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El-Dib M, Abend NS, Austin T, Boylan G, Chock V, Cilio MR, Greisen G, Hellström-Westas L, Lemmers P, Pellicer A, Pressler RM, Sansevere A, Tsuchida T, Vanhatalo S, Wusthoff CJ, Wintermark P, Aly H, Chang T, Chau V, Glass H, Lemmon M, Massaro A, Wusthoff C, deVeber G, Pardo A, McCaul MC. Neuromonitoring in neonatal critical care part I: neonatal encephalopathy and neonates with possible seizures. Pediatr Res 2022:10.1038/s41390-022-02393-1. [PMID: 36476747 DOI: 10.1038/s41390-022-02393-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 12/12/2022]
Abstract
The blooming of neonatal neurocritical care over the last decade reflects substantial advances in neuromonitoring and neuroprotection. The most commonly used brain monitoring tools in the neonatal intensive care unit (NICU) are amplitude integrated EEG (aEEG), full multichannel continuous EEG (cEEG), and near-infrared spectroscopy (NIRS). While some published guidelines address individual tools, there is no consensus on consistent, efficient, and beneficial use of these modalities in common NICU scenarios. This work reviews current evidence to assist decision making for best utilization of neuromonitoring modalities in neonates with encephalopathy or with possible seizures. Neuromonitoring approaches in extremely premature and critically ill neonates are discussed separately in the companion paper. IMPACT: Neuromonitoring techniques hold promise for improving neonatal care. For neonatal encephalopathy, aEEG can assist in screening for eligibility for therapeutic hypothermia, though should not be used to exclude otherwise eligible neonates. Continuous cEEG, aEEG and NIRS through rewarming can assist in prognostication. For neonates with possible seizures, cEEG is the gold standard for detection and diagnosis. If not available, aEEG as a screening tool is superior to clinical assessment alone. The use of seizure detection algorithms can help with timely seizures detection at the bedside.
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Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - Valerie Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - M Roberta Cilio
- Department of Pediatrics, Division of Pediatric Neurology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital & Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lena Hellström-Westas
- Department of Women's and Children's Health, Uppsala University, and Division of Neonatology, Uppsala University Hospital, Uppsala, Sweden
| | - Petra Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain; Neonatology Group, IdiPAZ, Madrid, Spain
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, and Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Arnold Sansevere
- Department of Neurology and Pediatrics, George Washington University School of Medicine and Health Sciences; Children's National Hospital Division of Neurophysiology, Epilepsy and Critical Care, Washington, DC, USA
| | - Tammy Tsuchida
- Department of Neurology and Pediatrics, George Washington University School of Medicine and Health Sciences; Children's National Hospital Division of Neurophysiology, Epilepsy and Critical Care, Washington, DC, USA
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, Children's Hospital, BABA Center, Neuroscience Center/HILIFE, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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3
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Shellhaas RA, Wusthoff CJ, Numis AL, Chu CJ, Massey SL, Abend NS, Soul JS, Chang T, Lemmon ME, Thomas C, McNamara NA, Guillet R, Franck LS, Sturza J, McCulloch CE, Glass HC. Early-life epilepsy after acute symptomatic neonatal seizures: A prospective multicenter study. Epilepsia 2021; 62:1871-1882. [PMID: 34212365 DOI: 10.1111/epi.16978] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We aimed to evaluate early-life epilepsy incidence, seizure types, severity, risk factors, and treatments among survivors of acute neonatal seizures. METHODS Neonates with acute symptomatic seizures born 7/2015-3/2018 were prospectively enrolled at nine Neonatal Seizure Registry sites. One-hour EEG was recorded at age three months. Post-neonatal epilepsy and functional development (Warner Initial Developmental Evaluation of Adaptive and Functional Skills - WIDEA-FS) were assessed. Cox regression was used to assess epilepsy-free survival. RESULTS Among 282 infants, 37 (13%) had post-neonatal epilepsy by 24-months [median age of onset 7-months (IQR 3-14)]. Among those with post-neonatal epilepsy, 13/37 (35%) had infantile spasms and 12/37 (32%) had drug-resistant epilepsy. Most children with post-neonatal epilepsy had abnormal neurodevelopment at 24-months (WIDEA-FS >2SD below normal population mean for 81% of children with epilepsy vs 27% without epilepsy, RR 7.9, 95% CI 3.6-17.3). Infants with severely abnormal neonatal EEG background patterns were more likely to develop epilepsy than those with mild/moderate abnormalities (HR 3.7, 95% CI 1.9-5.9). Neonatal EEG with ≥3 days of seizures also predicted hazard of epilepsy (HR 2.9, 95% CI 1.4-5.9). In an adjusted model, days of neonatal EEG-confirmed seizures (HR 1.4 per day, 95% CI 1.2-1.6) and abnormal discharge examination (HR 3.9, 95% CI 1.9-7.8) were independently associated with time to epilepsy onset. Abnormal (vs. normal) three-month EEG was not associated with epilepsy. SIGNIFICANCE In this multicenter study, only 13% of infants with acute symptomatic neonatal seizures developed post-neonatal epilepsy by age 24-months. However, there was a high risk of severe neurodevelopmental impairment and drug-resistant seizures among children with post-neonatal epilepsy. Days of EEG-confirmed neonatal seizures was a potentially modifiable epilepsy risk factor. An EEG at three months was not clinically useful for predicting epilepsy. These practice changing findings have implications for family counseling, clinical follow-up planning, and future research to prevent post-neonatal epilepsy.
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Affiliation(s)
- Renée A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Courtney J Wusthoff
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA, USA.,Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Departments of Anesthesia & Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy A McNamara
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Linda S Franck
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA, USA
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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