A review of important electroencephalogram features for the assessment of brain maturation in premature infants

Investigation of mothers' elicited infant-directed speech and singing for preterm infants

BACKGROUND

Mother's voice is a salient auditory stimulus commonly experienced during early development; after birth, characteristic acoustic modulations of mothers' infant-directed speech (IDSpeech) and singing (IDSinging) contribute to neurodevelopment. For preterm infants, early separation leads to decreased exposure to mother's voice; the impact on maternal ability to produce IDSpeech/IDSinging and infant perception of mother's voice is unknown.

METHODS

Fifty mother/preterm-infant dyads were enrolled in this prospective cohort study. Forty-four mothers recorded Twinkle, Twinkle Little Star in coached adult-directed speech (ADSpeech), IDSpeech, and IDSinging. Between 34.0-36.9w CGA, infants underwent high-density EEG during exposure to their mother's voice recordings. Acoustic features of mothers' voice and infant cortical response were analyzed and correlated.

RESULTS

Acoustic features of recorded maternal ADSpeech, IDSpeech, and IDSinging were significantly different. In 33 infants with EEG, mean fundamental frequency and speech production rate (SPR) variability correlated with infant responses to ADSpeech; SPR and SPR variability correlated with IDSpeech; SPR correlated with IDSinging. Correlations were found at differing scalp locations for speech versus singing.

CONCLUSION

Mothers of hospitalized preterm infants differentially modulate their voice during coached recorded language; features can then be differentiated by their preterm infants thus presenting opportunities for targeted interventions when parents cannot be present.

IMPACT

Mothers of preterm infants can record their voice with acoustically quantifiable characteristics of infant-directed singing and speech, even when not at their infant's bedside. Recorded adult- and infant-directed speech stimuli are differentially processed in the brains of hospitalized preterm infants. The ability for mothers to create acoustically-distinct infant-directed speech in the absence of their infant may be driven by coaching to achieve an approximated sense of connection with their infant.

Early EEG and NIRS measurements in preterm babies: a systematic review

Preterm birth represents a public health problem, with prematurity being the leading cause of infant mortality. An objective brain maturation and oxygenation measurement are necessary. The objective has been To test the feasibility of EEG and NIRS combination in the assessment of physiological brain maturation and oxygenation in preterm and non-preterm babies. A systematic review in Pubmed, Web of Science, MEDLINE, Cochrane, Dialnet, CINAHL, Scopus, Lilacs and PEDro databases until December 2022 was developed. 598 registers were found, finally 5 of them reached the inclusion criteria. Two independent reviewers analyzed data and a third reviewer were available for discrepancies. All articles combined EEG and NIRS to assess brain oxygenation and maturation in healthy new-born babies. There is an agreement on the electrode's placement for EEG at P3 and P4; besides, these regions have been shown to be a development predictive area, as well as the frontoparietal region for the NIRS region and comparison between regions. There is little evidence about the physiological brain electrical activity and oxygenation without stimuli.Conclusion: EEG and NIRS have been useful to assess brain electrical activity and oxygenation in preterm and non-preterm. The combined measurement of these instruments could be essential in neurological disorders diagnosis or their sequels. Unfortunately, the heterogeneity of the results found prevents a consensus on which variables are the most appropriate for the assessment of this population. What is Known • Brain assessment could help clinicians to prevent sequels. • There is an agreement for EEG electrodes placement at P3 and P4 region. What is New • EEG and NIRS assessment are effective measurements for preterm babies. • P3 and P4 regions have shown to be a predictive area of development, as well as the frontoparietal region for NIRS assessment.

Microstate Analysis Reflects Maturation of the Preterm Brain

Preterm neonates are at risk of long-term neurodevelopmental impairments due to disruption of natural brain development. Electroencephalography (EEG) analysis can provide insights into brain development of preterm neonates. This study aims to explore the use of microstate (MS) analysis to evaluate global brain dynamics changes during maturation in preterm neonates with normal neurodevelopmental outcome.The dataset included 135 EEGs obtained from 48 neonates at varying postmenstrual ages (26.4 to 47.7 weeks), divided into four age groups. For each recording we extracted a 5-minute epoch during quiet sleep (QS) and during non-quiet sleep (NQS), resulting in eight groups (4 age group x 2 sleep states). We compared MS maps and corresponding (map-specific) MS metrics across groups using group-level maps. Additionally, we investigated individual map metrics.Four group-level MS maps accounted for approximately 70% of the global variance and showed non-random syntax. MS topographies and transitions changed significantly when neonates reached 37 weeks. For both sleep states and all MS maps, MS duration decreased and occurrence increased with age. The same relationships were found using individual maps, showing strong correlations (Pearson coefficients up to 0.74) between individual map metrics and post-menstrual age. Moreover, the Hurst exponent of the individual MS sequence decreased with age.The observed changes in MS metrics with age might reflect the development of the preterm brain, which is characterized by formation of neural networks. Therefore, MS analysis is a promising tool for monitoring preterm neonatal brain maturation, while our study can serve as a valuable reference for investigating EEGs of neonates with abnormal neurodevelopmental outcomes.

Questions and Controversies in Neonatal Seizures

Neonatal seizures are relatively common, but their diagnosis and management remain challenging. We reviewed the scientific literature on neonatal seizures from July 1973 to November 2023. Several parameters were considered, including pathophysiology, diagnostic criteria, electroencephalographic findings and treatment. Recent classification system of seizures and epilepsies in the newborn, as well as treatment recommendations of neonatal seizures, have been proposed. Nonetheless, the approach to neonatal seizures varies among clinicians and centres, including detection, investigation, treatment and follow-up of patients. There are still many issues on the diagnosis and treatment of neonatal seizures, including the meaning or relevance of some electroencephalographic findings, the precise estimation of the seizure burden, the limited efficacy and side effects risk of antiseizure medications, and the best measures to establish the outcome.

Scalp high-frequency oscillations differentiate neonates with seizures from healthy neonates

OBJECTIVE

We aimed to investigate (1) whether an automated detector can capture scalp high-frequency oscillations (HFO) in neonates and (2) whether scalp HFO rates can differentiate neonates with seizures from healthy neonates.

METHODS

We considered 20 neonates with EEG-confirmed seizures and four healthy neonates. We applied a previously validated automated HFO detector to determine scalp HFO rates in quiet sleep.

RESULTS

Etiology in neonates with seizures included hypoxic-ischemic encephalopathy in 11 cases, structural vascular lesions in 6, and genetic causes in 3. The HFO rates were significantly higher in neonates with seizures (0.098 ± 0.091 HFO/min) than in healthy neonates (0.038 ± 0.025 HFO/min; P = 0.02) with a Hedge's g value of 0.68 indicating a medium effect size. The HFO rate of 0.1 HFO/min/ch yielded the highest Youden index in discriminating neonates with seizures from healthy neonates. In neonates with seizures, etiology, status epilepticus, EEG background activity, and seizure patterns did not significantly impact HFO rates.

SIGNIFICANCE

Neonatal scalp HFO can be detected automatically and differentiate neonates with seizures from healthy neonates. Our observations have significant implications for neuromonitoring in neonates. This is the first step in establishing neonatal HFO as a biomarker for neonatal seizures.

[A preliminary study on a new method for evaluating brain maturation in preterm infants]

OBJECTIVES

To establish a new method for evaluating the brain maturation of preterm infants based on the features of electroencephalographic activity.

METHODS

A prospective study was conducted on the video electroencephalography (vEEG) and amplitude-integrated electroencephalography (aEEG) recordings within 7 days after birth of preterm infants who had a postmenstrual age (PMA) of 25-36 weeks and met the inclusion criteria. The background activity of aEEG+conventional electroencephalography (cEEG) was scored according to the features of brain maturation as a new evaluation system and was compared with the aEEG evaluation system. The correlations of the evaluation results of the two methods with gestational age (GA), PMA, and head circumference were evaluated. The intervals of the total scores of aEEG+cEEG and aEEG were calculated for preterm infants with different PMAs and were compared between groups. The consistency of the new scoring system was evaluated among different raters.

RESULTS

A total of 52 preterm infants were included. The total scores of aEEG+cEEG and aEEG were positively correlated with GA, PMA, and head circumference (P<0.05), and the correlation coefficient between the total scores of the two systems and PMA and GA was >0.9. The normal score intervals for aEEG+cEEG and aEEG scoring systems were determined in preterm infants with different PMAs as follows: infants with a PMA of less than 28 weeks had scores of 13.0 (11.0, 14.0) points for aEEG+cEEG and 6.0 (4.0, 7.0) points for aEEG; infants with a PMA between 28 and 29+6 weeks had scores of 16.0 (14.5, 17.0) points for aEEG+cEEG and 8.0 (6.0, 8.0) points for aEEG; infants with a PMA between 30 and 31+6 weeks had scores of 18.0 (17.0, 21.0) points for aEEG+cEEG and 9.0 (8.0, 10.0) points for aEEG; infants with between 32 and 33+6 weeks had scores of 22.0 (20.0, 24.5) points for aEEG+cEEG and 10.0 (10.0, 10.8) points for aEEG; infants with a PMA between 34 and 36 weeks had scores of 26.0 (24.5, 27.5) points for aEEG+cEEG and 11.0 (10.0, 12.0) points for aEEG. There were significant differences in the total scores of aEEG+cEEG and aEEG among the different PMA groups (P<0.05). There was a high consistency between different raters when using the scoring system to evaluate the brain maturation of preterm infants (κ=0.86).

CONCLUSIONS

The aEEG+cEEG scoring system established in this study can quantitatively reflect the brain maturation of preterm infants, with a good discriminatory ability between preterm infants with different PMAs and high consistency between different raters.

Combining MRI and Spectral EEG for Assessment of Neurocognitive Outcomes in Preterm Infants

INTRODUCTION

Predicting impairment in preterm children is challenging. Our aim is to explore the association between MRI at term-equivalent age (TEA) and neurocognitive outcomes in late childhood and to assess whether the addition of EEG improves prognostication.

METHODS

This prospective observational study included forty infants with gestational age 24 + 0-30 + 6. Children were monitored with multichannel EEG for 72 h after birth. Total absolute band power for the delta band on day 2 was calculated. Brain MRI was performed at TEA and scored according to the Kidokoro scoring system. At 10-12 years of age, we evaluated neurocognitive outcomes with Wechsler Intelligence Scale for Children 4th edition, Vineland adaptive behavior scales 2nd edition and Behavior Rating Inventory of Executive Function. We performed linear regression analysis to examine the association between outcomes and MRI and EEG, respectively, and multiple regression analysis to explore the combination of MRI and EEG.

RESULTS

Forty infants were included. There was a significant association between global brain abnormality score and composite outcomes of WISC and Vineland test, but not the BRIEF test. The adjusted R2 was 0.16 and 0.08, respectively. For EEG, adjusted R2 was 0.34 and 0.15, respectively. When combining MRI and EEG data, adjusted R2 changed to 0.36 for WISC and 0.16 for the Vineland test.

CONCLUSION

There was a small association between TEA MRI and neurocognitive outcomes in late childhood. Adding EEG to the model improved the explained variance. Combining EEG and MRI data did not have any additional benefit over EEG alone.

Feasibility of automated early postnatal sleep staging in extremely and very preterm neonates using dual-channel EEG

OBJECTIVE

To investigate the feasibility of automated sleep staging based on quantitative analysis of dual-channel electroencephalography (EEG) for extremely and very preterm infants during their first postnatal days.

METHODS

We enrolled 17 preterm neonates born between 25 and 30 weeks of gestational age. Three-hour behavioral sleep observations and simultaneous dual-channel EEG monitoring were conducted for each infant within their first 72 hours after birth. Four kinds of representative and complementary quantitative EEG (qEEG) metrics (i.e., bursting, synchrony, spectral power, and complexity) were calculated and compared between active sleep, quiet sleep, and wakefulness. All analyses were performed in offline mode.

RESULTS

In separate comparison analyses, significant differences between sleep-wake states were found for bursting, spectral power and complexity features. The automated sleep-wake state classifier based on the combination of all qEEG features achieved a macro-averaged area under the curve of receiver operating characteristic of 74.8%. The complexity features contributed the most to sleep-wake state classification.

CONCLUSIONS

It is feasible to distinguish between sleep-wake states within the first 72 postnatal hours for extremely and very preterm infants using qEEG metrics.

SIGNIFICANCE

Our findings offer the possibility of starting personalized care dependent on preterm infants' sleep-wake states directly after birth, potentially yielding long-run benefits for their developmental outcomes.

Sleep state organisation of moderate to late preterm infants in the neonatal unit

BACKGROUND

Sleep supports neurodevelopment and sleep architecture reflects brain maturation. This prospective observational study describes the nocturnal sleep architecture of healthy moderate to late preterm (MLP) infants in the neonatal unit at 36 weeks post menstrual age (PMA).

METHODS

MLP infants, in the neonatal unit of a tertiary hospital in Ireland from 2017 to 2018, had overnight continuous electroencephalography (cEEG) with video for a minimum 12 h at 36 weeks PMA. The total sleep time (TST) including periods of active sleep (AS), quiet sleep (QS), indeterminate sleep (IS), wakefulness and feeding were identified, annotated and quantified.

RESULTS

A total of 98 infants had cEEG with video monitoring suitable for analysis. The median (IQR) of TST in the 12 h period was 7.09 h (IQR 6.61-7.76 h), 4.58 h (3.69-5.09 h) in AS, 2.02 h (1.76-2.36 h) in QS and 0.65 h (0.48-0.89 h) in IS. The total duration of AS was significantly lower in infants born at lower GA (p = 0.007) whilst the duration of individual QS periods was significantly higher (p = 0.001).

CONCLUSION

Overnight cEEG with video at 36 weeks PMA showed that sleep state architecture is dependent on birth GA. Infants with a lower birth GA have less AS and more QS that may have implications for later neurodevelopment.

IMPACT

EEG provides objective information about the sleep organisation of the moderate to late preterm (MLP) infant. Quantitative changes in sleep states occur with each week of advancing gestational age (GA). Active sleep (AS) is the dominant sleep state that was significantly lower in infants born at lower GA. MLP infants who were exclusively fed orally had a shorter total sleep time and less AS compared to infants who were fed via nasogastric tube.

Developmental characteristics of early electroencephalography in preterm neonates: Differences between twins and singletons

BACKGROUND

To analyze the early electroencephalography (EEG) development of twins and singleton preterm neonates using 5 measurement indicators.

METHODS

On the 1st and 7th days after birth, EEG monitoring was performed on 102 preterm neonates (62 males, median gestational age 33.15 weeks, IQR 31.00-35.75). The minimum amplitude, maximum amplitude, maximum interburst intervals (IBI), total duration of trace discontinue (TD), maximum duration of single TD, and the Burdjalov score of amplitude-integrated electroencephalography (aEEG) were used to evaluate EEG recordings.

RESULTS

The minimum amplitude of EEG increases with gestational age (GA), while the maximum amplitude decreases, the maximum IBI decreases, and the total duration of TD and the maximum duration of single TD decrease (all p < 0.05). Burdjalov score did not differ significantly between the 1st and 7th days (p = 0.075). There is no significant difference between twins and singleton preterm infants in the five EEG measurement indicators (p > 0.05 for all).

CONCLUSION

The five EEG measurement indicators can better reflect preterm infants' brain maturation than the Burdjalov score in aEEG. There were no statistical differences in brain maturation between twin and singleton preterm infants.

Multiscale entropy as a metric of brain maturation in a large cohort of typically developing children born preterm using longitudinal high-density EEG in the first two years of life

Objective.We aimed to analyze whether complexity of brain electrical activity (EEG) measured by multiscale entropy (MSE) increases with brain maturation during the first two years of life. We also aimed to investigate whether this complexity shows regional differences across the brain, and whether changes in complexity are influenced by extrauterine life experience duration.Approach.We measured MSE of EEG signals recorded longitudinally using a high-density setup (64 or 128 electrodes) in 84 typically developing infants born preterm (<32 weeks' gestation) from term age to two years. We analyzed the complexity index and maximum value of MSE over increasing age, across brain regions, and in function of extrauterine life duration, and used correlation matrices as a metric of functional connectivity of the cerebral cortex.Main results.We found an increase of strong inter-channel correlation of MSE (R > 0.8) with increasing age. Regional analysis showed significantly increased MSE between 3 and 24 months of corrected age in the posterior and middle regions with respect to the anterior region. We found a weak relationship (adjusted R²= 0.135) between MSE and extrauterine life duration.Significance.These findings suggest that brain functional connectivity increases with maturation during the first two years of life. EEG complexity shows regional differences with earlier maturation of the visual cortex and brain regions involved in joint attention than of regions involved in cognitive analysis, abstract thought, and social behavior regulation. Finally, our MSE analysis suggested only a weak influence of early extrauterine life experiences (prior to term age) on EEG complexity.

The relationship between interhemispheric synchrony, morphine and microstructural development of the corpus callosum in extremely preterm infants

The primary aim of this study is to examine whether bursting interhemispheric synchrony (bIHS) in the first week of life of infants born extremely preterm, is associated with microstructural development of the corpus callosum (CC) on term equivalent age magnetic resonance imaging scans. The secondary aim is to address the effects of analgesics such as morphine, on bIHS in extremely preterm infants. A total of 25 extremely preterm infants (gestational age [GA] < 28 weeks) were monitored with the continuous two-channel EEG during the first 72 h and after 1 week from birth. bIHS was analyzed using the activation synchrony index (ASI) algorithm. Microstructural development of the CC was assessed at ~ 30 and ~ 40 weeks of postmenstrual age (PMA) using fractional anisotropy (FA) measurements. Multivariable regression analyses were used to assess the primary and secondary aim. Analyses were adjusted for important clinical confounders: morphine, birth weight z-score, and white matter injury score. Due to the reduced sample size, only the most relevant variables, according to literature, were included. ASI was not significantly associated with FA of the CC at 30 weeks PMA and at 40 weeks PMA (p > .5). ASI was positively associated with the administration of morphine (p < .05). Early cortical synchrony may be affected by morphine and is not associated with the microstructural development of the CC. More studies are needed to evaluate the long-term effects of neonatal morphine treatment to optimize sedation in this high-risk population.

CARFS7: A guide and proforma for reading a preterm neonate's EEG

OBJECTIVES

The important role of the EEG in preterm and term babies in investigating brain function and seizures, predicting outcomes, evaluating therapeutic interventions and decision-making is being increasingly acknowledged. Development of the brain in the last trimester of pregnancy results in rapid changes in the EEG patterns in this period. Acquiring and interpreting the EEG of a preterm baby can be challenging. The aim of this study was to develop a proforma titled CARFS⁷ (Continuity, Amplitude, Reactivity, Frequency, Synchrony, Symmetry, Sleep, Sharps, Shapes, Size and Seizures) to enable neurologists to read EEGs of premature babies with greater confidence, ease and accuracy and produce a report more easily repeatable and homogenous among operators.

METHODS

The CARFS⁷proforma was developed based on a literature review and the personal experience of the authors. The parameters of the EEG evaluated and scored in the proforma are Continuity, Amplitude, Reactivity/Variability, Frequency, Synchrony, Symmetry, Sleep, Sharps, Shapes/Patterns, Size and Seizures. We also assessed the interrater reliability of the proposed scoring system incorporated in the proforma.

RESULTS

CARFS⁷ proforma incorporates a number of parameters that help evaluate the preterm EEG. The interrater reliability of the proposed scoring system in the CARFS⁷proforma was high.

CONCLUSIONS

CARFS⁷ is a user friendly proforma for reading EEGs in the preterm infant. Interrater reliability using Cohen's k shows high agreement between two child neurologists who independently rated the EEGs of 25 premature babies using this proforma. CARFS⁷ has the potential to provide, accurate, reproducible and valuable information on brain function in the preterm infant in clinical practice.

Development of the Ontogenetic Self-Regulation Clock

To date, there is no overarching proposition for the ontogenetic-neurobiological basis of self-regulation. This paper suggests that the balanced self-regulatory reaction of the fetus, newborn and infant is based on a complex mechanism starting from early brainstem development and continuing to progressive control of the cortex over the brainstem. It is suggested that this balance occurs through the synchronous reactivity between the sympathetic and parasympathetic systems, both which originate from the brainstem. The paper presents an evidence-based approach in which molecular excitation-inhibition balance, interchanges between excitatory and inhibitory roles of neurotransmitters as well as cardiovascular and white matter development across gestational ages, are shown to create sympathetic-parasympathetic synchrony, including the postnatal development of electroencephalogram waves and vagal tone. These occur in developmental milestones detectable in the same time windows (sensitive periods of development) within a convergent systematic progress. This ontogenetic stepwise process is termed "the self-regulation clock" and suggest that this clock is located in the largest connection between the brainstem and the cortex, the corticospinal tract. This novel evidence-based new theory paves the way towards more accurate hypotheses and complex studies of self-regulation and its biological basis, as well as pointing to time windows for interventions in preterm infants. The paper also describes the developing indirect signaling between the suprachiasmatic nucleus and the corticospinal tract. Finally, the paper proposes novel hypotheses for molecular, structural and functional investigation of the "clock" circuitry, including its associations with other biological clocks. This complex circuitry is suggested to be responsible for the developing self-regulatory functions and their neurobehavioral correlates.

Case Report: Electroencephalography in a neonate with isolated sulfite oxidase deficiency - a case report and literature review

Isolated sulfite oxidase deficiency (ISOD) is a rare autosomal recessive neuro-metabolic disorder caused by a mutation in the sulfite oxidase (SUOX) gene situated on chromosome 12. Due to the deficiency of this mitochondrial enzyme (sulfite oxidase), the oxidative degradation of toxic sulfites is disrupted. The most common form of this disease has an early onset (classical ISOD) in the neonatal period, with hypotonia, poor feeding and intractable seizures, mimicking hypoxic-ischaemic encephalopathy. The evolution is rapidly progressive to severe developmental delay, microcephaly and early death. Unfortunately, there is no effective treatment and the prognosis is very poor.

In this article, we described the evolution of early continuous electroencephalography (EEG) in a case of ISOD with neonatal onset, as severely encephalopathic background, with refractory seizures and distinct delta-beta complexes. The presence of the delta-beta complexes might be a diagnostic marker in ISOD. We also performed a literature review of published cases of neonatal ISOD that included EEG monitoring.

Current and Future Uses of Continuous EEG in the NICU

Continuous EEG (cEEG) is a fundamental neurodiagnostic tool in the care of critically ill neonates and is increasingly recommended. cEEG enhances prognostication via assessment of the background brain activity, plays a role in predicting which neonates are at risk for seizures when combined with clinical factors, and allows for accurate diagnosis and management of neonatal seizures. Continuous EEG is the gold standard method for diagnosis of neonatal seizures and should be used for detection of seizures in high-risk clinical conditions, differential diagnosis of paroxysmal events, and assessment of response to treatment. High costs associated with cEEG are a limiting factor in its widespread implementation. Centralized remote cEEG interpretation, automated seizure detection, and pre-natal EEG are potential future applications of this neurodiagnostic tool.

Trajectory of the incidence of brushes on preterm electroencephalogram and its association with neurodevelopment in extremely low birth weight infants

BACKGROUND

Brush or delta brush is a well-known characteristic waveform in preterm electroencephalograms. However, the longitudinal trajectory of brushes and its association with neurodevelopment remain uncertain.

METHODS

We analyzed the longitudinal incidence of brushes in 36 extremely low birth weight infants without severe brain lesions and its association with neurodevelopment and white matter abnormality. Conventional eight-channel electroencephalograms were recorded at 30, 32, 36, and 40 postmenstrual weeks (PMW). Incidence of brushes was calculated as the sum of brushes from each channel separated by active sleep and quiet sleep. A developmental delay was defined as a developmental quotient of <85 assessed at corrected age of 18 months. White matter abnormalities were evaluated with term-equivalent magnetic resonance imaging.

RESULTS

The median incidence of brushes (per minute) in 36 infants at PMW 30, 32, 36, and 40 was 16.4, 20.4, 22.5, and 1.8 during active sleep and 7.5, 10.3, 11.5, and 1.7 during quiet sleep, respectively. Among the 36 infants, 14 infants were diagnosed with developmental delay. Longitudinal trajectories of the incidence of brushes were different between the normal and the delayed development groups. Brushes were observed most frequently at 36 PMW in the delayed development group. The incidence of brushes at 36 PMW was significantly correlated with the severity of white matter abnormalities and negatively correlated with the developmental quotient.

CONCLUSION

The incidence of brushes at 36 PMW can be a unique predictor of early neurodevelopment in extremely low birth weight infants without severe brain lesions.

An Introduction to Neonatal EEG

Newborn care has witnessed significant improvements in survival, but ongoing concerns persist about neurodevelopmental outcome. Protecting the newborn brain is the focus of neurocritical care in the intensive care unit. Brain-focused care places emphasis on clinical practices supporting neurodevelopment in conjunction with early detection, diagnosis, and treatment of brain injury. Technology now facilitates continuous cot-side monitoring of brain function. Neuromonitoring techniques in neonatal intensive care units include the use of electroencephalography (EEG) or amplitude-integrated EEG (aEEG) and near-infrared spectroscopy. This article aims to provide an introduction to EEG, which is appropriate for neonatal healthcare professionals.

Sleep maturation influences cognitive development of preterm toddlers

Our recent study on full-term toddlers demonstrated that daytime nap properties affect the distribution ratio between nap and nighttime sleep duration in total sleep time but does not affect the overall total amount of daily sleep time. However, there is still no clear scientific consensus as to whether the ratio between naps and nighttime sleep or just daily total sleep duration itself is more important for healthy child development. In the current study, to gain an answer to this question, we examined the relationship between the sleep properties and the cognitive development of toddlers born prematurely using actigraphy and the Kyoto scale of psychological development (KSPD) test. 101 premature toddlers of approximately 1.5 years of age were recruited for the study. Actigraphy units were attached to their waist with an adjustable elastic belt for 7 consecutive days and a child sleep diary was completed by their parents. In the study, we found no significant correlation between either nap or nighttime sleep duration and cognitive development of the preterm toddlers. In contrast, we found that stable daily wake time was significantly associated with better cognitive development, suggesting that sleep regulation may contribute to the brain maturation of preterm toddlers.

The effect of early procedural pain in preterm infants on the maturation of electroencephalogram and heart rate variability

ABSTRACT

Preterm infants show a higher incidence of cognitive, social, and behavioral problems, even in the absence of major medical complications during their stay in the neonatal intensive care unit (NICU). Several authors suggest that early-life experience of stress and procedural pain could impact cerebral development and maturation resulting in an altered development of cognition, behavior, or motor patterns in later life. However, it remains very difficult to assess this impact of procedural pain on physiological development. This study describes the maturation of electroencephalogram (EEG) signals and heart rate variability in a prospective cohort of 92 preterm infants (<34 weeks gestational age) during their NICU stay. We took into account the number of noxious, ie, skin-breaking, procedures they were subjected in the first 5 days of life, which corresponded to a median age of 31 weeks and 4 days. Using physiological signal modelling, this study shows that a high exposure to early procedural pain, measured as skin-breaking procedures, increased the level of discontinuity in both EEG and heart rate variability in preterm infants. These findings have also been confirmed in a subset of the most vulnerable preterm infants with a gestational age lower than 29 weeks. We conclude that a high level of early pain exposure in the NICU increases the level of functional dysmaturity, which can ultimately impact preterm infants' future developmental outcome.

Delta brushes are not just a hallmark of EEG in human preterm infants

The delta brush, a well-known characteristic waveform of the human preterm electroencephalogram, represents spontaneous electrical activity. Recent experimental animal model evidence suggests that delta brushes are not only spontaneous intrinsic activity but are also evoked by external sensory stimulation or spontaneous movement. They are also likely to reflect the activity of subplate neurons, which play an important role in early brain development and network organization. Here, evidence about delta brushes in human preterm electroencephalogram is provided along with future perspectives.

Deep Learning for EEG Seizure Detection in Preterm Infants

EEG is the gold standard for seizure detection in the newborn infant, but EEG interpretation in the preterm group is particularly challenging; trained experts are scarce and the task of interpreting EEG in real-time is arduous. Preterm infants are reported to have a higher incidence of seizures compared to term infants. Preterm EEG morphology differs from that of term infants, which implies that seizure detection algorithms trained on term EEG may not be appropriate. The task of developing preterm specific algorithms becomes extra-challenging given the limited amount of annotated preterm EEG data available. This paper explores novel deep learning (DL) architectures for the task of neonatal seizure detection in preterm infants. The study tests and compares several approaches to address the problem: training on data from full-term infants; training on data from preterm infants; training on age-specific preterm data and transfer learning. The system performance is assessed on a large database of continuous EEG recordings of 575[Formula: see text]h in duration. It is shown that the accuracy of a validated term-trained EEG seizure detection algorithm, based on a support vector machine classifier, when tested on preterm infants falls well short of the performance achieved for full-term infants. An AUC of 88.3% was obtained when tested on preterm EEG as compared to 96.6% obtained when tested on term EEG. When re-trained on preterm EEG, the performance marginally increases to 89.7%. An alternative DL approach shows a more stable trend when tested on the preterm cohort, starting with an AUC of 93.3% for the term-trained algorithm and reaching 95.0% by transfer learning from the term model using available preterm data. The proposed DL approach avoids time-consuming explicit feature engineering and leverages the existence of the term seizure detection model, resulting in accurate predictions with a minimum amount of annotated preterm data.

Normal EEG during the neonatal period: maturational aspects from premature to full-term newborns

Electroencephalography (EEG) is the reference tool for the analysis of brain function, reflecting normal and pathological neuronal network activity. During the neonatal period, EEG patterns evolve weekly, according to gestational age. The first analytical criteria for the various maturational stages and standardized neonatal EEG terminology were published by a group of French neurophysiologists training in Paris (France) in 1999. These criteria, defined from analog EEG, were completed in 2010 with digital EEG analysis. Since then, this work has continued, aided by the technical progress in EEG acquisition, the improvement of knowledge on the maturating processes of neuronal networks, and the evolution of critical care. In this review, we present an exhaustive and didactic overview of EEG characteristics from extremely premature to full-term infants. This update is based on the scientific literature, enhanced by the study of normal EEGs of extremely premature infants by our group of neurophysiologists. For educational purposes, particular attention has been paid to illustrations using new digital tools.

Detection of Transient Bursts in the EEG of Preterm Infants using Time-Frequency Distributions and Machine Learning

Short-duration bursts of spontaneous activity are important markers of maturation in the electroencephalogram (EEG) of premature infants. This paper examines the application of a feature-less machine learning approach for detecting these bursts. EEGs were recorded over the first 3 days of life for infants with a gestational age below 30 weeks. Bursts were annotated on the EEG from 36 infants. In place of feature extraction, the time-series EEG is transformed into a time-frequency distribution (TFD). A gradient boosting machine is then trained directly on the whole TFD using a leave-one-out procedure. TFD kernel parameters, length of the Doppler and lag windows, are selected within a nested cross-validation procedure during training. Results indicate that detection performance is sensitive to Doppler-window length but not lag-window length. Median area under the receiver operator characteristic for detection is 0.881 (inter-quartile range 0.850 to 0.913). Examination of feature importance highlights a critical wideband region <15 Hz in the TFD. Burst detection methods form an important component in any fully-automated brain-health index for the vulnerable preterm infant.

A perinatal stress calculator for the neonatal intensive care unit: an unobtrusive approach

OBJECTIVE

Early experience of pain and stress in the neonatal intensive care unit is known to have an effect on the neurodevelopment of the infant. However, an automated method to quantify the procedural pain or perinatal stress in premature patients does not exist.

APPROACH

In the current study, EEG and ECG data were collected for more than 3 hours from 136 patients in order to quantify stress exposure. Specifically, features extracted from the EEG and heart-rate variability in both quiet and non-quiet sleep segments were used to develop a subspace linear-discriminant analysis stress classifier.

MAIN RESULTS

The main novelty of the study lies in the absence of intrusive methods or pain elicitation protocols to develop the stress classifier. Three main findings can be reported. First, we developed different stress classifiers for the different age groups and stress intensities, obtaining an area under the curve in the range [0.78-0.93] for non-quiet sleep and [0.77-0.96] for quiet sleep. Second, a dysmature EEG was found in patients under stress. Third, an enhanced cortical connectivity and increased brain-heart communication was correlated with a higher stress load, while the autonomic activity did not seem to be associated to stress exposure.

SIGNIFICANCE

The results shed a light on the pain and stress processing in preterm neonates, suggesting that software tools to investigate dysmature EEG might be helpful to assess stress load in premature patients. These results could be the foundation to assess the impact of stress on infants' development and to tune preventive care.

Reliability and accuracy of EEG interpretation for estimating age in preterm infants

OBJECTIVES

To determine the accuracy of, and agreement among, EEG and aEEG readers' estimation of maturity and a novel computational measure of functional brain age (FBA) in preterm infants.

METHODS

Seven experts estimated the postmenstrual ages (PMA) in a cohort of recordings from preterm infants using cloud-based review software. The FBA was calculated using a machine learning-based algorithm. Error analysis was used to determine the accuracy of PMA assessments and intraclass correlation (ICC) was used to assess agreement between experts.

RESULTS

EEG recordings from a PMA range 25 to 38 weeks were successfully interpreted. In 179 recordings from 62 infants interpreted by all human readers, there was moderate agreement between experts (aEEG ICC = 0.724; 95%CI:0.658-0.781 and EEG ICC = 0.517; 95%CI:0.311-0.664). In 149 recordings from 61 infants interpreted by all human readers and the FBA algorithm, random and systematic errors in visual interpretation of PMA were significantly higher than the computational FBA estimate. Tracking of maturation in individual infants showed stable FBA trajectories, but the trajectories of the experts' PMA estimate were more likely to be obscured by random errors. The accuracy of visual interpretation of PMA estimation was compromised by neurodevelopmental outcome for both aEEG and EEG review.

INTERPRETATION

Visual assessment of infant maturity is possible from the EEG or aEEG, with an average of human experts providing the highest accuracy. Tracking PMA of individual infants was hampered by errors in experts' estimates. FBA provided the most accurate maturity assessment and has potential as a biomarker of early outcome.

Predicting future handedness and hemispheric dominance during infancy by analyzing sleep spindles

OBJECTIVE

To investigate whether sleep spindles asynchrony (SSA) using scalp sleep electroencephalogram (EEG) among children below 2 years of age can predict future handedness.

METHODS

This is a retrospective study conducted from October 2016 until June 2017 at the King Fahad Medical City (KFMC), Riyadh, Kingdom of Saudi Arabia. We retrospectively reviewed 300 EEGs recorded at our neurophysiology laboratory.We included EEGs performed during sleep for infants aged 2 months to 2 years who have already attained their handedness or those aged above 2 years. We excluded records of children younger than 2 months or above 2 years of age (at the time of the EEG) or those aged below 2 years (at the time of the interview), and severely abnormal tracings and those without sleep or enough SSA.

RESULTS

The lateralization of Sleep Spindles (SS) was mostly right-hemispheric (52%) compared to left-hemispheric (36.4%). The overall SS laterality did not correlate with handedness (p=0.81). In the majority of right-handed (64%) and left-handed (60%) children, the SSA was contralateral to the side of hand preference; however, it did not correlate statistically (p=0.377).

CONCLUSION

We were unable to prove a statistically significant correlation between SSA and future hand preference. Further research involving larger cohorts is still needed.

A Bradycardia-Based Stress Calculator for the Neonatal Intensive Care Unit: A Multisystem Approach

Early life stress in the neonatal intensive care unit (NICU) can predispose premature infants to adverse health outcomes and neurodevelopment delays. Hands-on-care and procedural pain might induce apneas, hypoxic events, and sleep-wake disturbances, which can ultimately impact maturation, but a data-driven method based on physiological fingerprints to quantify early-life stress does not exist. This study aims to provide an automatic stress detector by investigating the relationship between bradycardias, hypoxic events and perinatal stress in NICU patients. EEG, ECG, and SpO 2 were recorded from 136 patients for at least 3 h in three different monitoring groups. In these subjects, the stress burden was assessed using the Leuven Pain Scale. Different subspace linear discriminant analysis models were designed to detect the presence or the absence of stress based on information in each bradycardic spell. The classification shows an area under the curve in the range [0.80-0.96] and a kappa score in the range [0.41-0.80]. The results suggest that stress seems to increase SpO 2 desaturations and EEG regularity as well as the interaction between the cardiovascular and neurological system. It might be possible that stress load enhances the reaction to respiratory abnormalities, which could ultimately impact the neurological and behavioral development.

Applying a data-driven approach to quantify EEG maturational deviations in preterms with normal and abnormal neurodevelopmental outcomes

Premature babies are subjected to environmental stresses that can affect brain maturation and cause abnormal neurodevelopmental outcome later in life. Better understanding this link is crucial to developing a clinical tool for early outcome estimation. We defined maturational trajectories between the Electroencephalography (EEG)-derived ‘brain-age’ and postmenstrual age (the age since the last menstrual cycle of the mother) from longitudinal recordings during the baby’s stay in the Neonatal Intensive Care Unit. Data consisted of 224 recordings (65 patients) separated for normal and abnormal outcome at 9–24 months follow-up. Trajectory deviations were compared between outcome groups using the root mean squared error (RMSE) and maximum trajectory deviation (δ^max). 113 features were extracted (per sleep state) to train a data-driven model that estimates brain-age, with the most prominent features identified as potential maturational and outcome-sensitive biomarkers. RMSE and δ^max showed significant differences between outcome groups (cluster-based permutation test, p < 0.05). RMSE had a median (IQR) of 0.75 (0.60–1.35) weeks for normal outcome and 1.35 (1.15–1.55) for abnormal outcome, while δ^max had a median of 0.90 (0.70–1.70) and 1.90 (1.20–2.90) weeks, respectively. Abnormal outcome trajectories were associated with clinically defined dysmature and disorganised EEG patterns, cementing the link between early maturational trajectories and neurodevelopmental outcome.

Comparison of conventional, amplitude-integrated and geodesic sensor net EEG used in premature neonates: a systematic review

INTRODUCTION

The use of methods to evaluate cortical activity in neonates has great importance in modern medicine, as it allows the observation and evaluation of several clinical aspects, which guarantees that the health team has knowledge about possible intervention measures that may be necessary in the treatment of newborns.

OBJECTIVE

This systematic review aimed to compare the main technologies available for the evaluation of brain functions in neonates, among them: the conventional electroencephalogram (EEG), the amplitude-integrated electroencephalogram (aEEG) and the geodesic sensor net EEG.

METHODS

A search was conducted forarticles from national and international periodicals included in the Web of Science, LILACS, SciELO and Medline electronic databases.

RESULTS

The search found 39 among 155 articles of interest and the analyses indicated that, in the clinical environment, the use of both conventional EEG and aEEG is highly recommended, as the combination of their functions allows, for example, a greater number of subclinical seizures to be detected. Conversely, the use of a geodesic sensor net EEG could be of great value, as it allows a large amount of data to be analyzed.

CONCLUSION

This analysis may be useful in studies and research related to diseases and symptoms, such as seizures, a current challenge for neonatal neuromonitoring, as well as aspects of neurological development and functional studies. However, despite many advances in technology, electroencephalography in preterm neonates remains a challenge worldwide and still requires more robust research and efforts towards the best clinical assistance in this extremely early stage of life.

Evaluation of maturity of sleep states in preterm infants using conventional and amplitude-integrated electroencephalography

OBJECTIVE

To determine whether sleep state maturity can be estimated accurately using conventional electroencephalography (cEEG) or amplitude-integrated electroencephalography (aEEG) features concerning sleep in neurologically unimpaired preterm infants.

METHODS

A total of 51 preterm infants were monitored with cEEG-polygraphy and simultaneous aEEG. Sleep state maturity of EEG corresponded to specific postmenstrual age (PMA). PMA on cEEG was blindly estimated according to cEEG patterns (indicated as background continuity, frequencies, and voltages) as well as developmental markers in specific states. PMA on aEEG was blindly estimated based on the cycling score (cycling representing sleep state transitions) according to a pre-established scoring system.

RESULTS

A total of 51 EEGs recorded between 32 and 37 weeks PMA were analysed. A significant relationship between estimated PMA (ePMA) and actual chronological PMA (cPMA) was shown by linear regression both on cEEG (r = 0.93, β = 0.98, 95% confidence interval (CI) 0.87-1.09, p < 0.001) and aEEG (r = 0.85, β = 0.83, 95% CI 0.69-0.98, p < 0.001). The estimation gap (defined as ePMA minus cPMA) was between -2 and +2 weeks both on cEEG and aEEG. The percentage of estimation gap between -1 and +1 weeks was 96% for cEEG, which was higher than the estimate of 88% for aEEG.

CONCLUSION

Estimated maturity of sleep state was well correlated with cPMA both on cEEG and aEEG. PMA corresponding to state maturity could be estimated within two weeks of actual cPMA using either of these two tools. However, cEEG had higher accuracy compared with aEEG in the evaluation of sleep state maturity.

Exploring the EEG mu rhythm associated with observation and execution of a goal-directed action in 14-month-old preterm infants

Electroencephalographic mu rhythm desynchronization is thought to reflect Mirror Neuron System (MNS) activity and represents an important neural correlate of the coupling between action execution and perception. It is still unclear if the MNS in human ontogeny is already available at the beginning of postnatal life and how early experience impacts its development. Premature birth provides a "natural condition" for investigating the effects of early, atypical extra-uterine experience on MNS. The main aim of the present study was to investigate whether the MNS activity is associated with prematurity. We compared the mu rhythm activity in preterm (PT) and full-term (FT) 14-month old infants during an action observation/execution (AO/AE) task. Mu rhythm desynchronization was computed over frontal, central, parietal and occipital regions. Both groups showed mu rhythm suppression in all the scalp regions during action execution. Different desynchronization patterns emerged during action observation. Specifically, FT infants showed mu suppression in the right frontal, bilateral parietal and occipital regions; whereas PT infants exhibited mu suppression only in the right parietal region. Overall, these preliminary findings indicate that an atypical extra uterine experience might have an impact on the MNS activity.

Neuroprocessing Mechanisms of Music during Fetal and Neonatal Development: A Role in Neuroplasticity and Neurodevelopment

The primary aim of this viewpoint article is to examine recent literature on fetal and neonatal processing of music. In particular, we examine the behavioral, neurophysiological, and neuroimaging literature describing fetal and neonatal music perception and processing to the first days of term equivalent life. Secondly, in light of the recent systematic reviews published on this topic, we discuss the impact of music interventions on the potential neuroplasticity pathways through which the early exposure to music, live or recorded, may impact the fetal, preterm, and full-term infant brain. We conclude with recommendations for music stimuli selection and its role within the framework of early socioemotional development and environmental enrichment.

Quantitative Preterm EEG Analysis: The Need for Caution in Using Modern Data Science Techniques

Hemodynamic changes during neonatal transition increase the vulnerability of the preterm brain to injury. Real-time monitoring of brain function during this period would help identify the immediate impact of these changes on the brain. Neonatal EEG provides detailed real-time information about newborn brain function but can be difficult to interpret for non-experts; preterm neonatal EEG poses even greater challenges. An objective quantitative measure of preterm brain health would be invaluable during neonatal transition to help guide supportive care and ultimately protect the brain. Appropriate quantitative measures of preterm EEG must be calculated and care needs to be taken when applying the many techniques available for this task in the era of modern data science. This review provides valuable information about the factors that influence quantitative EEG analysis and describes the common pitfalls. Careful feature selection is required and attention must be paid to behavioral state given the variations encountered in newborn EEG during different states. Finally, the detrimental influence of artifacts on quantitative EEG analysis is illustrated.

Diagnosis of seizures and encephalopathy using conventional EEG and amplitude integrated EEG

Seizures are more common in the neonatal period than at any other time of life, partly due to the relative hyperexcitability of the neonatal brain. Brain monitoring of sick neonates in the NICU using either conventional electroencephalography or amplitude integrated EEG is essential to accurately detect seizures. Treatment of seizures is important, as evidence increasingly indicates that seizures damage the brain in addition to that caused by the underlying etiology. Prompt treatment has been shown to reduce seizure burden with the potential to ameliorate seizure-mediated damage. Neonatal encephalopathy most commonly caused by a hypoxia-ischemia results in an alteration of mental status and problems such as seizures, hypotonia, apnea, and feeding difficulties. Confirmation of encephalopathy with EEG monitoring can act as an important adjunct to other investigations and the clinical examination, particularly when considering treatment strategies such as therapeutic hypothermia. Brain monitoring also provides useful early prognostic indicators to clinicians. Recent use of machine learning in algorithms to continuously monitor the neonatal EEG, detect seizures, and grade encephalopathy offers the exciting prospect of real-time decision support in the NICU in the very near future.

Swedish consensus reached on recording, interpretation and reporting of neonatal continuous simplified electroencephalography that is supported by amplitude-integrated trend analysis

Continuous monitoring of electroencephalography (EEG), with a focus on amplitude-integrated EEG (aEEG), has been used in neonatal intensive care for decades. A number of systems have been suggested for describing and quantifying aEEG patterns. Extensive full-montage EEG monitoring is used in specialised intensive care units. The American Clinical Neurophysiology Society published recommendations for defining and reporting EEG findings in critically ill adults and infants. Swedish neonatologists and clinical neurophysiologists collaborated to optimise simplified neonatal continuous aEEG and EEG recordings based on these American documents.

CONCLUSION

This paper describes the Swedish consensus document produced by those meetings.

Coupling between mean blood pressure and EEG in preterm neonates is associated with reduced illness severity scores

Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term neurological outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relationship between BP and brain functioning. This study aims to investigate the interaction (coupling) between BP and continuous multichannel unedited EEG recordings in preterm infants less than 32 weeks of gestational age. The EEG was represented by spectral power in four frequency sub-bands: 0.3-3 Hz, 3-8 Hz, 8-15 Hz and 15-30 Hz. BP was represented as mean arterial pressure (MAP). The level of coupling between the two physiological systems was estimated using linear and nonlinear methods such as correlation, coherence and mutual information. Causality of interaction was measured using transfer entropy. The illness severity was represented by the clinical risk index for babies (CRIB II score) and contrasted to the computed level of interaction. It is shown here that correlation and coherence, which are linear measures of the coupling between EEG and MAP, do not correlate with CRIB values, whereas adjusted mutual information, a nonlinear measure, is associated with CRIB scores (r = -0.57, p = 0.003). Mutual information is independent of the absolute values of MAP and EEG powers and quantifies the level of coupling between the short-term dynamics in both signals. The analysis indicated that the dominant causality is from changes in EEG producing changes in MAP. Transfer entropy (EEG to MAP) is associated with the CRIB score (0.3-3 Hz: r = 0.428, p = 0.033, 3-8 Hz: r = 0.44, p = 0.028, 8-15 Hz: r = 0.416, p = 0.038) and indicates that a higher level of directed coupling from brain activity to blood pressure is associated with increased illness in preterm infants. This is the first study to present the nonlinear measure of interaction between brain activity and blood pressure and to demonstrate its relation to the initial illness severity in the preterm infant. The obtained results allow us to hypothesise that the normal wellbeing of a preterm neonate can be characterised by a nonlinear coupling between brain activity and MAP, whereas the presence of weak coupling with distinctive directionality of information flow is associated with an increased mortality rate in preterms.