL, major trial registries, and grey literature (from inception to October 31, 2021), for randomized controlled trials (RCT) comparing TH vs normothermia in neonatal encephalopathy. We included RCTs enrolling neonates (gestation ≥35 weeks) with perinatal asphyxia and encephalopathy, who received either TH (temperature ≤34°C) initiated within 6 hours of birth for ≥48 hours, vs no cooling. We excluded non-RCTs, those with delayed cooling, or cooling to >34°C. Two authors independently appraised risk-of-bias and extracted data on mortality and neurologic disability at four time points: neonatal (from randomization to discharge/death), infancy (18-24 months), childhood (5-10 years), and long-term (>10 years). Other outcomes included seizures, EEG abnormalities, and MRI findings. Summary data from published RCTs were pooled through fixed-effect meta-analysis. Results We identified 36 863 citations and included 39 publications representing 29 RCTs with 2926 participants. Thirteen studies each had low, moderate, and high risk-of-bias. The pooled risk ratios (95% confidence interval, CI) were as follows: neonatal mortality: 0.87 (95% CI = 0.75, 1.00), n = 2434, I2 = 38%; mortality at 18-24 months: 0.88 (95% CI = 0.78, 1.01), n = 2042, I2 = 51%; mortality at 5-10 years: 0.81 (95% CI = 0.62, 1.04), n = 515, I2 = 59%; disability at 18-24 months: 0.62 (95% CI = 0.52, 0.75), n = 1440, I2 = 26%; disability at 5-10 years: 0.68 (95% CI = 0.52, 0.90), n = 442, I2 = 3%; mortality or disability at 18-24 months: 0.78 (95% CI = 0.72, 0.86), n = 1914, I2 = 54%; cerebral palsy at 18-24 months: 0.63 (95% CI = 0.50, 0.78), n = 1136, I2 = 39%; and childhood cerebral palsy: 0.63 (95% CI = 0.46, 0.85), n = 449, I2 = 0%. Some outcomes showed significant differences by study-setting; the risk ratio (95% CI) for mortality at 18-24 months was 0.79 (95% CI = 0.66,0.93), n = 1212, I2 = 7% in high-income countries, 0.67 (95% CI = 0.41, 1.09), n = 276, I2 = 0% in upper-middle-income countries, and 1.18 (95% CI = 0.94, 1.47), n = 554, I2 = 75% in lower-middle-income countries. The corresponding pooled risk ratios for ‘mortality or disability at 18-24 months’ were 0.77 (95% CI = 0.69, 0.86), n = 1089, I2 = 0%; 0.56 (95% CI = 0.41, 0.78), n = 276, I2 = 30%; and 0.92 (95% CI = 0.77, 1.09), n = 549, I2 = 86% respectively. Trials with low risk of bias showed risk ratio of 0.97 (95% CI = 0.80, 1.16, n = 1475, I2 = 62%) for neonatal mortality, whereas trials with higher risk of bias showed 0.71 (95% CI = 0.55, 0.91), n = 959, I2 = 0%. Likewise, risk ratio for mortality at 18-24 months was 0.96 (95% CI = 0.83, 1.13), n = 1336, I2 = 58% among low risk-of-bias trials, but 0.72 (95% CI = 0.56, 0.92), n = 706, I2 = 0%, among higher risk of bias trials. Conclusions Therapeutic hypothermia for neonatal encephalopathy reduces neurologic disability and cerebral palsy, but its effect on neonatal, infantile and childhood mortality is uncertain. The setting where it is implemented affects the outcomes. Low(er) quality trials overestimated the potential benefit of TH.
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Affiliation(s)
- Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Navneet Kaur
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
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Diggikar S, Krishnegowda R. Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Literature Review. J Trop Pediatr 2022; 68:6534393. [PMID: 35191983 DOI: 10.1093/tropej/fmac016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS This structured review aimed to discuss the existing literature on therapeutic hypothermia for moderate to severe neonatal encephalopathy exclusively in low- and middle-income countries (LMICs). METHODS Medline, Embase, CINHAL and Cochrane Registry were searched for original papers with therapeutic hypothermia (TH) for treating neonatal encephalopathy in LMIC with no language restrictions. The search identified 1413 papers from 1990 to 31 August 2021. RESULTS Twenty-one original papers were included after duplicates removal and full-text screening in the final review. Fourteen randomized control studies and seven non-randomized studies were discussed with various modes of cooling (servo-controlled, phase changing material, traditional methods), complications during cooling, mortality and long-term neurodevelopmental assessment. Although there is sufficient evidence in LMIC favouring cooling for the reduction in mortality and improving the neurodevelopmental outcomes, nonetheless these studies were widely heterogeneous in terms of method of cooling, tools for assessing developmental outcomes, age at assessment and variations in neuroimaging tools and reporting. CONCLUSION Therapeutic hypothermia is beneficial in LMICs with low certainty of evidence in reducing mortality and improving neurodevelopmental outcomes.
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Affiliation(s)
- Shivashankar Diggikar
- Department of Pediatrics, Ovum Woman and Child Specialty Hospital, Banaswadi, Bengaluru 560043, India
| | - Roshani Krishnegowda
- Department of Pediatrics, SDM College of Medical Sciences, Dharwad 580009, India
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Bellos I, Devi U, Pandita A. Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Meta-Analysis. Neonatology 2022; 119:300-310. [PMID: 35340015 DOI: 10.1159/000522317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) represent substantial sources of neonatal morbidity and mortality in low- and middle-income countries (LMICs), leading to high rates of adverse long-term neurological outcomes. METHODS A systematic review with meta-analysis of randomized controlled trials in LMICs was conducted. PubMed, Scopus, Web of Science, CENTRAL, ClinicalTrials.gov, and Google Scholar were searched from inception to August 20, 2021. The population of the study consisted of neonates with gestational age ≥34 weeks and HIE. The main endpoints were overall mortality and the composite outcome of death or severe disability. The certainty of evidence was evaluated with the GRADE approach. RESULTS Ten studies were included comprising 1,293 neonates. Some concerns of bias were raised due to the nonblinded nature of the intervention. The risk of death was similar between the two groups (risk ratio [RR]: 0.78, 95% confidence interval [CI]: 0.52-1.18). No significant differences were observed in the composite outcome of death or severe disability between the two groups (RR: 0.78, 95% CI: 0.56-1.10, very low quality of evidence). Furthermore, no significant differences were observed in the endpoints of sepsis, shock, acute kidney injury, major arrhythmia, and length of hospital stay. Therapeutic hypothermia was associated with significantly higher risk of thrombocytopenia (RR: 2.13, 95% CI: 1.34-3.38) and clinically significant hemorrhage (RR: 1.57, 95% CI: 1.25-1.97). CONCLUSION Therapeutic hypothermia probably results in little to no difference in clinical outcomes among neonates with HIE in LMICs. Further large-scale research targeting proper patient selection is needed to elucidate the utility of therapeutic hypothermia in resource-limited settings. PROTOCOL REGISTRATION The protocol of the study has been prospectively registered by Prospero, CRD42021272284.
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Affiliation(s)
- Ioannis Bellos
- National and Kapodistrian University of Athens, Athens, Greece
| | - Usha Devi
- Department of Neonatology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Rios DR, Lapointe A, Schmolzer GM, Mohammad K, VanMeurs KP, Keller RL, Sehgal A, Lakshminrusimha S, Giesinger RE. Hemodynamic optimization for neonates with neonatal encephalopathy caused by a hypoxic ischemic event: Physiological and therapeutic considerations. Semin Fetal Neonatal Med 2021; 26:101277. [PMID: 34481738 DOI: 10.1016/j.siny.2021.101277] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Neonatal encephalopathy due to a hypoxic-ischemic event is commonly associated with cardiac dysfunction and acute pulmonary hypertension; both therapeutic hypothermia and rewarming modify loading conditions and blood flow. The pathophysiological contributors to disease are complex with a high degree of clinical overlap and traditional bedside measures used to assess circulatory adequacy have multiple confounders. Comprehensive, quantitative echocardiography may be used to delineate the relative contribution of lung parenchymal, pulmonary vascular, and cardiac disease to hypotension and/or hypoxemic respiratory failure. In this review, we provide a detailed overview of the contributors to hemodynamic instability following perinatal hypoxic-ischemic injury. Our proposed approach to therapy focuses on physiopathological considerations with interventions individualized to this potentially complex condition and considers the pharmacological idiosyncrasies, which may occur among neonates with NE presenting with multiorgan dysfunction while undergoing therapeutic hypothermia.
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Affiliation(s)
- Danielle R Rios
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
| | - Anie Lapointe
- CHU Ste-Justine, Montreal University, CHU Sainte-Justine 3175, chemin Côte Sainte-Catherine Montréal (Québec), H3T 1C5, Canada.
| | - Georg M Schmolzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, 10240 Kingsway Avenue NW AB, Edmonton, T5H 3V9, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada.
| | - Krisa P VanMeurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Center for Academic Medicine Division of Neonatology - MC 5660 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Roberta L Keller
- Department of Pediatrics, University of California San Francisco, 550 16th. Street, San Francisco, CA, 94158, USA.
| | - Arvind Sehgal
- Department of Pediatrics, Monash University, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatology, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817, USA.
| | - Regan E Giesinger
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
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Krishnan V, Kumar V, Shankaran S, Thayyil S. Rise and Fall of Therapeutic Hypothermia in Low-Resource Settings: Lessons from the HELIX Trial. Indian J Pediatr 2021:10.1007/s12098-021-03861-y. [PMID: 34297336 DOI: 10.1007/s12098-021-03861-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/14/2021] [Indexed: 12/13/2022]
Abstract
In the past decade, therapeutic hypothermia using a variety of low-cost devices has been widely implemented in India and other low-and middle-income countries (LMIC) without adequate evidence of either safety or efficacy. The recently reported data from the world's largest cooling trial (HELIX - hypothermia for encephalopathy in low- and middle-income countries) in LMIC provides definitive evidence of harm of cooling therapy with increase in mortality (number to harm 9) and lack of neuroprotection. Although the HELIX participating centers were highly selected tertiary neonatal intensive care units in South Asia with facilities for invasive ventilation, cardiovascular support, and 3 Tesla magnetic resonance imaging (MRI), and the trial used state-of-the-art automated servo-controlled cooling devices, a therapy that is harmful under such optimal conditions cannot be safe in low-resource settings that cannot even afford servo-controlled cooling devices.The HELIX trial has set a new benchmark for conducting high quality randomized controlled trials in terms of research governance, consent, ethics, follow-up rates, and involvement of parents. The standard care for neonatal encephalopathy in LMIC should remain normothermia, with close attention to prevention of hyperthermia. There is no role for therapeutic hypothermia in LMIC as the efficacy of hypothermia is dependent on the population, and not merely on the level of neonatal intensive care facilities. Future research should explore timings and origins of brain injury and prevention of brain injury in LMIC, with a strong emphasis on academic research capacity building and patient and public engagement.
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Affiliation(s)
- Vaisakh Krishnan
- Institute of Maternal and Child Health, Calicut Medical College, Kozhikode, Kerala, India
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK
| | - Vijay Kumar
- Neonatal Intensive Care Unit, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK
| | - Seetha Shankaran
- Neonatal Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sudhin Thayyil
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK.
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11
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Fu C, Zheng Y, Lin K, Wang H, Chen T, Li L, Huang J, Lin W, Zhu J, Li P, Fu X, Lin Z. Neuroprotective effect of apigenin against hypoxic-ischemic brain injury in neonatal rats via activation of the PI3K/Akt/Nrf2 signaling pathway. Food Funct 2021; 12:2270-2281. [PMID: 33599218 DOI: 10.1039/d0fo02555k] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Neonatal hypoxic-ischemic (HI) brain injury can lead to mortality and severe long-term disabilities including cerebral palsy and brain injury. However, the treatment options for neonatal hypoxic-ischemic (HI) brain injury are limited. Apigenin is abundantly present in vegetables, celery, and chamomile tea with diverse biological functions, such as anti-inflammatory, anti-apoptotic, antioxidant, and anticancer effects. However, it has not yet been reported whether apigenin exerts a neuroprotective effect against neonatal hypoxic-ischemic (HI) brain injury. In this study, we investigated whether apigenin could ameliorate HI brain injury and explored the associated mechanism using in vivo experiments. We found that apigenin remarkably reduced the infarct volume and ameliorated cerebral edema, decreased inflammatory response, inhibited apoptosis, promoted the recovery of tissue structure, and improved prognosis following HI brain injury. Mechanistically, we found that apigenin exerted a neuroprotective effect against HI brain injury by activating the PI3K/Akt/Nrf2 pathway. In summary, all these results demonstrate that apigenin could be a potential therapeutic approach for neonatal hypoxic-ischemic (HI) brain injury.
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Affiliation(s)
- Changchang Fu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Yihui Zheng
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Kun Lin
- The University of Illinois at Chicago, College of Pharmacy, 60612, USA
| | - Hongzeng Wang
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Tingting Chen
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Luyao Li
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Jiali Huang
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Wei Lin
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China
| | - Jianghu Zhu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Peijun Li
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China
| | - Xiaoqin Fu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, Zhejiang 325000, China.
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12
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Abate BB, Bimerew M, Gebremichael B, Mengesha Kassie A, Kassaw M, Gebremeskel T, Bayih WA. Effects of therapeutic hypothermia on death among asphyxiated neonates with hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials. PLoS One 2021; 16:e0247229. [PMID: 33630892 PMCID: PMC7906350 DOI: 10.1371/journal.pone.0247229] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hypoxic perinatal brain injury is caused by lack of oxygen to baby’s brain and can lead to death or permanent brain damage. However, the effectiveness of therapeutic hypothermia in birth asphyxiated infants with encephalopathy is uncertain. This systematic review and meta-analysis was aimed to estimate the pooled relative risk of mortality among birth asphyxiated neonates with hypoxic-ischemic encephalopathy in a global context. Methods We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search randomized control trials from electronic databases (PubMed, Cochrane library, Google Scholar, MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and meta register of Current Controlled Trials (mCRT)). The authors extracted the author’s name, year of publication, country, method of cooling, the severity of encephalopathy, the sample size in the hypothermic, and non-hypothermic groups, and the number of deaths in the intervention and control groups. A weighted inverse variance fixed-effects model was used to estimate the pooled relative risk of mortality. The subgroup analysis was done by economic classification of countries, methods of cooling, and cooling devices. Publication bias was assessed with a funnel plot and Eggers test. A sensitivity analysis was also done. Results A total of 28 randomized control trials with a total sample of 35, 92 (1832 hypothermic 1760 non-hypothermic) patients with hypoxic-ischemic encephalopathy were used for the analysis. The pooled relative risk of mortality after implementation of therapeutic hypothermia was found to be 0.74 (95%CI; 0.67, 0.80; I2 = 0.0%; p<0.996). The subgroup analysis revealed that the pooled relative risk of mortality in low, low middle, upper-middle and high income countries was 0.32 (95%CI; -0.95, 1.60; I2 = 0.0%; p<0.813), 0.5 (95%CI; 0.14, 0.86; I2 = 0.0%; p<0.998), 0.62 (95%CI; 0.41–0.83; I2 = 0.0%; p<0.634) and 0.76 (95%CI; 0.69–0.83; I2 = 0.0%; p<0.975) respectively. The relative risk of mortality was the same in selective head cooling and whole-body cooling method which was 0.74. Regarding the cooling device, the pooled relative risk of mortality is the same between the cooling cap and cooling blanket (0.74). However, it is slightly lower (0.73) in a cold gel pack. Conclusions Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Both selective head cooling and whole-body cooling method are effective in reducing the mortality of infants with this condition. Moreover, low income countries benefit the most from the therapy. Therefore, health professionals should consider offering therapeutic hypothermia as part of routine clinical care to newborns with hypoxic-ischemic encephalopathy especially in low-income countries.
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Affiliation(s)
- Biruk Beletew Abate
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
- * E-mail:
| | - Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | | | | | - MesfinWudu Kassaw
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Teshome Gebremeskel
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
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13
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Fu C, Zheng Y, Zhu J, Chen B, Lin W, Lin K, Zhu J, Chen S, Li P, Fu X, Lin Z. Lycopene Exerts Neuroprotective Effects After Hypoxic-Ischemic Brain Injury in Neonatal Rats via the Nuclear Factor Erythroid-2 Related Factor 2/Nuclear Factor-κ-Gene Binding Pathway. Front Pharmacol 2020; 11:585898. [PMID: 33390957 PMCID: PMC7774511 DOI: 10.3389/fphar.2020.585898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/19/2020] [Indexed: 01/10/2023] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is a brain injury caused by perinatal asphyxia and is the main cause of neonatal death and chronic neurological diseases. Protection of neuron after hypoxic-ischemic (HI) brain injury is considered as a potential therapeutic target of HI brain injury. To date, there are no effective medicines for neonatal HI brain injury. Lycopene (Lyc), a member of the carotenoids family, has been reported to have anti-oxidative and anti-inflammatory effects. However, its effects and potential mechanisms in HI brain injury have not yet to be systematically evaluated. In this study, we investigated whether Lyc could ameliorate HI brain injury and explored the associated mechanism both in vivo and in vitro experiments. In vivo study, Lyc significantly reduced infarct volume and ameliorated cerebral edema, decreased inflammatory response, promoted the recovery of tissue structure, and improved prognosis following HI brain injury. In vitro study, results showed that Lyc reduced expression of apoptosis mediators in oxygen-glucose deprivation (OGD)-induced primary cortical neurons. Mechanistically, we found that Lyc-induced Nrf2/NF-κB pathway could partially reversed by Brusatol (an Nrf2 inhibitor), indicated that the Nrf2/NF-κB pathway was involved in the therapy of Lyc. In summary, our findings indicate that Lyc can attenuated HI brain injury in vivo and OGD-induced apoptosis of primary cortical neurons in vitro through the Nrf2/NF-κB signaling pathway.
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Affiliation(s)
- Changchang Fu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,School of Second Clinical Medical, Wenzhou Medical University, Wenzhou, China
| | - Yihui Zheng
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,School of Second Clinical Medical, Wenzhou Medical University, Wenzhou, China
| | - Jinjin Zhu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,School of Second Clinical Medical, Wenzhou Medical University, Wenzhou, China
| | - Binwen Chen
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,School of Second Clinical Medical, Wenzhou Medical University, Wenzhou, China
| | - Wei Lin
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Kun Lin
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL, United States
| | - Jianghu Zhu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shangqin Chen
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peijun Li
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaoqin Fu
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.,School of Second Clinical Medical, Wenzhou Medical University, Wenzhou, China
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14
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Kariholu U, Montaldo P, Markati T, Lally PJ, Pryce R, Teiserskas J, Liow N, Oliveira V, Soe A, Shankaran S, Thayyil S. Therapeutic hypothermia for mild neonatal encephalopathy: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2020; 105:225-228. [PMID: 30567775 DOI: 10.1136/archdischild-2018-315711] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/26/2018] [Accepted: 11/29/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine if therapeutic hypothermia reduces the composite outcome of death, moderate or severe disability at 18 months or more after mild neonatal encephalopathy (NE). DATA SOURCE MEDLINE, Cochrane database, Scopus and ISI Web of Knowledge databases, using 'hypoxic ischaemic encephalopathy', 'newborn' and 'hypothermia', and 'clinical trials' as medical subject headings and terms. Manual search of the reference lists of all eligible articles and major review articles and additional data from the corresponding authors of selected articles. STUDY SELECTION Randomised and quasirandomised controlled trials comparing therapeutic hypothermia with usual care. DATA EXTRACTION Safety and efficacy data extracted independently by two reviewers and analysed. RESULTS We included the data on 117 babies with mild NE inadvertently recruited to five cooling trials (two whole-body cooling and three selective head cooling) of moderate and severe NE, in the meta-analysis. Adverse outcomes occurred in 11/56 (19.6%) of the cooled babies and 12/61 (19.7%) of the usual care babies (risk ratio 1.11 (95% CIs 0.55 to 2.25)). CONCLUSIONS Current evidence is insufficient to recommend routine therapeutic hypothermia for babies with mild encephalopathy and significant benefits or harm cannot be excluded.
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Affiliation(s)
- Ujwal Kariholu
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Theodora Markati
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Russell Pryce
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Medway Hospital NHS Trust, Gillingham, UK
| | | | - Natasha Liow
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Aung Soe
- Neonatal Unit, Medway Hospital NHS Trust, Gillingham, UK
| | - Seetha Shankaran
- Neonatal Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
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15
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Yan C, Zhang B. Clinical significance of detecting serum melatonin and SBDPs in brain injury in preterm infants. Pediatr Neonatol 2019; 60:435-440. [PMID: 30559060 DOI: 10.1016/j.pedneo.2018.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/11/2018] [Accepted: 11/21/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To investigate the clinical values of serum melatonin and αII spectrin cleavage products (SBDPs) in assessing the severity of brain injury in preterm infants. METHODS Sixty-four premature infants in total were selected and classified into the brain injury group (BI, n = 30) and the non-brain injury group (CON, n = 34) according to cranial imaging examination. The serum melatonin and SBDPs were detected by ELISA. All the preterm infants were received NBNA testing at 40 weeks of corrected gestational age. RESULTS The levels of melatonin and SBDPs in the BI group were significantly higher than the CON group (p < 0.05) and the levels in the infants with severe brain injury were significantly higher than those with mild brain injury (p < 0.05), as well as exhibiting a negative correlation with the NBNA score at 40 weeks of corrected gestational age (p < 0.05). CONCLUSIONS Detecting melatonin and SBDPs has clinical value in diagnosing and assessing the severity of brain injury in preterm infants.
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Affiliation(s)
- Caixia Yan
- Department of Neonatology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China
| | - Binghong Zhang
- Department of Neonatology, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei, China.
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16
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Chen YJ, Liu C, Huang LL, Ai SH, Sun L, Huang Z, Li J, Lei HS, Liu J, Liu YA, Wang X, Liu XY, Cheng YH, Wang YX, Pan A, Lu WQ. First-trimester blood concentrations of drinking water trihalomethanes and neonatal neurobehavioral development in a Chinese birth cohort. JOURNAL OF HAZARDOUS MATERIALS 2019; 362:451-457. [PMID: 30265976 DOI: 10.1016/j.jhazmat.2018.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 06/08/2023]
Abstract
Toxicological evidence indicates that exposure to drinking water trihalomethanes (THMs) can impair neural development. However, no epidemiologic study to date has evaluated the relation of trihalomethanes exposure with neonatal neurobehavioral development. Here we aimed to evaluate if prenatal exposure to THMs during early pregnancy is associated with neonatal neurobehavioral development in 451 Chinese mother-child pairs. First trimester blood THMs [chloroform (TCM), bromodichloromethane (BDCM), dibromochloromethane (DBCM), and bromoform (TBM)] were determined by solid phase micro-extraction gas chramatography. Neonatal neurobehavioral development was assessed using neonatal behavioral neurological assessment (NBNA) on the third day after birth. Multivariable linear regression models and restricted cubic spline models were constructed to evaluate the associations between blood THMs and neonatal neurological development scores. Blood concentrations of BDCM, whether modeled as continuous or categorical variables, were inversely associated with total NBNA score of newborns based on the multivariable linear regression. The association was further confirmed in the cubic spline model, and a linear dose-response relationship was observed. Stratified analysis showed that the inverse association between blood BDCM and total NBNA score was more evident in male infants than females. Our findings suggest that exposure to THMs during early pregnancy may be associated with impaired neonatal neurobehavioral development.
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Affiliation(s)
- Ying-Jun Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Chong Liu
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Li-Li Huang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Song-Hua Ai
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Li Sun
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Zhen Huang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Jin Li
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Han-Sheng Lei
- Xiaogan Center for Disease Control and Prevention, Xiaogan, Hubei, PR China
| | - Jing Liu
- The Maternal and Child Health Care Service Centre of Xiaonan District at Xiaogan City, Xiaogan, Hubei, PR China
| | - Yong-An Liu
- The Maternal and Child Health Care Service Centre of Xiaonan District at Xiaogan City, Xiaogan, Hubei, PR China
| | - Xiu Wang
- The Maternal and Child Health Care Service Centre of Xiaonan District at Xiaogan City, Xiaogan, Hubei, PR China
| | - Xiao-Ying Liu
- The Maternal and Child Health Care Service Centre of Xiaonan District at Xiaogan City, Xiaogan, Hubei, PR China
| | - Ying-Hui Cheng
- The Maternal and Child Health Care Service Centre of Xiaonan District at Xiaogan City, Xiaogan, Hubei, PR China
| | - Yi-Xin Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China; Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - An Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Wen-Qing Lu
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
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17
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Benedetti GM, Silverstein FS. Targeted Temperature Management in Pediatric Neurocritical Care. Pediatr Neurol 2018; 88:12-24. [PMID: 30309737 DOI: 10.1016/j.pediatrneurol.2018.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/14/2018] [Indexed: 12/19/2022]
Abstract
Targeted temperature management encompasses a range of clinical interventions to regulate systemic temperature, and includes both induction of varying degrees of hypothermia and fever prevention ("targeted normothermia"). Targeted temperature management plays a key role in the contemporary management of critically ill neonates and children with acute brain injury. Yet, many unanswered questions remain regarding optimal temperature management in pediatric neurocritical care. The introduction highlights experimental studies that have evaluated the neuroprotective efficacy of therapeutic hypothermia and explored possible mechanisms of action in several brain injury models. The next section focuses on three major clinical conditions in which therapeutic hypothermia has been evaluated in randomized controlled trials in pediatric populations: neonatal hypoxic-ischemic encephalopathy, postcardiac arrest encephalopathy, and traumatic brain injury. Clinical implications of targeted temperature management in pediatric neurocritical care are also discussed. The final section examines some of the factors that may underlie the limited neuroprotective efficacy of hypothermia that has been observed in several major pediatric clinical trials, and outlines important directions for future research.
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Affiliation(s)
- Giulia M Benedetti
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
| | - Faye S Silverstein
- Departments of Pediatrics and Neurology, University of Michigan, Ann Arbor, Michigan
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18
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Lemyre B, Chau V. L’hypothermie pour les nouveau-nés atteints d’encéphalopathie hypoxo-ischémique. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brigitte Lemyre
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Vann Chau
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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19
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Lemyre B, Chau V. Hypothermia for newborns with hypoxic-ischemic encephalopathy. Paediatr Child Health 2018; 23:285-291. [PMID: 30657134 DOI: 10.1093/pch/pxy028] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Therapeutic hypothermia is a standard of care for infants ≥36 weeks gestational age (GA) with moderate-to-severe hypoxic-ischemic encephalopathy. Because some studies included infants born at 35 weeks GA, hypothermia should be considered if they meet other criteria. Cooling for infants <35 weeks GA is not recommended. Passive cooling should be started promptly in community centres, in consultation with a tertiary care centre neonatologist, while closely monitoring the infant's temperature. Best evidence suggests that maintaining core body temperature between 33°C and 34°C for 72 hours, followed by a period of rewarming of 6 to 12 hours, is optimal. Antiepileptic medications should be used when clinical or electrographic seizures are present. Maintaining serum electrolytes and glucose within normal ranges, and avoiding hypo- or hypercarbia and hyperoxia, are important adjunct treatments. A brain magnetic resonance image (MRI) is advised shortly after rewarming and, in cases where earlier findings do not match the clinical picture, a repeat MRI after 10 days of life is suggested. Multidisciplinary neurodevelopmental follow-up is recommended.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Vann Chau
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Empfehlung zum Temperaturmanagement nach Atem-Kreislauf-Stillstand und schwerem Schädel-Hirn-Trauma im Kindesalter jenseits der Neonatalperiode. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Safety of Moderate Hypothermia for Perinatal Hypoxic-Ischemic Encephalopathy: A Meta-analysis. Pediatr Neurol 2017; 74:51-61. [PMID: 28750727 DOI: 10.1016/j.pediatrneurol.2017.04.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/25/2017] [Accepted: 04/25/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND We investigated the safety of therapeutic hypothermia during intervention in infants with hypoxic-ischemic encephalopathy (HIE). METHODS The MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials from onset to November 30, 2016 were searched for studies on perinatal HIE. Randomized controlled trials comparing the use of therapeutic hypothermia with normothermia for perinatal HIE were included in the study. Safety and efficacy data for therapeutic hypothermia in 1806 infants with HIE were included in this meta-analysis. The primary outcomes were safety variables, and the secondary outcomes were efficacy variables. A fixed-effect model was used to perform the meta-analysis. Risk ratios (RR), risk differences (RD), and 95% confidence intervals (CI) were calculated. RESULTS Thirteen trials, including 1806 infants, contained information on safety and efficacy variables. Moderate hypothermia significantly increased the risk of thrombocytopenia (RR 1.18, 95% CI 1.02 to 1.37, P = 0.03; RD 0.06, 95% CI -0.02 to 0.09) and cardiac arrhythmia (RR 2.52, 95% CI 1.62 to 3.93, P < 0.0001; RD 0.19, 95% CI 0.09 to 0.03) during intervention. CONCLUSIONS In infants with HIE, the application of therapeutic hypothermia increases the risk of thrombocytopenia and cardiac arrhythmia during intervention.
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Stafford TD, Hagan JL, Sitler CG, Fernandes CJ, Kaiser JR. Therapeutic Hypothermia During Neonatal Transport: Active Cooling Helps Reach the Target. Ther Hypothermia Temp Manag 2017; 7:88-94. [DOI: 10.1089/ther.2016.0022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Tiffany D. Stafford
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, Texas
| | - Joseph L. Hagan
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, Texas
- Newborn Center, Texas Children's Hospital, Houston, Texas
| | - Curtis G. Sitler
- Department of Transport Services, Texas Children's Hospital, Houston, Texas
| | | | - Jeffrey R. Kaiser
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Brenner S, Eich C, Rellensmann G, Schuhmann MU, Nicolai T, Hoffmann F. [Recommendation on temperature management after cardiopulmonary arrest and severe traumatic brain injury in childhood beyond the neonatal period : Statement of the German Society for Neonatology and Pediatric Intensive Care Medicine (GNPI) and the scientific Working Group for Paediatric Anaesthesia (WAKKA) of the German Society of Anaesthesiology and Intensive Care (DGAI)]. Anaesthesist 2017; 66:128-133. [PMID: 28091756 DOI: 10.1007/s00101-016-0256-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The available data on the effectiveness of therapeutic hypothermia in different patient groups are heterogeneous. Although the benefits have been proven for some collectives, recommendations for the use of hypothermia treatment in other groups are based on less robust data and conclusions by analogy. This article gives a review of the current evidence of temperature management in all age groups and based on this state of knowledge, recommends active temperature management with the primary aim of strict normothermia (36-36.5 °C) for 72 hours after cardiopulmonary arrest or severe traumatic brain injury for children beyond the neonatal period.
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Affiliation(s)
- S Brenner
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Eich
- Abteilung Anästhesie, Kinderintensiv- und Notfallmedizin, Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover, Deutschland
| | - G Rellensmann
- Neonatologie und pädiatrische Intensivmedizin, Klinik für Kinder- und Jugendmedizin - Allgemeine Pädiatrie, Universitätsklinikum Münster, Münster, Deutschland
| | - M U Schuhmann
- Bereich Pädiatrische Neurochirurgie, Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - T Nicolai
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
| | - F Hoffmann
- Interdisziplinäre Kinderintensivstation, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
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Therapeutic hypothermia increases the risk of cardiac arrhythmia for perinatal hypoxic ischaemic encephalopathy: A meta-analysis. PLoS One 2017; 12:e0173006. [PMID: 28273115 PMCID: PMC5342232 DOI: 10.1371/journal.pone.0173006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/12/2017] [Indexed: 01/09/2023] Open
Abstract
Objective To determine whether therapeutic hypothermia after hypoxic ischaemic encephalopathy (HIE) in neonates increases the risk of cardiac arrhythmia during intervention. Design A meta-analysis was conducted using a fixed-effect model. Risk ratios, risk differences, and 95% confidence intervals, were measured. Data sources Studies identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Google Scholar, previous reviews, and abstracts from onset to August, 2016. Review methods Reports that compared therapeutic hypothermia with normal care for neonates with HIE and that included data on safety or cardiac arrhythmia, which is of interest to patients and clinicians, were selected. Results We found seven trials, encompassing 1322 infants that included information on safety or cardiac arrhythmia during intervention. Therapeutic hypothermia considerably increased the combined rate of cardiac arrhythmia in the seven trials (risk ratio 2.42, 95% confidence interval 1.23 to 4.76. p = 0.01; risk difference 0.02, 95% CI 0.01 to 0.04) during intervention. Conclusions In infants with hypoxic ischaemic encephalopathy, therapeutic hypothermia is associated with a consistent increase in cardiac arrhythmia during intervention.
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Giesinger RE, Bailey LJ, Deshpande P, McNamara PJ. Hypoxic-Ischemic Encephalopathy and Therapeutic Hypothermia: The Hemodynamic Perspective. J Pediatr 2017; 180:22-30.e2. [PMID: 27742125 DOI: 10.1016/j.jpeds.2016.09.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/13/2016] [Accepted: 09/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Regan E Giesinger
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Liane J Bailey
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Poorva Deshpande
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
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McAdams RM, Juul SE. Neonatal Encephalopathy: Update on Therapeutic Hypothermia and Other Novel Therapeutics. Clin Perinatol 2016; 43:485-500. [PMID: 27524449 PMCID: PMC4987711 DOI: 10.1016/j.clp.2016.04.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neonatal encephalopathy (NE) is a major cause of neonatal mortality and morbidity. Therapeutic hypothermia (TH) is standard treatment for newborns at 36 weeks of gestation or greater with intrapartum hypoxia-related NE. Term and late preterm infants with moderate to severe encephalopathy show improved survival and neurodevelopmental outcomes at 18 months of age after TH. TH can increase survival without increasing major disability, rates of an IQ less than 70, or cerebral palsy. Neonates with severe NE remain at risk of death or severe neurodevelopmental impairment. This review discusses the evidence supporting TH for term or near term neonates with NE.
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Silveira RC, Procianoy RS. Hypothermia therapy for newborns with hypoxic ischemic encephalopathy. J Pediatr (Rio J) 2015; 91:S78-83. [PMID: 26354871 DOI: 10.1016/j.jped.2015.07.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Therapeutic hypothermia reduces cerebral injury and improves the neurological outcome secondary to hypoxic ischemic encephalopathy in newborns. It has been indicated for asphyxiated full-term or near-term newborn infants with clinical signs of hypoxic-ischemic encephalopathy (HIE). SOURCES A search was performed for articles on therapeutic hypothermia in newborns with perinatal asphyxia in PubMed; the authors chose those considered most significant. SUMMARY OF THE FINDINGS There are two therapeutic hypothermia methods: selective head cooling and total body cooling. The target body temperature is 34.5 °C for selective head cooling and 33.5 °C for total body cooling. Temperatures lower than 32 °C are less neuroprotective, and temperatures below 30 °C are very dangerous, with severe complications. Therapeutic hypothermia must start within the first 6h after birth, as studies have shown that this represents the therapeutic window for the hypoxic-ischemic event. Therapy must be maintained for 72 h, with very strict control of the newborn's body temperature. It has been shown that therapeutic hypothermia is effective in reducing neurologic impairment, especially in full-term or near-term newborns with moderate hypoxic-ischemic encephalopathy. CONCLUSION Therapeutic hypothermia is a neuroprotective technique indicated for newborn infants with perinatal asphyxia and hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Rita C Silveira
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Renato S Procianoy
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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Hypothermia therapy for newborns with hypoxic ischemic encephalopathy. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Although cooling therapy has been the standard of care for neonatal encephalopathy (NE) in high-income countries for more than half a decade, it is still not widely used in low- and middle-income countries (LMIC), which bear 99% of the encephalopathy burden; neither is it listed as a priority research area in global health. Here we explore the major roadblocks that prevent the use of cooling in LMIC, including differences in population comorbidities, suboptimal intensive care, and the lack of affordable servo-controlled cooling devices. The emerging data from LMIC suggest that the incidence of coexisting perinatal infections in NE is no different to that in high-income countries, and that cooling can be effectively provided without tertiary intensive care and ventilatory support; however, the data on safety and efficacy of cooling are limited. Without adequately powered clinical trials, the creeping and uncertain introduction of cooling therapy in LMIC will be plagued by residual safety concerns, and any therapeutic benefit will be even more difficult to translate into widespread clinical use.
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Burnsed JC, Chavez-Valdez R, Hossain MS, Kesavan K, Martin LJ, Zhang J, Northington FJ. Hypoxia-ischemia and therapeutic hypothermia in the neonatal mouse brain--a longitudinal study. PLoS One 2015; 10:e0118889. [PMID: 25774892 PMCID: PMC4361713 DOI: 10.1371/journal.pone.0118889] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 01/08/2015] [Indexed: 11/22/2022] Open
Abstract
Therapeutic hypothermia is standard of care for infants with hypoxic ischemic encephalopathy. Murine models of hypoxic-ischemic injury exist; however, a well-established mouse model of therapeutic hypothermia following hypoxic-ischemic injury is lacking. The goal of this study was to develop a full-term-equivalent murine model of therapeutic hypothermia after hypoxia-ischemia and examine magnetic resonance imaging, behavior, and histology in a region and sex specific manner. Hypoxic-ischemic injury was induced at postnatal day 10 in C57BL6 mice using a modified Vannucci model. Mice were randomized to control, hypothermia (31˚C for 4h), or normothermia (36˚C) following hypoxic-ischemic injury and stratified by sex. T2-weighted magnetic resonance imaging was obtained at postnatal day 18 and 30 and regional and total cerebral and cerebellar volumes measured. Behavioral assessments were performed on postnatal day 14, 21, and 28. On postnatal day 18, normothermic mice had smaller cerebral volumes (p < 0.001 vs. controls and p = 0.009 vs. hypothermia), while at postnatal day 30 both injured groups had smaller volumes than controls. When stratified by sex, only normothermia treated male mice had smaller cerebral volumes (p = 0.001 vs. control; p = 0.008 vs. hypothermia) at postnatal day 18, which persisted at postnatal day 30 (p = 0.001 vs. control). Female mice had similar cerebral volumes between groups at both day 18 and 30. Cerebellar volumes of hypothermia treated male mice differed from control at day 18, but not at 30. Four hours of therapeutic hypothermia in this murine hypoxic-ischemic injury model provides sustained neuroprotection in the cerebrum of male mice. Due to variable degree of injury in female mice, response to therapeutic hypothermia is difficult to discern. Deficits in female behavior tests are not fully explained by imaging measures and likely represent injury not detectable by volume measurements alone.
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Affiliation(s)
- Jennifer C. Burnsed
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Mir Shanaz Hossain
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Kalpashri Kesavan
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Lee J. Martin
- Division of Neuropathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jiangyang Zhang
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Hines M, Swinburn K, McIntyre S, Novak I, Badawi N. Infants at risk of cerebral palsy: a systematic review of outcomes used in Cochrane studies of pregnancy, childbirth and neonatology. J Matern Fetal Neonatal Med 2014; 28:1871-83. [PMID: 25283846 DOI: 10.3109/14767058.2014.972355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To systematically review meta-analyses (MAs) and randomised controlled trials (RCTs) of interventions for infants at risk of cerebral palsy (CP), to determine if consensus exists in study end-points. METHODS MAs within the "Neonatal" and "Pregnancy and Childbirth" Review Groups in Cochrane Database of Systematic Reviews (to June 2011) were included if they contained risk factors for CP as a study end-point, and were either published in 2010 or 2011 or cited >20 times in Sciverse Scopus. Up to 20 RCTs from each MA were included. Outcome measures, definitions and cut-points for ordinal groupings were extracted from MAs and RCTs and frequencies calculated. RESULTS Twenty-two MAs and 165 RCTs were appraised. High consistency existed in types of outcome domains listed as important in MAs. For 10/16 most frequently cited outcome domains, <50% of RCTs contributed data for meta-analyses. Low consistency in outcome definitions, measures, cut-points in RCTs and long-term follow-up prohibited data aggregation. CONCLUSIONS Variation in outcome measurement and long-term follow up has hampered the ability of RCTs to contribute data on important outcomes for CP, resulting in lost opportunities to measure the impact of maternal and neonatal interventions. There is an urgent need for and long-term follow up of these interventions and an agreed set of standardised and clinically relevant common data elements for study end-points.
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Affiliation(s)
- Monique Hines
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia
| | - Katherine Swinburn
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Sarah McIntyre
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Iona Novak
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia
| | - Nadia Badawi
- a Cerebral Palsy Alliance Research Institute , Darlinghurst , Australia .,b School of Medicine, University of Notre Dame Australia , Darlinghurst , Australia .,c Discipline of Paediatrics & Child Health, Sydney Medical School, University of Sydney , Sydney , Australia , and.,d The Children's Hospital at Westmead, Grace Centre for Newborn Care , Westmead , Australia
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Orbach SA, Bonifacio SL, Kuzniewicz M, Glass HC. Lower incidence of seizure among neonates treated with therapeutic hypothermia. J Child Neurol 2014; 29:1502-7. [PMID: 24334344 PMCID: PMC4053513 DOI: 10.1177/0883073813507978] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Animal studies suggest that hypothermia decreases seizure burden, whereas limited human data are inconclusive. This retrospective cohort study examines the relationship between therapeutic hypothermia and seizure in neonates with hypoxic-ischemic encephalopathy. Our center admitted 224 neonates from July 2004 to December 2011 who met institutional cooling criteria. Seventy-three neonates were born during the pre-cooling era, prior to November 2007, and 151 were born during the cooling era. Among neonates with moderate encephalopathy, the incidence of seizure in cooled infants was less than half the incidence in those not cooled (26% cooling, 61% pre-cooling era; risk ratio = 0.43, 95% confidence interval = 0.30-0.61). Among neonates with severe encephalopathy, there was no difference in the incidence (83% vs. 87%; risk ratio = 1.05, 95% confidence interval = 0.78-1.39). These results support animal data and suggest a mechanism by which neonates with moderate encephalopathy can benefit more from cooling than neonates with severe encephalopathy.
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Affiliation(s)
- Sharon A Orbach
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sonia L Bonifacio
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Michael Kuzniewicz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Hannah C Glass
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Liu J, Gao D, Chen Y, Jing J, Hu Q, Chen Y. Lead exposure at each stage of pregnancy and neurobehavioral development of neonates. Neurotoxicology 2014; 44:1-7. [PMID: 24704588 DOI: 10.1016/j.neuro.2014.03.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/11/2014] [Accepted: 03/11/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Our pilot studies showed that there was a significant relationship between blood lead levels of women at the first trimester and scores of neonatal behavioral neurological assessment (NBNA). This study went further (1) to determine particular neurotoxicity during a specific trimester, (2) to analyze "safe" levels of Pb in neonates, and (3) to identify influencing factors for prenatal Pb exposure. METHOD A total of 415 mothers with newborn located Shenzhen, Guangdong, China participated in the study: 219 in the high lead group [blood lead levels (BLLs) at first trimester≥4.89μg/dl] and 196 in the low lead group [BLLs≤1.96μg/dl]. The maternal BLLs at each stage of pregnancy and delivery were measured by atomic absorption spectrophotometry, equipped with a graphite furnace. The developmental functioning of newborns was assessed with NBNA in 3 days. The children's birth outcome and the rest of information was obtained from their medical records or a comprehensive questionnaire from their parents, which contained demographic characteristics, lifestyle, IQ, occupation and influencing factors for lead exposure during and before first trimester, etc. RESULTS Of 415 newborns, 332 (80.00%) had complete data collection for all variables at four-stage follow-up. The maternal mean BLL at first trimester for 332 newborns was 3.98±1.15μg/dl (0.38-15.86μg/dl) and the geometric mean (GM) was 3.63±0.35μg/dl (95%CI: 2.98-4.32μg/dl). In total, about 4.82% of newborns had maternal BLLs>10μg/dl. Significant inverse associations have been found between the maternal BLLs at the first trimester and the NBNA scores (P<0.05). Drinking milk and supplements of Ca, Fe, or Zn are protective factors of high BLLs (OR=0.363, P<0.05). CONCLUSION Our study demonstrate that fetal lead exposure as low as 5μg/dl has an adverse effect on neurodevelopment, most expressed during the first trimester and best arrested by measuring maternal BLLs. The collective evidence indicates that screening and intervention after the first trimester may be too late to prevent the fetal neurotoxic effects.
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Affiliation(s)
- Jian'an Liu
- Department of Maternal and Child Health, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Dingguo Gao
- Department of Psychology, Sun Yat-Sen University, Guangzhou, China
| | - Yuming Chen
- Department of Epidemiology and Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Jin Jing
- Department of Maternal and Child Health, School of Public Health, Sun Yat-Sen University, Guangzhou, China.
| | - Qiansheng Hu
- Department of Preventive Medicine, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Yajun Chen
- Department of Maternal and Child Health, School of Public Health, Sun Yat-Sen University, Guangzhou, China.
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Effect of low-level prenatal mercury exposure on neonate neurobehavioral development in China. Pediatr Neurol 2014; 51:93-9. [PMID: 24938141 DOI: 10.1016/j.pediatrneurol.2014.03.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study aimed to assess the effects of low-level prenatal mercury exposure on neonate neurobehavioral development in China. METHODS In total, 418 mother-neonate pairs were included in the study. Maternal urine, hair, and blood samples and cord blood samples were used to document prenatal exposure to mercury. The Neonatal Behavioral Neurological Assessment was used to estimate neurobehavioral development in the neonates at 3 days of age. RESULTS Total mercury level was significantly higher in cord blood than that in maternal blood. A strong correlation was found between total mercury levels in maternal blood and those in cord blood (r = 0.7431; P < 0.0001). Trend analysis revealed that mothers who consumed more fish had higher blood and cord blood mercury levels (all P < 0.0001). Significant differences were also found between male and female cord blood mercury levels among groups with different fish consumption frequencies (all P < 0.0001). Cord blood mercury level was significantly associated with total Neonatal Behavioral Neurological Assessment scores (β = 0.03; standard error = 0.01; P = 0.0409), passive muscle tone (odds ratio = 1.07; 95% confidence interval = 1.12-1.13; P = 0.0071), and active muscle tone (odds ratio = 1.06; 95% confidence interval = 1.01-1.11; P = 0.0170) scores after adjustment, respectively. CONCLUSIONS Neonatal neurodevelopment was associated with prenatal exposure to mercury. Women with high mercury levels should avoid intake seafood excessively during pregnancy. Long-term effects of exposure to mercury on childhood development need to be further explored.
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Biselele T, Naulaers G, Tady B. Evolution of the Thompson score during the first 6 h in infants with perinatal asphyxia. Acta Paediatr 2014; 103:145-8. [PMID: 24354612 DOI: 10.1111/apa.12470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 09/27/2013] [Accepted: 10/14/2013] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to determine the evolution of the Thompson score, which provides composite grading of encephalopathy signs, during the first 6 h of birth in neonates with perinatal asphyxia. METHODS Twenty term infants with perinatal asphyxia were prospectively studied from the University Hospital of Kinshasa during a 12-month period. The Thompson score was performed after 1 h, then hourly until 6 h of birth. RESULTS Fourteen infants had a Thompson score ≥7 and six had a score <7 after 1 h of birth. The Thompson score remained higher than 7 after 3 h in nine infants (64.3%) and in four infants (25.6%) after 6 h. After 3 h of birth, four infants moved from a score ≥7 to a score below 7. After 6 h, five infants had a score below 7. Seventy per cent of patients had a Thompson score higher than 7 after 1 h, 45% after 3 h and 20% after 6 h. CONCLUSION The Thompson score changes over the time during the first 6 h of birth, and this should be taken into account when it is being used as an entry criterion for cooling.
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Affiliation(s)
- Thérèse Biselele
- Neonatal Unit; Department of Pediatrics; University Hospital of Kinshasa; Kinshasa DR Congo
| | - Gunnar Naulaers
- Organ Systems; Department of Growth and Regeneration; KU Leuven; Leuven Belgium
| | - Bruno Tady
- Neonatal Unit; Department of Pediatrics; University Hospital of Kinshasa; Kinshasa DR Congo
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Chevallier M, Ego A, Cans C, Debillon T. Adherence to hypothermia guidelines: a French multicenter study of fullterm neonates. PLoS One 2013; 8:e83742. [PMID: 24391817 PMCID: PMC3877096 DOI: 10.1371/journal.pone.0083742] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/07/2013] [Indexed: 11/18/2022] Open
Abstract
AIM The objective of this study was to describe the French practice of hypothermia treatment (HT) in full-term newborns with hypoxic-ischemic encephalopathy (HIE) and to analyze the deviations from the guidelines of the French Society of Neonatology. MATERIALS AND METHODS From May 2010 to March 2012 we recorded all cases of HIE treated by HT in a French national database. The population was divided into three groups, "optimal HT" (OHT), "late HT" (LHT) and "non-indicated" HT (NIHT), according to the guidelines. RESULTS Of the 311 newborns registered in the database and having HT, 65% were classified in the OHT group, 22% and 13% in the LHT and NIHT groups respectively. The severity of asphyxia and HIE were comparable between newborns with OHT and LHT, apart from EEG. HT was initiated at a mean time of 12 hours of life in the LHT group. An acute obstetrical event was more likely to be identified among newborns with LHT (46%), compared to OHT (34%) and NIHT (22%). There was a gradation in the rate of complications from the NIHT group (29%) to the LHT (38%) group and the OHT group (52%). Despite an insignificant difference in the rates of death or abnormal neurological examination at discharge, nearly 60% of newborns in the OHT group had an MRI showing abnormalities, compared to 44% and 49% in the LHT and NIHT groups respectively. CONCLUSION The conduct of the HT for HIE newborns is not consistent with French guidelines for 35% of newborns, 22% being explained by an excessive delay in the start of HT, 13% by the lack of adherence to the clinical indications. This first report illustrates the difficulties in implementing guidelines for HT and should argue for an optimization of perinatal care for HIE.
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Affiliation(s)
- Marie Chevallier
- Neonatology and Pediatric Intensive Care Unit, Grenoble University Hospital, Grenoble, France
| | - Anne Ego
- Clinical Research Center (CICO3), Grenoble University Hospital, Grenoble, France
| | - Christine Cans
- THEMAS (Techniques pour l'évaluation et la modélisation des actions de santé), Joseph Fourier University-Grenoble1, Grenoble, France
| | - Thierry Debillon
- Neonatology and Pediatric Intensive Care Unit, Grenoble University Hospital, Grenoble, France
- * E-mail:
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Galvao TF, Silva MT, Marques MC, de Oliveira ND, Pereira MG. Hypothermia for perinatal brain hypoxia-ischemia in different resource settings: a systematic review. J Trop Pediatr 2013; 59:453-9. [PMID: 23780995 DOI: 10.1093/tropej/fmt047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess the effect of hypothermia on mortality of neonates with hypoxic-ischemic encephalopathy in different economic resources settings. METHODS We searched for randomized controlled trials on MEDLINE, Embase and other databases. Duplicate reviewers selected the studies and extracted data. We calculated meta-analyses of the relative risks (RR) and 95% confidence intervals (95% CI), and used meta-regression to evaluate the gross domestic product per capita influence on hypothermia efficacy. RESULTS Sixteen studies were included (n = 1889); eight were conducted in lower income countries (n = 662). Hypothermia significantly reduced mortality (RR = 0.77; 95% CI: 0.65-0.92). Meta-regression revealed that hypothermia efficacy does not increase as the gross domestic product per capita rises. CONCLUSIONS There is enough evidence to support hypothermia as the standard care for hypoxic-ischemic encephalopathy. Evidence from low-resource settings is limited, but hypothermia efficacy was not shown to be associated with better resources countries.
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Affiliation(s)
- Tais F Galvao
- University of Brasilia, Faculty of Medicine, Brasilia, Distrito Federal, 70910-900, Brazil
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Hansen G, Grimason M, Collins JW, Wainwright MS. Selective head cooling for the treatment of neurologic complications of acute liver failure in a newborn with disseminated herpes infection. SPRINGERPLUS 2013; 2:572. [PMID: 24255865 PMCID: PMC3825224 DOI: 10.1186/2193-1801-2-572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 10/20/2013] [Indexed: 01/06/2023]
Abstract
Background Neurologic complications of pediatric acute liver failure (ALF) are a major determinant of outcome. Management of these complications, including increased intracranial pressure (ICP) is largely supportive. Although hypothermia is an effective treatment for perinatal asphyxia and is used to reduce ICP following traumatic brain injury, it has not been evaluated for neurologic complications of ALF in the newborn. Methods Case report. Results We present a case of neonatal herpes simplex virus (HSV)-associated ALF with profound neurologic impairment and increased ICP. The patient was treated with selective head cooling, and monitored with transcranial doppler (TCD) studies of cerebral blood flow velocity, and electroencephalograms (EEG). The duration of head cooling was influenced by absent diastolic flow on TCDs, which subsequently improved during hypothermia. Continuous EEGs captured subclinical seizures, which improved with antiepileptic medications. Her death was attributed to a massive pulmonary hemorrhage and a hypoxemic cardiac arrest secondary to significant coagulopathy. Conclusion This case demonstrates that selective head cooling may attenuate increased ICP in neonatal encephalopathy, and that TCDs may guide management in the absence of invasive monitoring.
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Affiliation(s)
- Gregory Hansen
- Department of Pediatrics, Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611 USA
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Topjian AA, Berg RA, Bierens JJLM, Branche CM, Clark RS, Friberg H, Hoedemaekers CWE, Holzer M, Katz LM, Knape JTA, Kochanek PM, Nadkarni V, van der Hoeven JG, Warner DS. Brain resuscitation in the drowning victim. Neurocrit Care 2013; 17:441-67. [PMID: 22956050 DOI: 10.1007/s12028-012-9747-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.
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Affiliation(s)
- Alexis A Topjian
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 7C23, Philadelphia, PA 19104, USA.
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Pauliah SS, Shankaran S, Wade A, Cady EB, Thayyil S. Therapeutic hypothermia for neonatal encephalopathy in low- and middle-income countries: a systematic review and meta-analysis. PLoS One 2013; 8:e58834. [PMID: 23527034 PMCID: PMC3602578 DOI: 10.1371/journal.pone.0058834] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/07/2013] [Indexed: 11/23/2022] Open
Abstract
Although selective or whole body cooling combined with optimal intensive care improves outcomes following neonatal encephalopathy in high-income countries, the safety and efficacy of cooling in low-and middle-income countries is not known.
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Affiliation(s)
- Shreela S. Pauliah
- Academic Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Seetha Shankaran
- Neonatal/Perinatal Medicine, Wayne State University School of Medicine, Children's Hospital of Michigan and Hutzel Women's Hospital, Detroit, Michigan, United States of America
| | - Angie Wade
- Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London, London, United Kingdom
| | - Ernest B. Cady
- Medical Physics and Bioengineering, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sudhin Thayyil
- Academic Neonatology, Institute for Women's Health, University College London, London, United Kingdom
- * E-mail:
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Cerio FGD, Lara-Celador I, Alvarez A, Hilario E. Neuroprotective therapies after perinatal hypoxic-ischemic brain injury. Brain Sci 2013; 3:191-214. [PMID: 24961314 PMCID: PMC4061821 DOI: 10.3390/brainsci3010191] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/13/2013] [Accepted: 02/22/2013] [Indexed: 12/29/2022] Open
Abstract
Hypoxic-ischemic (HI) brain injury is one of the main causes of disabilities in term-born infants. It is the result of a deprivation of oxygen and glucose in the neural tissue. As one of the most important causes of brain damage in the newborn period, the neonatal HI event is a devastating condition that can lead to long-term neurological deficits or even death. The pattern of this injury occurs in two phases, the first one is a primary energy failure related to the HI event and the second phase is an energy failure that takes place some hours later. Injuries that occur in response to these events are often manifested as severe cognitive and motor disturbances over time. Due to difficulties regarding the early diagnosis and treatment of HI injury, there is an increasing need to find effective therapies as new opportunities for the reduction of brain damage and its long term effects. Some of these therapies are focused on prevention of the production of reactive oxygen species, anti-inflammatory effects, anti-apoptotic interventions and in a later stage, the stimulation of neurotrophic properties in the neonatal brain which could be targeted to promote neuronal and oligodendrocyte regeneration.
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Affiliation(s)
- Felipe Goñi de Cerio
- Biotechnology Area, GAIKER Technology Centre, Parque Tecnológico de Zamudio Ed 202, 48170 Zamudio, Vizcaya, Spain.
| | - Idoia Lara-Celador
- Department of Cell Biology and Histology, School of Medicine and Dentistry, University of the Basque Country, 48949 Leioa, Bizkaia, Spain.
| | - Antonia Alvarez
- Department of Cell Biology and Histology, School of Medicine and Dentistry, University of the Basque Country, 48949 Leioa, Bizkaia, Spain.
| | - Enrique Hilario
- Department of Cell Biology and Histology, School of Medicine and Dentistry, University of the Basque Country, 48949 Leioa, Bizkaia, Spain.
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Ramos G, Brotschi B, Latal B, Bernet V, Wagner B, Hagmann C. Therapeutic hypothermia in term infants after perinatal encephalopathy: the last 5 years in Switzerland. Early Hum Dev 2013; 89:159-64. [PMID: 23116611 DOI: 10.1016/j.earlhumdev.2012.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 07/25/2012] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) following perinatal asphyxial encephalopathy in term infants improves mortality and neurodevelopmental outcome. In Europe, most neonatal units perform active cooling whereas in Switzerland passive cooling is predominantly used. AIMS (i) To determine how many infants were cooled within the last 5years in Switzerland, (ii) to assess the cooling methods, (iii) to evaluate the variation of temperature of different cooling methods, and (iv) to evaluate the use of neuromonitoring. STUDY DESIGN Retrospective cohort study. PATIENTS Notes of all cooled term infants between March 2005 and December 2010 in 9 perinatal and two paediatric intensive care centres were retrospectively reviewed. Active cooling was compared to passive cooling alone and to passive cooling in combination with gel packs. RESULTS 150 infants were cooled. Twenty-seven (18.2%) were cooled actively, 34 (23%) passively and 87 (58.8%) passively in combination with gel packs. Variation of temperature was significantly different between the three methods. Passive cooling had a significant higher variation of temperature (SD of 0.89) than both passive cooling in combination with gel packs (SD of 0.79) and active cooling (SD of 0.76). aEEG before TH was obtained in 35.8% of the infants and 86.5% had full EEG. One cUS was performed in 95.3% and MRI in 62.2% of the infants. CONCLUSION Target temperature can be achieved with all three cooling methods. Passive cooling has the highest variation of temperature. Neuromonitoring should be improved in Swiss neonatal and paediatric intensive care units. Our results stress the importance of national registries.
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Affiliation(s)
- G Ramos
- Clinic of Neonatology, University Hospital Zurich, Zurich, Switzerland
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Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013; 2013:CD003311. [PMID: 23440789 PMCID: PMC7003568 DOI: 10.1002/14651858.cd003311.pub3] [Citation(s) in RCA: 769] [Impact Index Per Article: 69.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Newborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae without adverse effects. OBJECTIVES To determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long-term neurodevelopmental disability and clinically important side effects. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007). Randomised controlled trials evaluating therapeutic hypothermia in term and late preterm newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2007, Issue 2), MEDLINE (1966 to June 2007), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching. We updated this search in May 2012. SELECTION CRITERIA We included randomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic term or late preterm infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS Four review authors independently selected, assessed the quality of and extracted data from the included studies. Study authors were contacted for further information. Meta-analyses were performed using risk ratios (RR) and risk differences (RD) for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals (CI). MAIN RESULTS We included 11 randomised controlled trials in this updated review, comprising 1505 term and late preterm infants with moderate/severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (typical RR 0.75 (95% CI 0.68 to 0.83); typical RD -0.15, 95% CI -0.20 to -0.10); number needed to treat for an additional beneficial outcome (NNTB) 7 (95% CI 5 to 10) (8 studies, 1344 infants). Cooling also resulted in statistically significant reductions in mortality (typical RR 0.75 (95% CI 0.64 to 0.88), typical RD -0.09 (95% CI -0.13 to -0.04); NNTB 11 (95% CI 8 to 25) (11 studies, 1468 infants) and in neurodevelopmental disability in survivors (typical RR 0.77 (95% CI 0.63 to 0.94), typical RD -0.13 (95% CI -0.19 to -0.07); NNTB 8 (95% CI 5 to 14) (8 studies, 917 infants). Some adverse effects of hypothermia included an increase sinus bradycardia and a significant increase in thrombocytopenia. AUTHORS' CONCLUSIONS There is evidence from the 11 randomised controlled trials included in this systematic review (N = 1505 infants) that therapeutic hypothermia is beneficial in term and late preterm newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. Hypothermia should be instituted in term and late preterm infants with moderate-to-severe hypoxic ischaemic encephalopathy if identified before six hours of age. Further trials to determine the appropriate techniques of cooling, including refinement of patient selection, duration of cooling and method of providing therapeutic hypothermia, will refine our understanding of this intervention.
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Affiliation(s)
- Susan E Jacobs
- Neonatal Services, Royal Women’s Hospital, Parkville, Melbourne, Australia.
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Chang M. Therapeutic Hypothermia for Newborns with Hypoxic Ischemic Encephalopathy. NEONATAL MEDICINE 2013. [DOI: 10.5385/nm.2013.20.1.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Meayoung Chang
- Department of Pediatrics, Graduate School of Medicine, Chungnam National University, Daejeon, Korea
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Pearsall-Jones JG, Piek JP, Rigoli D, Martin NC, Levy F. An Investigation Into Etiological Pathways of DCD and ADHD Using a Monozygotic Twin Design. Twin Res Hum Genet 2012; 12:381-91. [DOI: 10.1375/twin.12.4.381] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AbstractWe previously described a co-twin control design using questionnaire data on monozygotic twins discordant and concordant for developmental coordination disorder (DCD) and attention deficit hyperactivity disorder (ADHD). Our results suggested that DCD and developmental ADHD had different causal pathways, and that second-born twins were at higher risk for oxygen perfusion problems than first-born twins. In the current study we further explored our findings using DNA confirmed zygosity and assessments of 4 female and 10 male sets of monozygotic twins, aged 8 to 17 years, from the first study. Using the McCarron Assessment of Neuromuscular Development (MAND), twice as many second- as first-born twins met criteria for DCD. Second-born twins attained significantly lower scores on 1-minute Apgar, MAND Gross Motor, Bimanual Dexterity and Neuromuscular Development Index. Seven of the nine twins who met criteria for DCD experienced perinatal oxygen perfusion problems. This supported findings in the first study of an association between perinatal oxygen perfusion problems and DCD, and our hypothesis that DCD and cerebral palsy have similar causal pathways. We found similar numbers of males and females discordant for DCD. On telephone interview using the Diagnostic Interview Schedule for Children Parent Interview, the only first-, and all five second-born twins who met criteria for ADHD had an inattentive component — three Inattentive; three Combined. All twins positive for ADHD were male. This adds support to our hypothesis that ADHD symptoms found in some participants may reflect secondary ADHD associated with environmental factors, rather than developmental ADHD.
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Takenouchi T, Iwata O, Nabetani M, Tamura M. Therapeutic hypothermia for neonatal encephalopathy: JSPNM & MHLW Japan Working Group Practice Guidelines Consensus Statement from the Working Group on Therapeutic Hypothermia for Neonatal Encephalopathy, Ministry of Health, Labor and Welfare (MHLW), Japan, and Japan Society for Perinatal and Neonatal Medicine (JSPNM). Brain Dev 2012; 34:165-70. [PMID: 21930356 DOI: 10.1016/j.braindev.2011.06.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 06/03/2011] [Accepted: 06/07/2011] [Indexed: 11/19/2022]
Abstract
Neonatal encephalopathy (NE) secondary to intrapartum asphyxia remains a major cause of post-natal death and permanent neurological deficits worldwide. Supportive therapy has been the mainstay of the treatment until recent series of large clinical trials demonstrating benefit of therapeutic hypothermia (TH) in this high risk population. Now the International Liaison Committee on Resuscitation (ILCOR) recommends TH as a standard of care with the protocols used in the large clinical trials as tentative standard protocols. Our goal is to develop a nationwide consensus practice guideline not only consistent with the international standard protocols but also practical and compatible with the current medical system in Japan. In summary, TH should be offered to newborn infants born ≥36 weeks gestational age and birth weight ≥1800 g exhibiting clinical signs of moderate to severe NE as well as evidence of hypoxia-ischemia, i.e. 10 min Apgar score ≤5, a need for resuscitation at 10 min, blood pH<7.00, or base deficit ≥16 mmol/L. TH should be conducted in the NICUs capable of multidisciplinary care and under the standard protocols, i.e. utilization of cooling device, target (rectal or esophageal) temperatures at 33.5±0.5 and 34.5±0.5°C for whole body and selective head cooling respectively, duration of TH for 72 h, gradual rewarming not exceeding the rate of 0.5°C/h. Long term follow-up with multidisciplinary approach including standardized psychological assessment is warranted.
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Affiliation(s)
- Toshiki Takenouchi
- Division of Pediatric Neurology, Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Abstract
Therapeutic hypothermia (TH) is the intentional reduction of core body temperature to 32°C to 35°C, and is increasingly applied by intensivists for a variety of acute neurological injuries to achieve neuroprotection and reduction of elevated intracranial pressure. TH improves outcomes in comatose patients after a cardiac arrest with a shockable rhythm, but other off-label applications exist and are likely to increase in the future. This comprehensive review summarizes the physiology and cellular mechanism of action of TH, as well as different means of TH induction and maintenance with potential side effects. Indications of TH are critically reviewed by disease entity, as reported in the most recent literature, and evidence-based recommendations are provided.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Jiaying Zhang
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
- Departments of Neurology (Division of Neurocritical Care), Anesthesia/Critical Care and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
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Higgins RD, Raju T, Edwards AD, Azzopardi DV, Bose CL, Clark RH, Ferriero DM, Guillet R, Gunn AJ, Hagberg H, Hirtz D, Inder TE, Jacobs SE, Jenkins D, Juul S, Laptook AR, Lucey JF, Maze M, Palmer C, Papile L, Pfister RH, Robertson NJ, Rutherford M, Shankaran S, Silverstein FS, Soll RF, Thoresen M, Walsh WF. Hypothermia and other treatment options for neonatal encephalopathy: an executive summary of the Eunice Kennedy Shriver NICHD workshop. J Pediatr 2011; 159:851-858.e1. [PMID: 21875719 PMCID: PMC3263823 DOI: 10.1016/j.jpeds.2011.08.004] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/16/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
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Targeted temperature management in critical care: a report and recommendations from five professional societies. Crit Care Med 2011; 39:1113-25. [PMID: 21187745 DOI: 10.1097/ccm.0b013e318206bab2] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Representatives of five international critical care societies convened topic specialists and a nonexpert jury to review, assess, and report on studies of targeted temperature management and to provide clinical recommendations. DATA SOURCES Questions were allocated to experts who reviewed their areas, made formal presentations, and responded to questions. Jurors also performed independent searches. Sources used for consensus derived exclusively from peer-reviewed reports of human and animal studies. STUDY SELECTION Question-specific studies were selected from literature searches; jurors independently determined the relevance of each study included in the synthesis. CONCLUSIONS AND RECOMMENDATIONS 1) The jury opines that the term "targeted temperature management" replace "therapeutic hypothermia." 2) The jury opines that descriptors (e.g., "mild") be replaced with explicit targeted temperature management profiles. 3) The jury opines that each report of a targeted temperature management trial enumerate the physiologic effects anticipated by the investigators and actually observed and/or measured in subjects in each arm of the trial as a strategy for increasing knowledge of the dose/duration/response characteristics of temperature management. This enumeration should be kept separate from the body of the report, be organized by body systems, and be made without assertions about the impact of any specific effect on the clinical outcome. 4) The jury STRONGLY RECOMMENDS targeted temperature management to a target of 32°C-34°C as the preferred treatment (vs. unstructured temperature management) of out-of-hospital adult cardiac arrest victims with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation (strong recommendation, moderate quality of evidence). 5) The jury WEAKLY RECOMMENDS the use of targeted temperature management to 33°C-35.5°C (vs. less structured management) in the treatment of term newborns who sustained asphyxia and exhibit acidosis and/or encephalopathy (weak recommendation, moderate quality of evidence).
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Cooper DJ. Induced hypothermia for neonatal hypoxic-ischemic encephalopathy: pathophysiology, current treatment, and nursing considerations. Neonatal Netw 2011; 30:29-35. [PMID: 21317095 DOI: 10.1891/0730-0832.30.1.29] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) can lead to devastating neurodevelopmental consequences such as cerebral palsy, seizure disorders, and significant developmental delays. HIE in the newborn is often the result of a hypoxic event, such as uterine rupture, placental abruption, or cord prolapse. Biphasic brain injury occurs in HIE. The first phase involves activation of the sympathetic nervous system as a compensatory mechanism. The second phase, known as reperfusion brain injury, occurs hours later. Induced hypothermia, a neuroprotective strategy for treating HIE, targets the second phase to prevent reperfusion injury. NICU nurses are in a unique position to detect patient instability and to maintain the therapeutic interventions that contribute to the healing process. This article highlights the significant role nurses play in the management of infants diagnosed with HIE who are treated with induced hypothermia.
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