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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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Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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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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Mackay CA, O'Dea MI, Athalye-Jape G. Therapeutic hypothermia for neonates with sudden unexpected postnatal collapse. Arch Dis Child 2023; 108:236-239. [PMID: 36600300 DOI: 10.1136/archdischild-2022-324916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Cheryl Anne Mackay
- Neonatology Directorate, King Edward Memorial Hospital for Women Perth, Subiaco, Western Australia, Australia
| | - Mary Isabel O'Dea
- Neonatology Directorate, King Edward Memorial Hospital for Women Perth, Subiaco, Western Australia, Australia.,Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Gayatri Athalye-Jape
- Neonatology Directorate, King Edward Memorial Hospital for Women Perth, Subiaco, Western Australia, Australia .,School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Bedetti L, Lugli L, Garetti E, Guidotti I, Roversi MF, Della Casa E, Miselli F, Bariola MC, Di Caprio A, Pugliese M, Ferrari F, Berardi A. Sudden Unexpected Postnatal Collapse and Therapeutic Hypothermia: What's Going On? CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121925. [PMID: 36553368 PMCID: PMC9776888 DOI: 10.3390/children9121925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Abstract
Sudden unexpected postnatal collapse (SUPC) is a rare event, potentially associated with catastrophic consequences. Since the beginning of the 2000s, therapeutic hypothermia (TH) has been proposed as a treatment for asphyxiated neonates after SUPC. However, only a few studies have reported the outcome of SUPC after TH. The current study presents the long-term neurodevelopmental outcome of four cases of SUPC treated with TH in a single Italian center. Furthermore, we reviewed the previous literature concerning 49 cases of SUPC treated with TH. Among 53 total cases (of whom four occurred in our center), 15 (28.3%) died before discharge from the NICU. A neurodevelopmental follow-up was available only for 21 (55.3%) out of the 38 surviving cases, and seven infants developed neurodevelopmental sequelae. TH should be considered in neonates with asphyxia after SUPC. However, SUPC is a rare event, and there is a lack of comparative clinical data to establish the risk/benefit of TH after SUPC with different degrees of asphyxia. Analysis of large cohorts of newborns with SUPC, whether treated with TH or untreated, are needed in order to better identify infants who should undergo TH.
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Affiliation(s)
- Luca Bedetti
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Licia Lugli
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
| | | | - Elisa Della Casa
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41121 Modena, Italy
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
- Correspondence:
| | - Maria Carolina Bariola
- Pediatric Post-Graduate School, University Hospital of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Antonella Di Caprio
- Pediatric Post-Graduate School, University Hospital of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Marisa Pugliese
- Psychology Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Fabrizio Ferrari
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy
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Legge N, Guaran R. Critical bleeding protocol for infants used for a catastrophic subgaleal haemorrhage. J Paediatr Child Health 2022; 58:542-545. [PMID: 34043250 DOI: 10.1111/jpc.15591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Nele Legge
- Neonatal Intensive Care, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Robert Guaran
- Neonatal Intensive Care, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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Ten years since the introduction of therapeutic hypothermia in neonates with perinatal hypoxic-ischaemic encephalopathy in Spain. NEUROLOGÍA (ENGLISH EDITION) 2022:S2173-5808(22)00018-9. [DOI: 10.1016/j.nrleng.2020.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/31/2020] [Indexed: 11/17/2022] Open
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Torre Monmany N, Maya Gallego S, Esclapés Giménez T, Sardà Sánchez M, Rodríguez Losada O, Martínez Planas A, Oller Fradera O, Alarcón A, Esteban E. Challenges in the application of non-servocontrolled therapeutic hypothermia during neonatal transport in Catalonia. An Pediatr (Barc) 2021; 95:459-466. [PMID: 34844879 DOI: 10.1016/j.anpede.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) improves survival and neurological prognosis in hypoxic-ischemic encephalopathic (HIE) babies, being better the sooner TH is implemented. HIE babies are born more frequently in a non-cooling centre and need to be referred. METHODS Prospective-observational study (April 18 2018 - November 19 2019). Newborns (≥34 weeks of gestational age (GA) and >1800 g) with moderate/severe HIE on non-servocontrolled therapeutic hypothermia by the two neonatal transport teams in Catalonia. RESULTS 51 newborns. The median stabilisation and transport time were 68 min (p25-75, 45-85 min) and 30 min (p25-75, 15-45 min), respectively. The mean age at arrival at the receiving unit was 4 h and 18 min (SD 96.6). The incubator was set off in 43 (84%), iced-packs 11 (21.5%) and both (11, 21.5%). Target temperature was reached in 19 (37.3%) babies. There were no differences in the overcooling in relation to the measures applied. The transport duration was not related with temperature stabilisation or target temperature reachiness. CONCLUSIONS Rectal temperature monitorisation is compulsory for the stabilisation and the application of non-servocontrolled hypothermia during transport. There is still time for improving in the administration of this treatment during transport. Servo-controlled hypothermia would be a better alternative to improve the management of HIE babies.
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Affiliation(s)
- Nuria Torre Monmany
- Neonatal and Paediatric Transport Unit. Sant Joan de Déu Hospital, Esplugues de Llobregat. Spain; Neonatal unit, Parc Taulí Hospital, Sabadell, Spain; Aerial Paediatric and Neonatal Transport Unit, Parc Taulí Hospital, Sabadell, Spain.
| | - Sara Maya Gallego
- Neonatal and Paediatric Transport Unit. Sant Joan de Déu Hospital, Esplugues de Llobregat. Spain
| | - Teresa Esclapés Giménez
- Neonatal and Paediatric Transport Unit, Vall Hebrón Hospital, Barcelona, Spain; Neonatology Unit, Vall Hebrón Hospital, Barcelona, Spain
| | - Marta Sardà Sánchez
- Neonatal and Paediatric Transport Unit. Sant Joan de Déu Hospital, Esplugues de Llobregat. Spain; Neonatal unit, Parc Taulí Hospital, Sabadell, Spain; Aerial Paediatric and Neonatal Transport Unit, Parc Taulí Hospital, Sabadell, Spain
| | | | - Aina Martínez Planas
- Neonatal and Paediatric Transport Unit. Sant Joan de Déu Hospital, Esplugues de Llobregat. Spain; Paediatric hospitalization unit, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Olga Oller Fradera
- Neonatal and Paediatric Transport Unit, Vall Hebrón Hospital, Barcelona, Spain; Paediatric Intensive Care Unit, Vall Hebrón Hospital, Barcelona, Spain
| | - Ana Alarcón
- Neonatology Unit, Sant Joan de Déu Hospital, Esplugues de Llobregat, Spain; Sant Joan de Déu research unit, Barcelona university, Esplugues de Llobregat, Spain
| | - Elisabeth Esteban
- Neonatal and Paediatric Transport Unit. Sant Joan de Déu Hospital, Esplugues de Llobregat. Spain; Paediatric Intensive Care Unit, Sant Joan de Déu Hospital, Esplugues de Llobregat, Spain
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Torre Monmany N, Maya Gallego S, Esclapés Giménez T, Sardà Sánchez M, Rodríguez Losada O, Martínez Planas A, Oller Fradera O, Alarcón A, Esteban E. [Challenges in the application of non-servocontrolled therapeutic hypothermia during neonatal transport in Catalonia]. An Pediatr (Barc) 2021; 95:S1695-4033(21)00243-5. [PMID: 34462230 DOI: 10.1016/j.anpedi.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) improves survival and neurological prognosis in hypoxic-ischemic encephalopathic (HIE) babies, being better the sooner TH is implemented. HIE babies are born more frequently in a non-cooling centre and need to be referred. METHODS Prospective-observational study (April 18-November 19). Newborns (≥34 weeks of gestational age (GA) and >1800g) with moderate/severe HIE on non-servocontrolled therapeutic hypothermia by the two neonatal transport teams in Catalonia. RESULTS 51 newborns. The median stabilisation and transport time were 68min (p25-75, 45-85min) and 30min (p25-75, 15-45min), respectively. The mean age at arrival at the receiving unit was 4h and 18min (SD 96.6). The incubator was set off in 43 (84%), iced-packs 11 (21.5%) and both (11, 21.5%). Target temperature was reached in 19 (37.3%) babies. There was no differences in the overcooling in relation to the measures applied. The transport duration was not related with temperature stabilisation or target temperature reachiness. CONCLUSIONS Rectal temperature monitorisation is compulsory for the stabilisation and the application of non-servocontrolled hypothermia during transport. There is still time for improving in the administration of this treatment during transport. Servo-controlled hypothermia would be a better alternative to improve the management of HIE babies.
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Affiliation(s)
- Nuria Torre Monmany
- Unidad de Transporte Pediátrico y Neonatal, Hospital Sant Joan de Déu, Esplugues de Llobregat, España; Unidad de Neonatología, Hospital Parc Taulí, Sabadell, España; Unidad de Transporte Aéreo Pediátrico y Neonatal, Hospital Parc Taulí, Sabadell, España.
| | - Sara Maya Gallego
- Unidad de Transporte Pediátrico y Neonatal, Hospital Sant Joan de Déu, Esplugues de Llobregat, España
| | - Teresa Esclapés Giménez
- Unidad de Transporte Pediátrico y Neonatal, Hospital Vall d'Hebrón, Barcelona, España; Unidad de Neonatología, Hospital Vall d'Hebrón, Barcelona, España
| | - Marta Sardà Sánchez
- Unidad de Transporte Pediátrico y Neonatal, Hospital Sant Joan de Déu, Esplugues de Llobregat, España; Unidad de Neonatología, Hospital Parc Taulí, Sabadell, España; Unidad de Transporte Aéreo Pediátrico y Neonatal, Hospital Parc Taulí, Sabadell, España
| | | | - Aina Martínez Planas
- Unidad de Transporte Pediátrico y Neonatal, Hospital Sant Joan de Déu, Esplugues de Llobregat, España; Unidad de Hospitalización de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona. España
| | - Olga Oller Fradera
- Unidad de Transporte Pediátrico y Neonatal, Hospital Vall d'Hebrón, Barcelona, España; Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Vall d'Hebrón, Barcelona, España
| | - Ana Alarcón
- Unidad de Neonatología, Hospital Sant Joan de Déu, Esplugues de Llobregat, España; Institut de Recerca de Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, España
| | - Elisabeth Esteban
- Unidad de Transporte Pediátrico y Neonatal, Hospital Sant Joan de Déu, Esplugues de Llobregat, España; Unidad de Cuidados Intensivos Pediátricos, Hospital Sant Joan de Déu, Esplugues de Llobregat, España
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Gundersen JK, Chakkarapani E, Jary S, Menassa DA, Scull-Brown E, Frymoyer A, Walløe L, Thoresen M. Morphine and fentanyl exposure during therapeutic hypothermia does not impair neurodevelopment. EClinicalMedicine 2021; 36:100892. [PMID: 34308308 PMCID: PMC8257990 DOI: 10.1016/j.eclinm.2021.100892] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypothermia-treated and intubated infants with moderate or severe hypoxic-ischemic encephalopathy (HIE) usually receive morphine for sedation and analgesia (SA) during therapeutic hypothermia (TH) and endotracheal ventilation. Altered drug pharmacokinetics in this population increases the risk of drug accumulation. Opioids are neurotoxic in preterm infants. In term infants undergoing TH, the long-term effects of morphine exposure are unknown. We examined the effect of opioid administration during TH on neurodevelopmental outcome and time to extubation after sedation ended. METHODS In this prospectively collected population-based cohort of 282 infants with HIE treated with TH (2007-2017), the cumulative opioid dose of morphine and equipotent fentanyl (10-60 µg/kg/h) administered during the first week of life was calculated. Clinical outcomes and concomitant medications were also collected. Of 258 survivors, 229 underwent Bayley-3 neurodevelopmental assessments of cognition, language and motor function at 18-24 months. Multivariate stepwise linear regression analysis was used to examine the relation between cumulative opioid dose and Bayley-3 scores. Three severity-groups (mild-moderate-severe) were stratified by early (<6 h) amplitude-integrated electroencephalography (aEEG) patterns. FINDINGS The cumulative dose of opioid administered as SA during TH was median (IQR) 2121 µg/kg (1343, 2741). Time to extubation was independent of SA dose (p > 0.2). There was no significant association between cumulative SA dose and any of the Bayley-3 domains when analysing the entire cohort or any of the aEEG severity groups. INTERPRETATION Higher cumulative opioid doses in TH-treated infants with HIE was not associated with worse Bayley-3 scores at 18-24 months of age. FUNDING The Bristol cooling program was funded by the Children's Medical Research Charity SPARKS managing donations for our research from the UK and US, the UK Moulton Foundation, the Lærdal Foundation for Acute Medicine in Norway and the Norwegian Research Council (JKG).
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Affiliation(s)
- Julia K Gundersen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David A Menassa
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- The Queen's College, University of Oxford, Oxford, United Kingdom
| | - Emma Scull-Brown
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, California, United States
| | - Lars Walløe
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Thoresen M, Jary S, Walløe L, Karlsson M, Martinez-Biarge M, Chakkarapani E, Cowan FM. MRI combined with early clinical variables are excellent outcome predictors for newborn infants undergoing therapeutic hypothermia after perinatal asphyxia. EClinicalMedicine 2021; 36:100885. [PMID: 34308304 PMCID: PMC8257962 DOI: 10.1016/j.eclinm.2021.100885] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Binary prediction-models for outcome [death, cognition, presence and severity of cerebral palsy (CP)], using MRI and early clinical data applicable for individual outcome prediction have not been developed. METHODS From Dec 1st 2006 until Dec 31st 2013, we recruited 178 infants into a population-based cohort with moderate or severe hypoxic-ischaemic encephalopathy (HIE) including postnatal collapse (PNC, n = 12) and additional diagnoses (n = 12) using CoolCap/TOBY-trial entry-criteria including depressed amplitude-integrated EEG (aEEG). Early clinical/biochemical variables and MRI scans (median day 8) were obtained in 168 infants. Injury severity was scored for cortex, basal ganglia/thalami (BGT), white matter (WM) and posterior limb of the internal capsule, summating to a total injury score (TIS, range 0-11). Outcome was categorized as adverse or favourable at 18-24 months from Bayley-III domains (cut-off 85) and neurological examination including CP classification. FINDINGS HIE and entry-aEEG severity were stable throughout the study. Outcome was favourable in 133/178 infants and adverse in 45/178: 17 died, 28 had low Cognition/Language scores, (including 9 with severe CP and 6 mild); seven had mild CP with favourable cognitive outcome. WMxBGT product scores and TIS were strong outcome predictors, and prediction improved when clinical/biochemical variables were added in binary logistic regression. The Positive Predictive Value for adverse outcome was 88%, increasing to 95% after excluding infants with PNC and additional diagnoses. Using WMxBGT in the regression predicted 8 of the 9 children with severe CP. INTERPRETATION Binary logistic regression with WMxBGT or TIS and clinical variables gave excellent outcome prediction being 12% better than single variable cross-tabulation. Our MRI scoring and regression models are readily accessible and deserve investigation in other cohorts for group and individual prediction. FUNDING We thank the National Health Service (NHS) and our Universities and funders in UK and Norway: SPARKS, The Moulton Foundation, The Norwegian Research Council, The Lærdal Foundation for Acute Medicine and charitable donations for their support for cooling therapy.
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Key Words
- BGT, Basal ganglia/thalami
- BIC, Bayesian information criterion
- Basal ganglia and thalamus
- Bayley-III
- Bayley-III, Bayley Scales of Infant & Toddler Development 3rd edition
- CLC, Cognitive and Language Composite from the Bayley-III scales
- CP, Cerebral palsy
- CX, Cortex
- Cerebral palsy
- Cortex
- DWI, Diffusion-weighted imaging
- GA, Gestational age
- GMFCS, Gross Motor Function Classification System
- HIE, Hypoxic-ischaemic encephalopathy
- Hypoxic-ischaemic encephalopathy
- ILEA, International League Against Epilepsy
- IQR, Interquartile range
- LDH72h, Lactate dehydrogenase close to 72h post-asphyxial event
- LDHpeak, Highest LDH in the first 3 days
- Logistic regression
- MRI
- MRI, Magnetic Resonance Imaging
- Moderate or severe perinatal asphyxia
- NPV, Negative Predictive Value
- Neonatal seizures
- Neurodevelopmental outcome
- Outcome prediction
- PA, Predictive Accuracy
- PLIC, Posterior limb of the internal capsule
- PNC, Postnatal collapse
- PPV, Positive Predictive Value
- Posterior limb of the internal capsule
- RCT, Randomised controlled trial
- Se, Sensitivity
- Sp, Specificity
- T1 and T2
- TH, Therapeutic hypothermia
- TIS, Total injury score
- Therapeutic hypothermia
- WMxBGT, Product of white matter and basal ganglia/thalami scores
- White matter
- aEEG, amplitude integrated electroencephalography
- h, hours
- lactatehrs<5mmol, plasma lactate recovery time
- m, months
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Affiliation(s)
- Marianne Thoresen
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Sally Jary
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Lars Walløe
- Section for Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Mathias Karlsson
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Medical Sciences, Biomedical Structure and Function, Uppsala University, Uppsala, Sweden
| | - Miriam Martinez-Biarge
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Ela Chakkarapani
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Frances M Cowan
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Paediatrics, Imperial College London, London, United Kingdom
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12
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McAdams RM, Berube MW. Emerging therapies and management for neonatal encephalopathy-controversies and current approaches. J Perinatol 2021; 41:661-674. [PMID: 33712717 DOI: 10.1038/s41372-021-01022-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 01/31/2023]
Abstract
Neonatal encephalopathy (NE) continues to have a major impact on newborn survival and neurodevelopmental outcomes worldwide. In high-income settings, therapeutic hypothermia is the only established standard treatment for neonates with moderate-to-severe NE, with compelling evidence that cooling reduces mortality and major neurodevelopmental impairment in survivors. Despite therapeutic hypothermia, a significant proportion of cooled infants continue to suffer long-term disability from brain injury. Innovative therapies offer the possibility of further improving neurodevelopmental outcomes by working synergistically with therapeutic hypothermia to decrease hypoxia-ischemia-induced excitotoxicity, prevent progression to secondary energy failure, and in some cases, promote neuroregeneration in the developing neonatal brain. This review discusses emerging NE therapies currently under investigation, offers insight into controversies surrounding various approaches to clinical care during therapeutic hypothermia, and identifies ongoing knowledge deficits that hinder attainment of optimal outcomes for neonates with NE.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Megan W Berube
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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13
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Alake O, Rana R, Jain A, Chakkarapani E. Therapeutic hypothermia and outcome in hyponatraemic encephalopathy secondary to maternal water intoxication. BMJ Case Rep 2021; 14:e237213. [PMID: 33731399 PMCID: PMC7978085 DOI: 10.1136/bcr-2020-237213] [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] [Accepted: 02/28/2021] [Indexed: 11/03/2022] Open
Abstract
Misguided encouragement to consume large volumes of water during labour for pain relief results in dilutional hyponatraemia in mothers and their babies presenting with neurological dysfunction. We report three babies who were encephalopathic with seizures in the background of hyponatraemia secondary to maternal ingestion of large volumes of water and mild perinatal asphyxia. All babies underwent therapeutic hypothermia in addition to sodium supplementation with fluid restriction. Their neurodevelopment was appropriate for age. This case series highlights the dilemma that could arise with hyponatraemic encephalopathy and mild perinatal asphyxia in the first 6 hours of life, which is the window of opportunity for therapeutic hypothermia for hypoxic-ischaemic encephalopathy. It is important to educate pregnant mothers in labour on the adverse effects of excessive fluid ingestion.
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Affiliation(s)
- Oluwaseyi Alake
- Regional Neonatal Intensive Care Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Reena Rana
- Regional Neonatal Intensive Care Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Anoo Jain
- Regional Neonatal Intensive Care Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ela Chakkarapani
- Regional Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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14
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王 贝, 阚 清, 邹 芸, 程 锐, 周 晓. [Sudden unexpected postnatal collapse in a neonate]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:283-287. [PMID: 33691923 PMCID: PMC7969186 DOI: 10.7499/j.issn.1008-8830.2012020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/05/2021] [Indexed: 06/12/2023]
Abstract
A healthy full-term female neonate, aged 3 days and born by vaginal delivery (with a 1-minute Apgar score of 10 and a 5-minute Apgar score of 10), had unexpected cardiac and respiratory arrests in the early morning on day 3 after birth and recovered to spontaneous breathing and heartbeat after a 10-minute resuscitation. The child had poor response and convulsion after resuscitation. Blood gas analysis showed metabolic acidosis, and amplitude-integrated EEG showed a burst-suppression pattern. She was diagnosed with sudden unexpected postnatal collapse but improved after hypothermia and symptomatic/supportive treatment. This article reports the first case of sudden unexpected postnatal collapse in China and summarizes related risk factors, pathophysiological mechanisms, and preventive and treatment measures of this disorder.
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Affiliation(s)
- 贝贝 王
- />南京医科大学附属儿童医院新生儿医疗中心, 江苏南京 210008Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - 清 阚
- />南京医科大学附属儿童医院新生儿医疗中心, 江苏南京 210008Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - 芸苏 邹
- />南京医科大学附属儿童医院新生儿医疗中心, 江苏南京 210008Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - 锐 程
- />南京医科大学附属儿童医院新生儿医疗中心, 江苏南京 210008Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - 晓光 周
- />南京医科大学附属儿童医院新生儿医疗中心, 江苏南京 210008Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
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15
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Pisani F, Fusco C, Nagarajan L, Spagnoli C. Acute symptomatic neonatal seizures, brain injury, and long-term outcome: The role of neuroprotective strategies. Expert Rev Neurother 2020; 21:189-203. [PMID: 33176104 DOI: 10.1080/14737175.2021.1848547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal seizures are frequent but underdiagnosed manifestations of acute brain dysfunction and an important contributor to unfavorable outcomes. Etiology and severity of brain injury are the single strongest outcome determinants. AREAS COVERED The authors will discuss the prognostic role of acute symptomatic seizures versus brain injury and the main neuroprotective and neurorestorative strategies for full-term and preterm infants. EXPERT OPINION Prolonged acute symptomatic seizures likely contribute to long-term outcomes by independently adding further brain injury to initial insults. Correct timing and dosing of therapeutic interventions, depending on etiology and gestational ages, need careful evaluation. Although promising strategies are under study, the only standard of care is whole-body therapeutic hypothermia in full-term newborns with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine and Surgery Department, University of Parma , Parma, Italy
| | - Carlo Fusco
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, University of Western Australia , Perth, Australia
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
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16
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Garcia-Alix A, Arnaez J, Herranz-Rubia N, Alarcón A, Arca G, Valverde E, Blanco D, Lubian S. Ten years since the introduction of therapeutic hypothermia in neonates with perinatal hypoxic-ischaemic encephalopathy in Spain. Neurologia 2020; 38:S0213-4853(20)30227-9. [PMID: 32988661 DOI: 10.1016/j.nrl.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/01/2020] [Accepted: 05/31/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION More than a decade has passed since therapeutic hypothermia (TH) was introduced in Spain; this is the only neuroprotective intervention that has become standard practice in the treatment of perinatal hypoxic-ischaemic encephalopathy (HIE). This article aims to provide a current picture of the technique and to address the controversies surrounding its use. DEVELOPMENT In the last 10 years, TH has been successfully implemented in the vast majority of tertiary hospitals in Spain, and more than 85% of newborns with moderate or severe HIE currently receive the treatment. The factors that can improve the efficacy of TH include early treatment onset (first 6hours of life) and the control of comorbid factors associated with perinatal asphyxia. In patients with moderate HIE, treatment onset after 6hours seems to have some neuroprotective efficacy. TH duration longer than 72hours or deeper hypothermia do not offer greater neuroprotective efficacy, but instead increase the risk of adverse effects. Unclarified aspects are the sedation of patients during TH, the application of the treatment in infants with mild HIE, and its application in other scenarios. Prognostic information and time frame are one of the most challenging aspects. CONCLUSIONS TH is universal in countries with sufficient economic resources, although certain unresolved controversies remain. While the treatment is widespread in Spain, there is a need for cooling devices for the transfer of these patients and their centralisation.
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Affiliation(s)
- A Garcia-Alix
- Institut de Recerca Sant Joan de Déu, Hospital Universitario Sant Joan de Dèu, Barcelona, España; Universidad de Barcelona, Barcelona, España; Fundación NeNe, España; Grupo Cerebro Neonatal.
| | - J Arnaez
- Unidad de Neonatología, Hospital Universitario de Burgos, Burgos, España; Fundación NeNe, España; Grupo Cerebro Neonatal
| | - N Herranz-Rubia
- Institut de Recerca Sant Joan de Déu, Hospital Universitario Sant Joan de Dèu, Barcelona, España; Servicio de Neonatología. Hospital Sant Joan de Dèu, Barcelona, España; Universidad de Barcelona, Barcelona, España
| | - A Alarcón
- Institut de Recerca Sant Joan de Déu, Hospital Universitario Sant Joan de Dèu, Barcelona, España; Servicio de Neonatología. Hospital Sant Joan de Dèu, Barcelona, España; Grupo Cerebro Neonatal
| | - G Arca
- Departamento de Neonatología, Hospital Clinic, IDIBAPS, Barcelona, España; Fundación NeNe, España; Grupo Cerebro Neonatal
| | - E Valverde
- Servicio de Neonatología, Hospital Universitario La Paz, Madrid, España; Fundación NeNe, España; Grupo Cerebro Neonatal
| | - D Blanco
- Servicio de Neonatología, Hospital Gregorio Marañón, Madrid, España; Grupo Cerebro Neonatal
| | - S Lubian
- Servicio de Neonatología, Hospital Puerta del Mar, Cádiz, España; Fundación NeNe, España; Grupo Cerebro Neonatal
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17
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Ophelders DR, Gussenhoven R, Klein L, Jellema RK, Westerlaken RJ, Hütten MC, Vermeulen J, Wassink G, Gunn AJ, Wolfs TG. Preterm Brain Injury, Antenatal Triggers, and Therapeutics: Timing Is Key. Cells 2020; 9:E1871. [PMID: 32785181 PMCID: PMC7464163 DOI: 10.3390/cells9081871] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
With a worldwide incidence of 15 million cases, preterm birth is a major contributor to neonatal mortality and morbidity, and concomitant social and economic burden Preterm infants are predisposed to life-long neurological disorders due to the immaturity of the brain. The risks are inversely proportional to maturity at birth. In the majority of extremely preterm infants (<28 weeks' gestation), perinatal brain injury is associated with exposure to multiple inflammatory perinatal triggers that include antenatal infection (i.e., chorioamnionitis), hypoxia-ischemia, and various postnatal injurious triggers (i.e., oxidative stress, sepsis, mechanical ventilation, hemodynamic instability). These perinatal insults cause a self-perpetuating cascade of peripheral and cerebral inflammation that plays a critical role in the etiology of diffuse white and grey matter injuries that underlies a spectrum of connectivity deficits in survivors from extremely preterm birth. This review focuses on chorioamnionitis and hypoxia-ischemia, which are two important antenatal risk factors for preterm brain injury, and highlights the latest insights on its pathophysiology, potential treatment, and future perspectives to narrow the translational gap between preclinical research and clinical applications.
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Affiliation(s)
- Daan R.M.G. Ophelders
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Ruth Gussenhoven
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Luise Klein
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Reint K. Jellema
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Rob J.J. Westerlaken
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Matthias C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jeroen Vermeulen
- Department of Pediatric Neurology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands;
| | - Guido Wassink
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Alistair J. Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Tim G.A.M. Wolfs
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
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Lin JJ, Hsia SH, Chiang MC, Lin KL. Clinical application of target temperature management in children with acute encephalopathy-A practical review. Biomed J 2020; 43:211-217. [PMID: 32611538 PMCID: PMC7424089 DOI: 10.1016/j.bj.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/07/2019] [Accepted: 12/08/2019] [Indexed: 12/29/2022] Open
Abstract
Acute encephalopathy is a life-threatening disease involving acute brain dysfunction, and it is one of the most important causes of mortality and severe neurological sequelae in infants and children. Approximately 30% of cases of acute encephalopathy result in some degree of neurological sequelae. Although many strategies have been proposed, effective therapies to ameliorate the outcomes of acute encephalopathy have not yet been established. Target temperature management (TTM), previously termed therapeutic hypothermia, has been shown to be effective for various brain injuries due to multiple neuroprotective mechanisms, and it may be considered to be the cornerstone of neuroprotective strategies. Consequently, TTM is currently used in the neurocritical care of adult patients with cardiac arrest with shockable rhythm and perinatal asphyxia. In addition, increasing evidence also indicates that TTM could be useful in other acute encephalopathies, including status epilepticus, acute encephalitis/encephalopathy and traumatic brain injury. In this review, we discuss the recent practical aspects of TTM as a potential intervention for various acute encephalopathies in children.
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Affiliation(s)
- Jainn-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Hsuan Hsia
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Neonatology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Finder M, Boylan GB, Twomey D, Ahearne C, Murray DM, Hallberg B. Two-Year Neurodevelopmental Outcomes After Mild Hypoxic Ischemic Encephalopathy in the Era of Therapeutic Hypothermia. JAMA Pediatr 2020; 174:48-55. [PMID: 31710357 PMCID: PMC6865301 DOI: 10.1001/jamapediatrics.2019.4011] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Therapeutic hypothermia reduces risk of death and disability in infants with moderate to severe hypoxic ischemic encephalopathy (HIE). Randomized clinical trials of therapeutic hypothermia to date have not included infants with mild HIE because of a perceived good prognosis. OBJECTIVE To test the hypothesis that children with mild HIE have worse neurodevelopmental outcomes than their healthy peers. DESIGN, SETTING, AND PARTICIPANTS Analysis of pooled data from 4 prospective cohort studies in Cork, Ireland, and Stockholm, Sweden, between January 2007 and August 2015. The dates of data analysis were September 2017 to June 2019. Follow-up was performed at age 18 to 42 months. In this multicenter cohort study, all children were born or treated at the tertiary centers of Cork University Maternity Hospital, Cork, Ireland, or Karolinska University Hospital, Stockholm, Sweden. In all, 690 children were eligible for this study. EXPOSURES At discharge, all children were categorized into the following 5 groups using a modified Sarnat score: healthy controls, perinatal asphyxia (PA) without HIE, mild HIE, moderate HIE, and severe HIE. MAIN OUTCOMES AND MEASURES Cognitive, language, and motor development were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition (BSITD-III). The BSITD-III scores are standardized to a mean (SD) of 100 (15), with lower scores indicating risk of developmental delay. RESULTS Of the 690 children eligible for this study, 2-year follow-up data were available in 471 (mean [SD] age at follow-up, 25.6 [5.7] months; 54.8% male), including 152 controls, 185 children with PA without HIE, and 134 children with HIE, of whom 14 had died. Infants with mild HIE (n = 55) had lower cognitive composite scores compared with controls, with a mean (SD) of 97.6 (11.9) vs 103.6 (14.6); the crude mean difference was -6.0 (95% CI, -9.9 to -2.1), and the adjusted mean difference was -5.2 (95% CI, -9.1 to -1.3). There was no significant difference in the mean cognitive composite scores between untreated children (n = 47) with mild HIE and surviving children with moderate HIE (n = 53) treated with therapeutic hypothermia, with a crude mean difference for mild vs moderate of -2.2 (95% CI, -8.1 to 3.7). CONCLUSIONS AND RELEVANCE This study's findings suggest that, at age 2 years, the cognitive composite scores of children with a history of mild HIE may be lower than those of a contemporaneous control group and may not be significantly different from those of survivors of moderate HIE treated with therapeutic hypothermia.
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Affiliation(s)
- Mikael Finder
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden,Neonatal Department, Karolinska University Hospital, Stockholm, Sweden
| | - Geraldine B. Boylan
- INFANT Research Centre, Ireland, University College Cork, Cork, Ireland,Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland
| | - Deirdre Twomey
- INFANT Research Centre, Ireland, University College Cork, Cork, Ireland,Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland
| | - Caroline Ahearne
- INFANT Research Centre, Ireland, University College Cork, Cork, Ireland,Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland
| | - Deirdre M. Murray
- INFANT Research Centre, Ireland, University College Cork, Cork, Ireland,Department of Paediatrics and Child Health, Cork University Hospital, Cork, Ireland
| | - Boubou Hallberg
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden,Neonatal Department, Karolinska University Hospital, Stockholm, Sweden
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Prevention of excessive hypothermia in infants with hypoxic ischemic encephalopathy prior to admission to a quaternary care center: a neonatal outreach educational project. J Perinatol 2019; 39:1417-1427. [PMID: 31092886 DOI: 10.1038/s41372-019-0391-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/28/2019] [Accepted: 04/02/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Excessive hypothermia is common in infants that receive passive cooling for hypoxic ischemic encephalopathy (HIE). Our goal was to reduce the number of infants with admission temperature <33 °C from 33% to less than 10% by December 2017. METHODS Outcome measures included the number of infants with admission temperature <33 °C and number of infants with temperature within therapeutic range. Interventions included implementation of passive cooling guidelines and outreach education to birth hospitals and transport team. We used statistical process control chart to compare outcomes over a 3 year period. RESULTS The number of infants with admission temperature <33 °C decreased from 33.3% to 5.5% (p = 0.013). The number of infants with admission temperature within target range for hypothermia therapy increased from 61.1% to 77.7% (p = 0.014). Balancing measures and complications remained unchanged. CONCLUSION Implementation of passive cooling guidelines and outreach education led to significant decrease in excessive hypothermia in infants with HIE.
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Jary S, Lee‐Kelland R, Tonks J, Cowan FM, Thoresen M, Chakkarapani E. Motor performance and cognitive correlates in children cooled for neonatal encephalopathy without cerebral palsy at school age. Acta Paediatr 2019; 108:1773-1780. [PMID: 30883895 DOI: 10.1111/apa.14780] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 12/29/2022]
Abstract
AIM To investigate whether motor performance in school-age children without cerebral palsy (CP), cooled for neonatal encephalopathy, is associated with perinatal factors and 18-month developmental scores and to explore relationships between school-age motor and cognitive performance. METHODS Motor and cognitive performance was assessed in 29 previously cooled children at six to eight years using the Movement Assessment Battery for Children-2 (MABC-2) and the Wechsler Intelligence Scale for Children (WISC-IV). Associations between MABC-2 scores less than/equal (≤) 15th centile and perinatal factors, social/family background, 18-month Bayley-III scores and WISC-IV scores were explored. RESULTS Eleven of the 29 (38%) children had MABC-2 scores ≤15th centile including 7 (24%) ≤5th centile. No significant perinatal or socio-economic risk factors were identified. Motor scores <85 at 18 months failed to identify children with MABC-2 scores ≤15th centile. MABC-2 scores ≤15th centile were associated with lower Full Scale IQ (p = 0.045), Working Memory (p = 0.03) and Perceptual Reasoning (p = 0.005) scores at six to eight years and receiving greater support in school (p = 0.01). CONCLUSION A third of cooled children without CP had MABC-2 scores indicating motor impairment at school age that was not identified at 18 months by Bayley-III. Most children with low MABC scores needed support at school. Sub-optimal MABC-2 scores indicate need for detailed school-age cognitive evaluation.
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Affiliation(s)
- S Jary
- Translational Health Sciences Bristol Medical School University of Bristol Bristol UK
| | - R Lee‐Kelland
- Translational Health Sciences Bristol Medical School University of Bristol Bristol UK
| | - J Tonks
- University of Exeter Medical School Exeter UK
| | - F M Cowan
- Translational Health Sciences Bristol Medical School University of Bristol Bristol UK
| | - M Thoresen
- Translational Health Sciences Bristol Medical School University of Bristol Bristol UK
- University of Oslo Oslo Norway
| | - E Chakkarapani
- Translational Health Sciences Bristol Medical School University of Bristol Bristol UK
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Bingham A, Laptook AR. Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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23
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Abstract
This review of Sudden Unexpected Postnatal Collapse (SUPC) highlights the challenges in definition and nomenclature that currently exist. In comparing SUPC with Sudden Unexpected Death in Infancy (SUDI), the potentially avoidable nature of many SUPC is emphasised and the role of positioning and public awareness explored. The article focusses on the implementation of preventative strategies in the immediate postnatal period and the role of therapeutic hypothermia in ameliorating long term neurological injury.
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Affiliation(s)
- Vix Monnelly
- Department of Neonatology, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, EH16 4SA, United Kingdom.
| | - Julie-Clare Becher
- Department of Neonatology, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, EH16 4SA, United Kingdom.
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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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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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27
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Affiliation(s)
- Stephanie L Bourque
- Department of Pediatrics, Section of Neonatology, University of Colorado, Aurora, CO, USA
| | - Robert M Dietz
- Department of Pediatrics, Section of Neonatology, University of Colorado, Aurora, CO, USA
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28
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Burnsed J, Zanelli SA. Neonatal therapeutic hypothermia outside of standard guidelines: a survey of U.S. neonatologists. Acta Paediatr 2017; 106:1772-1779. [PMID: 28695691 DOI: 10.1111/apa.13983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/09/2017] [Accepted: 07/05/2017] [Indexed: 11/28/2022]
Abstract
AIM Therapeutic hypothermia is standard of care in term infants with moderate-to-severe hypoxic-ischaemic encephalopathy (HIE). The goal of this survey was to explore the attitudes of U.S. neonatologists caring for infants with HIE who fall outside of current guidelines. METHODS Case-based survey administered to members of the Section on Neonatal-Perinatal Medicine of the American Academy of Pediatrics. RESULTS A total of 447 responses were analysed, a response rate of 19%. We found significant variability amongst U.S. neonatologists with regard to the use of therapeutic hypothermia for infants with HIE who fall outside standard inclusion criteria. Scenarios with the most variability included HIE in a late preterm infant and HIE following a postnatal code. Provision of therapeutic hypothermia outside of standard guidelines was not influenced by number of years in practice, neonatal intensive care type (NICU) or NICU size. CONCLUSION Significant variability in practice exists when caring for infants with HIE who do not meet standard inclusion criteria, emphasizing the need for continued and rigorous research in this area.
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Affiliation(s)
- Jennifer Burnsed
- Department of Pediatrics; University of Virginia; Charlottesville VA USA
| | - Santina A. Zanelli
- Department of Pediatrics; University of Virginia; Charlottesville VA USA
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29
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Laptook AR, Shankaran S, Tyson JE, Munoz B, Bell EF, Goldberg RN, Parikh NA, Ambalavanan N, Pedroza C, Pappas A, Das A, Chaudhary AS, Ehrenkranz RA, Hensman AM, Van Meurs KP, Chalak LF, Khan AM, Hamrick SEG, Sokol GM, Walsh MC, Poindexter BB, Faix RG, Watterberg KL, Frantz ID, Guillet R, Devaskar U, Truog WE, Chock VY, Wyckoff MH, McGowan EC, Carlton DP, Harmon HM, Brumbaugh JE, Cotten CM, Sánchez PJ, Hibbs AM, Higgins RD. Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial. JAMA 2017; 318:1550-1560. [PMID: 29067428 PMCID: PMC5783566 DOI: 10.1001/jama.2017.14972] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hypothermia initiated at less than 6 hours after birth reduces death or disability for infants with hypoxic-ischemic encephalopathy at 36 weeks' or later gestation. To our knowledge, hypothermia trials have not been performed in infants presenting after 6 hours. Objective To estimate the probability that hypothermia initiated at 6 to 24 hours after birth reduces the risk of death or disability at 18 months among infants with hypoxic-ischemic encephalopathy. Design, Setting, and Participants A randomized clinical trial was conducted between April 2008 and June 2016 among infants at 36 weeks' or later gestation with moderate or severe hypoxic-ischemic encephalopathy enrolled at 6 to 24 hours after birth. Twenty-one US Neonatal Research Network centers participated. Bayesian analyses were prespecified given the anticipated limited sample size. Interventions Targeted esophageal temperature was used in 168 infants. Eighty-three hypothermic infants were maintained at 33.5°C (acceptable range, 33°C-34°C) for 96 hours and then rewarmed. Eighty-five noncooled infants were maintained at 37.0°C (acceptable range, 36.5°C-37.3°C). Main Outcomes and Measures The composite of death or disability (moderate or severe) at 18 to 22 months adjusted for level of encephalopathy and age at randomization. Results Hypothermic and noncooled infants were term (mean [SD], 39 [2] and 39 [1] weeks' gestation, respectively), and 47 of 83 (57%) and 55 of 85 (65%) were male, respectively. Both groups were acidemic at birth, predominantly transferred to the treating center with moderate encephalopathy, and were randomized at a mean (SD) of 16 (5) and 15 (5) hours for hypothermic and noncooled groups, respectively. The primary outcome occurred in 19 of 78 hypothermic infants (24.4%) and 22 of 79 noncooled infants (27.9%) (absolute difference, 3.5%; 95% CI, -1% to 17%). Bayesian analysis using a neutral prior indicated a 76% posterior probability of reduced death or disability with hypothermia relative to the noncooled group (adjusted posterior risk ratio, 0.86; 95% credible interval, 0.58-1.29). The probability that death or disability in cooled infants was at least 1%, 2%, or 3% less than noncooled infants was 71%, 64%, and 56%, respectively. Conclusions and Relevance Among term infants with hypoxic-ischemic encephalopathy, hypothermia initiated at 6 to 24 hours after birth compared with noncooling resulted in a 76% probability of any reduction in death or disability, and a 64% probability of at least 2% less death or disability at 18 to 22 months. Hypothermia initiated at 6 to 24 hours after birth may have benefit but there is uncertainty in its effectiveness. Trial Registration clinicaltrials.gov Identifier: NCT00614744.
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Affiliation(s)
- Abbot R Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Jon E Tyson
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Breda Munoz
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City
| | | | - Nehal A Parikh
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Angelita M Hensman
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Krisa P Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Amir M Khan
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Shannon E G Hamrick
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Michele C Walsh
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Brenda B Poindexter
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Roger G Faix
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City
| | | | - Ivan D Frantz
- Division of Newborn Medicine, Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Ronnie Guillet
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Uday Devaskar
- Department of Pediatrics, University of California, Los Angeles
| | - William E Truog
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri Kansas City School of Medicine, Kansas City
| | - Valerie Y Chock
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Elisabeth C McGowan
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - David P Carlton
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Heidi M Harmon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | | | - C Michael Cotten
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Anna Maria Hibbs
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Liu X, Jary S, Cowan F, Thoresen M. Reduced infancy and childhood epilepsy following hypothermia-treated neonatal encephalopathy. Epilepsia 2017; 58:1902-1911. [PMID: 28961316 DOI: 10.1111/epi.13914] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate what proportion of a regional cohort of cooled infants with neonatal encephalopathy develop epilepsy (determined by the International League Against Epilepsy [ILAE] definition and the number of antiepileptic drugs [AEDs]) up to 8 years of age. METHODS From 2006-2013, 151 infants with perinatal asphyxia underwent 72 h cooling. Clinical and amplitude-integrated electroencepalography (aEEG) with single-channel EEG-verified neonatal seizures were treated with AEDs. Brain magnetic resonance imaging (MRI) was assessed using a 0-11 severity score. Postneonatal seizures, epilepsy rates, and AED treatments were documented. One hundred thirty-four survivors were assessed at 18-24 months; adverse outcome was defined as death or Bayley III composite Cognition/Language or Motor scores <85 and/or severe cerebral palsy or severely reduced vision/hearing. Epilepsy rates in 103 children age 4-8 years were also documented. RESULTS aEEG confirmed seizures occurred precooling in 77 (57%) 151 of neonates; 48% had seizures during and/or after cooling and received AEDs. Only one infant was discharged on AEDs. At 18-24 months, one third of infants had an adverse outcome including 11% mortality. At 2 years, 8 (6%) infants had an epilepsy diagnosis (ILAE definition), of whom 3 (2%) received AEDs. Of the 103 4- to 8-year-olds, 14 (13%) had developed epilepsy, with 7 (7%) receiving AEDs. Infants/children on AEDs had higher MRI scores than those not on AEDs (median [interquartile range] 9 [8-11] vs. 2 [0-4]) and poorer outcomes. Nine (64%) of 14 children with epilepsy had cerebral palsy compared to 13 (11%) of 120 without epilepsy, and 10 (71%) of 14 children with epilepsy had adverse outcomes versus 23 (19%) of 120 survivors without epilepsy. The number of different AEDs given to control neonatal seizures, aEEG severity precooling, and MRI scores predicted childhood epilepsy. SIGNIFICANCE We report, in a regional cohort of infants cooled for perinatal asphyxia, 6% with epilepsy at 2 years (2% on AEDs) increasing to 13% (7% on AEDs) at early school age. These AED rates are much lower than those reported in the cooling trials, even with adjusting for our cohort's milder asphyxia. Long-term follow-up is needed to document final epilepsy rates.
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Affiliation(s)
- Xun Liu
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Frances Cowan
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marianne Thoresen
- Neonatal Neuroscience, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.,Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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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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Abstract
Birth asphyxia, also termed perinatal hypoxia-ischemia, is a modifiable condition as evidenced by improved outcomes of infants ≥36 weeks' gestation provided hypothermia treatment in randomized trials. Preterm animal models of asphyxia in utero demonstrate that hypothermia can provide short-term neuroprotection for the developing brain, supporting the interest in extending therapeutic hypothermia to preterm infants. This review focuses on the challenge of identifying preterm infants with perinatal asphyxia; the neuropathology of hypoxic-ischemic brain injury across extreme, moderate, and late preterm infants; and patterns of brain injury, use of therapeutic hypothermia, and approach to patient selection for neuroprotective treatments among preterm infants.
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Affiliation(s)
- Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, 101 Dudley Street, Providence, RI 02905, USA.
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Berg MT. Prevention of Cerebral Palsy: Which Infants Will Benefit from Therapeutic Hypothermia? J Pediatr 2015; 167:8-10. [PMID: 25929978 DOI: 10.1016/j.jpeds.2015.03.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/27/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Marie T Berg
- Division of Neonatal-Perinatal Medicine, University of Vermont College of Medicine, Burlington, Vermont.
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34
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Affiliation(s)
- Elie Saliba
- Department of Neonatology; Centre Hospitalier Gatien de Clocheville; CHRU; Tours France
- INSERM Research Unit 930; University François Rabelais; Tours France
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