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Galinsky R, Bennet L, Gunn AJ. Does MgSO4 protect the preterm brain? Dissecting its role in the pathophysiology of hypoxic ischemic encephalopathy. Neural Regen Res 2024; 19:1861-1862. [PMID: 38227499 DOI: 10.4103/1673-5374.390977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/10/2023] [Indexed: 01/17/2024] Open
Affiliation(s)
- Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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Shepherd E, Karim T, McIntyre S, Goldsmith S, Keir A, Badawi N, Hunt RW, Galinsky R. Neonatal magnesium sulphate for neuroprotection: A systematic review and meta-analysis. Dev Med Child Neurol 2024; 66:1157-1172. [PMID: 38468452 DOI: 10.1111/dmcn.15899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 03/13/2024]
Abstract
AIM To review the evidence of the effects of neonatal magnesium sulphate for neuroprotection in perinatal asphyxia and hypoxic-ischaemic encephalopathy (HIE). METHOD This was a systematic review of randomized controlled trials (RCTs) (with meta-analysis) and non-RCTs assessing magnesium sulphate for treating perinatal asphyxia and HIE at 35 weeks or more gestation (primary outcomes: neonatal death and death or long-term major neurodevelopmental disability). RESULTS Twenty-five RCTs (2099 infants) and four non-RCTs (871 infants) were included, 23 in low- and middle-income countries (LMICs). In RCTs, reductions in neonatal death with magnesium sulphate versus placebo or no treatment (risk ratio [RR] = 0.68; 95% confidence interval [CI] = 0.53-0.86; 13 RCTs), and magnesium sulphate with melatonin versus melatonin alone (RR = 0.74; 95% CI = 0.58-0.95; one RCT) were observed. No difference in neonatal death was seen for magnesium sulphate with therapeutic hypothermia versus therapeutic hypothermia alone (RR = 0.66, 95% CI = 0.34-1.26; three RCTs), or magnesium sulphate versus phenobarbital (RR = 3.00; 95% CI = 0.86-10.46; one RCT). No reduction in death or long-term neurodevelopmental disability (RR = 0.52; 95% CI = 0.14-1.89; one RCT) but reductions in several short-term adverse outcomes were observed with magnesium sulphate. Evidence was low- to very-low certainty because of risk of bias and imprecision. INTERPRETATION Given the uncertainty of the current evidence, further robust neonatal magnesium sulphate research is justified. This may include high-quality studies to determine stand-alone effects in LMICs and effects with and after therapeutic hypothermia in high-income countries.
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Affiliation(s)
- Emily Shepherd
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Tasneem Karim
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah McIntyre
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Shona Goldsmith
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Amy Keir
- Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Grace Centre for Newborn Intensive Care, The Children's Hospital, Sydney, New South Wales, Australia
| | - Rod W Hunt
- Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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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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Kelly SB, Tran NT, Polglase GR, Hunt RW, Nold MF, Nold-Petry CA, Olson DM, Chemtob S, Lodygensky GA, Robertson SA, Gunn AJ, Galinsky R. A systematic review of immune-based interventions for perinatal neuroprotection: closing the gap between animal studies and human trials. J Neuroinflammation 2023; 20:241. [PMID: 37864272 PMCID: PMC10588248 DOI: 10.1186/s12974-023-02911-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/28/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Perinatal infection/inflammation is associated with a high risk for neurological injury and neurodevelopmental impairment after birth. Despite a growing preclinical evidence base, anti-inflammatory interventions have not been established in clinical practice, partly because of the range of potential targets. We therefore systematically reviewed preclinical studies of immunomodulation to improve neurological outcomes in the perinatal brain and assessed their therapeutic potential. METHODS We reviewed relevant studies published from January 2012 to July 2023 using PubMed, Medline (OvidSP) and EMBASE databases. Studies were assessed for risk of bias using the SYRCLE risk of bias assessment tool (PROSPERO; registration number CRD42023395690). RESULTS Forty preclinical publications using 12 models of perinatal neuroinflammation were identified and divided into 59 individual studies. Twenty-seven anti-inflammatory agents in 19 categories were investigated. Forty-five (76%) of 59 studies reported neuroprotection, from all 19 categories of therapeutics. Notably, 10/10 (100%) studies investigating anti-interleukin (IL)-1 therapies reported improved outcome, whereas half of the studies using corticosteroids (5/10; 50%) reported no improvement or worse outcomes with treatment. Most studies (49/59, 83%) did not control core body temperature (a known potential confounder), and 25 of 59 studies (42%) did not report the sex of subjects. Many studies did not clearly state whether they controlled for potential study bias. CONCLUSION Anti-inflammatory therapies are promising candidates for treatment or even prevention of perinatal brain injury. Our analysis highlights key knowledge gaps and opportunities to improve preclinical study design that must be addressed to support clinical translation.
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Affiliation(s)
- Sharmony B Kelly
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Nhi T Tran
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Rodney W Hunt
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | - Marcel F Nold
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
| | - Claudia A Nold-Petry
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - David M Olson
- Department of Obstetrics and Gynaecology, University of Alberta, Edmonton, Canada
| | - Sylvain Chemtob
- Department of Paediatrics, CHU Sainte Justine Research Centre, University of Montreal, Quebec, Canada
| | - Gregory A Lodygensky
- Department of Paediatrics, CHU Sainte Justine Research Centre, University of Montreal, Quebec, Canada
| | - Sarah A Robertson
- The University of Adelaide, Robinson Research Institute, North Adelaide, SA, Australia
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne, VIC, 3168, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.
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Kelly SB, Dean JM, Zahra VA, Dudink I, Thiel A, Polglase GR, Miller SL, Hooper SB, Bennet L, Gunn AJ, Galinsky R. Progressive inflammation reduces high-frequency EEG activity and cortical dendritic arborisation in late gestation fetal sheep. J Neuroinflammation 2023; 20:124. [PMID: 37226206 DOI: 10.1186/s12974-023-02805-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Antenatal infection/inflammation is associated with disturbances in neuronal connectivity, impaired cortical growth and poor neurodevelopmental outcomes. The pathophysiological substrate that underpins these changes is poorly understood. We tested the hypothesis that progressive inflammation in late gestation fetal sheep would alter cortical neuronal microstructure and neural function assessed using electroencephalogram band power analysis. METHODS Fetal sheep (0.85 of gestation) were surgically instrumented for continuous electroencephalogram (EEG) recording and randomly assigned to repeated saline (control; n = 9) or LPS (0 h = 300 ng, 24 h = 600 ng, 48 h = 1200 ng; n = 8) infusions to induce inflammation. Sheep were euthanised 4 days after the first LPS infusion for assessment of inflammatory gene expression, histopathology and neuronal dendritic morphology in the somatosensory cortex. RESULTS LPS infusions increased delta power between 8 and 50 h, with reduced beta power from 18 to 96 h (P < 0.05 vs. control). Basal dendritic length, numbers of dendritic terminals, dendritic arborisation and numbers of dendritic spines were reduced in LPS-exposed fetuses (P < 0.05 vs. control) within the somatosensory cortex. Numbers of microglia and interleukin (IL)-1β immunoreactivity were increased in LPS-exposed fetuses compared with controls (P < 0.05). There were no differences in total numbers of cortical NeuN + neurons or cortical area between the groups. CONCLUSIONS Exposure to antenatal infection/inflammation was associated with impaired dendritic arborisation, spine number and loss of high-frequency EEG activity, despite normal numbers of neurons, that may contribute to disturbed cortical development and connectivity.
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Affiliation(s)
- Sharmony B Kelly
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Justin M Dean
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Valerie A Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
| | - Ingrid Dudink
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Alison Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Melbourne, VIC, 3168, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.
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