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Arellano Haro A, Cuzco Macías A. Quality assessment of clinical practice guidelines on hypoxic-ischaemic encephalopathy in newborns using the AGREE II tool: a systematic review. An Pediatr (Barc) 2024; 100:412-419. [PMID: 38821833 DOI: 10.1016/j.anpede.2024.05.008] [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: 01/17/2024] [Accepted: 04/03/2024] [Indexed: 06/02/2024] Open
Abstract
INTRODUCTION Hypoxic-ischaemic encephalopathy is a clinical syndrome of neurological dysfunction that occurs immediately after birth following an episode of perinatal asphyxia. We conducted a scoping review to assess the methodological quality of clinical practice guidelines that address this condition. METHODOLOGY We conducted the evaluation using the AGREE II tool. High methodological quality was defined as a score greater than 70% in every domain. RESULTS The analysis included three clinical practice guidelines; the highest scores were in the scope and purpose domain (84.26%; SD, 14.25%) and the clarity of presentation domain (84.26%; SD, 17.86%), while the lowest score corresponded to the applicability domain (62.50%; SD, 36.62%). Two guidelines were classified as high quality and one guideline as low-quality. CONCLUSIONS Two of the assessed guidelines were classified as being of high quality; however, the analysis identified shortcomings in the applicability domain, in addition to methodological variation between guidelines developed in middle- or low-income countries versus high-income countries. Efforts are needed to make high-quality guidelines available to approach the management of hypoxic-ischaemic encephalopathy in newborns.
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Affiliation(s)
- Ana Arellano Haro
- Maestría en Epidemiología Con Mención en Investigación Clínica Aplicada, Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Ashley Cuzco Macías
- Maestría en Epidemiología Con Mención en Investigación Clínica Aplicada, Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador.
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Ali MAM, Farghaly MAA, El-Dib I, Karnati S, Aly H, Acun C. Glucose instability and outcomes of neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. Brain Dev 2024:S0387-7604(24)00073-1. [PMID: 38782623 DOI: 10.1016/j.braindev.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 05/16/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND To investigate the prevalence and associated outcomes of glucose abnormalities in infants with hypoxic ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). METHODS Glucose values were reviewed in all HIE infants. Pearson's correlation was used to assess the association of hypo- and hyperglycemic episodes with neonatal brain MRI and neurodevelopmental outcomes (NDO) at 12 & 24 months. RESULTS Of 153 infants included, 31, 56 and 43 had episodes of hypo-, hyperglycemia and combined, respectively. Hyperglycemia and combined hypo/hyper had higher mortality (p = 0.035), seizures (p = 0.009), and longer hospitalization (p = 0.023). Hypo- and hyperglycemia were associated with parenchymal hemorrhages (p = 0.028 & p = 0.027, respectively). Hypoglycemia was associated with restricted diffusion (p = 0.014), while hyperglycemia was associated with cortical injuries (p = 0.045). Each hour of hyper- or hypoglycemia was associated with 5.2-5.8 times unfavorable outcomes (p < 0.001). CONCLUSION Blood glucose aberrations were detrimental in HIE infants treated with TH. Optimizing glucose management is crucial in this setting.
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Affiliation(s)
- Mahmoud A M Ali
- West Virginia University School of Medicine, Department of Pediatrics, Morgantown, WV 26505, USA; MetroHealth Medical Center, Case Western Reserve University, Department of Pediatrics, Division of Neonatology, Cleveland, OH 44109, USA.
| | - Mohsen A A Farghaly
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Injy El-Dib
- Biomedical Engineering Student, School of Engineering, Brown University, Providence, RI, USA
| | - Sreenivas Karnati
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Hany Aly
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
| | - Ceyda Acun
- Cleveland Clinic Children's Hospital, Department of Neonatology, Cleveland, OH 44106, USA
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Leandro DMK, Variane GFT, Dahlen A, Pietrobom RFR, de Castro JARR, Rodrigues DP, Magalhães M, Mimica MJ, Van Meurs KP, Chock VY. Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Reducing Variability in Practice through a Collaborative Telemedicine Initiative. Am J Perinatol 2024. [PMID: 38714205 DOI: 10.1055/s-0044-1786720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVE This study aimed to assess the viability of implementing a tele-educational training program in neurocritical care for newborns diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia (TH), with the goal of reducing practice variation. STUDY DESIGN Prospective study including newborns with HIE treated with TH from 12 neonatal intensive care units in Brazil conducted from February 2021 to February 2022. An educational intervention consisting of 12 biweekly, 1-hour, live videoconferences was implemented during a 6-month period in all centers. Half of the centers had the assistance of a remote neuromonitoring team. The primary outcome was the rate of deviations from TH protocol, and it was evaluated during a 3-month period before and after the intervention. Logistic regression via generalized estimating equations was performed to compare the primary and secondary outcomes. Protocol deviations were defined as practices not in compliance with the TH protocol provided. A subanalysis evaluated the differences in protocol deviations and clinical variables between centers with and without neuromonitoring. RESULTS Sixty-six (39.5%) newborns with HIE were treated with TH during the preintervention period, 69 (41.3%) during the intervention period and 32 (19.1%) after intervention. There was not a significant reduction in protocol deviations between the pre- and postintervention periods (37.8 vs. 25%, p = 0.23); however, a decrease in the rates of missing Sarnat examinations within 6 hours after birth was seen between the preintervention (n = 5, 7.6%) and postintervention (n = 2, 6.3%) periods (adjusted odds ratio [aOR]: 0.36 [0.25-0.52], p < 0.001). Centers with remote neuromonitoring support had significantly lower rates of seizures (27.6 vs. 57.5%; aOR: 0.26 [0.12-0.55], p < 0.001) and significant less seizure medication (27.6 vs. 68.7%; aOR: 0.17 [0.07-0.4], p < 0.001). CONCLUSION This study shows that implementing a tele-educational program in neonatal neurocritical care is feasible and may decrease variability in the delivery of care to patients with HIE treated with TH. KEY POINTS · Neurocritical care strategies vary widely in low- and middle-income countries.. · Heterogeneity of care may lead to suboptimal efficacy of neuroprotective strategies.. · Tele-education and international collaboration can decrease the variability of neurocritical care provided to infants with HIE..
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Affiliation(s)
- Danieli M K Leandro
- Division of Neonatology, Department of Pediatrics, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Gabriel F T Variane
- Division of Neonatology, Department of Pediatrics, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Alex Dahlen
- Department of Biostatistics, School of Global Public Health, New York University, New York, New York
| | - Rafaela F R Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Jessica A R R de Castro
- Division of Neonatology, Department of Pediatrics, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Daniela P Rodrigues
- Department of Pediatric Nursing, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Marcelo J Mimica
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Department of Pathology and Department of Pediatrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California
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Garcia-Alix A, Arnaez J, Arca G, Martinez-Biarge M. Hypoxic-ischaemic encephalopathy code: A systematic review for resource-limited settings. An Pediatr (Barc) 2024; 100:275-286. [PMID: 38614864 DOI: 10.1016/j.anpede.2024.04.001] [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: 01/11/2024] [Accepted: 02/28/2024] [Indexed: 04/15/2024] Open
Abstract
It is estimated that 96% of infants with hypoxic-ischaemic encephalopathy (HIE) are born in resource-limited settings with no capacity to provide the standard of care that has been established for nearly 15 years in high-resource countries, which includes therapeutic hypothermia (TH), continuous electroencephalographic monitoring and magnetic resonance imaging (MRI) in addition to close vital signs and haemodynamic monitoring. This situation does not seem to be changing; however, even with these limitations, currently available knowledge can help improve the care of HIE patients in resource-limited settings. The purpose of this systematic review was to provide, under the term "HIE Code", evidence-based recommendations for feasible care practices to optimise the care of infants with HIE and potentially help reduce the risks associated with comorbidity and improve neurodevelopmental outcomes. The content of the HIE code was grouped under 9 headings: (1) prevention of HIE, (2) resuscitation, (3) first 6h post birth, (4) identification and grading of encephalopathy, (5) seizure management, (6) other therapeutic interventions, (7) multiple organ dysfunction, (8) diagnostic tests and (9) family care.
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Affiliation(s)
- Alfredo Garcia-Alix
- Neurología Neonatal, NeNe Foundation, Madrid, Spain; Neonatología, Ibero-American Society of Neonatology (SIBEN), New Jersey, USA.
| | - Juan Arnaez
- Neurología Neonatal, NeNe Foundation, Madrid, Spain; Neonatología, Ibero-American Society of Neonatology (SIBEN), New Jersey, USA; Unidad Neonatal, Complejo Asistencial Universitario de Burgos, Burgos, Spain
| | - Gemma Arca
- Neurología Neonatal, NeNe Foundation, Madrid, Spain; Departamento de Neonatología, Hospital Clínic, IDIBAPS, Barcelona, Spain
| | - Miriam Martinez-Biarge
- Department of Paediatrics, Imperial College Healthcare NHS Trust, Londres, United Kingdom
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Tran HTT, Le HT, Tran DM, Nguyen GTH, Hellström-Westas L, Alfven T, Olson L. Therapeutic hypothermia after perinatal asphyxia in Vietnam: medium-term outcomes at 18 months - a prospective cohort study. BMJ Paediatr Open 2024; 8:e002208. [PMID: 38388007 PMCID: PMC10882320 DOI: 10.1136/bmjpo-2023-002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
AIM To determine neurodevelopmental outcome at 18 months after therapeutic hypothermia for hypoxic-ischaemic encephalopathy (HIE) infants in Vietnam, a low-middle-income country. METHOD Prospective cohort study investigating outcomes at 18 months in severely asphyxiated outborn infants who underwent therapeutic hypothermia for HIE in Hanoi, Vietnam, during the time period 2016-2019. Survivors were examined at discharge and at 6 and 18 months by a neonatologist, a neurologist and a rehabilitation physician, who were blinded to the infants' clinical severity during hospitalisation using two assessment tools: the Ages and Stages Questionnaire (ASQ) and the Hammersmith Infant Neurological Examination (HINE), to detect impairments and promote early interventions for those who require it. RESULTS In total, 130 neonates, 85 (65%) with moderate and 45 (35%) with severe HIE, underwent therapeutic hypothermia treatment using phase change material. Forty-three infants (33%) died during hospitalisation and in infancy. Among the 87 survivors, 69 (79%) completed follow-up until 18 months. Nineteen children developed cerebral palsy (8 diplegia, 3 hemiplegia, 8 dyskinetic), and 11 had delayed neurodevelopment. At each time point, infants with a normal or delayed neurodevelopment had significantly higher ASQ and HINE scores (p<0.05) than those with cerebral palsy. CONCLUSION The rates of mortality and adverse neurodevelopment rate were high and comparable to recently published data from other low-middle-income settings. The ASQ and HINE were useful tools for screening and evaluation of neurodevelopment and neurological function.
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Affiliation(s)
- Hang Thi Thanh Tran
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Neonatal Care Center, Vietnam National Children's Hospital, Ha Noi, Viet Nam
| | - Ha Thi Le
- Neonatal Care Center, Vietnam National Children's Hospital, Ha Noi, Viet Nam
| | | | | | | | - Tobias Alfven
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Linus Olson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Francke KH, Støen R, Thomas N, Aker K. Biochemical profiles and organ dysfunction in neonates with hypoxic-ischemic encephalopathy post-hoc analysis of the THIN trial. BMC Pediatr 2024; 24:46. [PMID: 38225562 PMCID: PMC10789058 DOI: 10.1186/s12887-024-04523-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/01/2024] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Therapeutic hypothermia for infants with moderate to severe hypoxic-ischemic encephalopathy is well established as standard of care in high-income countries. Trials from low- and middle-income countries have shown contradictory results, and variations in the level of intensive care provided may partly explain these differences. We wished to evaluate biochemical profiles and clinical markers of organ dysfunction in cooled and non-cooled infants with moderate/severe hypoxic-ischemic encephalopathy. METHODS This secondary analysis of the THIN (Therapeutic Hypothermia in India) study, a single center randomized controlled trial, included 50 infants with moderate to severe hypoxic-ischemic encephalopathy randomized to therapeutic hypothermia (n = 25) or standard care with normothermia (n = 25) between September 2013 and October 2015. Data were collected prospectively and compared by randomization groups. Main outcomes were metabolic acidosis, coagulopathies, renal function, and supportive treatments during the intervention. RESULTS Cooled infants had lower pH than non-cooled infants at 6-12 h (median (IQR) 7.28 (7.20-7.32) vs 7.36 (7.31-7.40), respectively, p = 0.003) and 12-24 h (median (IQR) 7.30 (7.24-7.35) vs 7.41 (7.37-7.43), respectively, p < 0.001). Thrombocytopenia (< 100 000) was, though not statistically significant, twice as common in cooled compared to non-cooled infants (4/25 (16%) and 2/25 (8%), respectively, p = 0.67). No significant difference was found in the use of vasopressors (14/25 (56%) and 17/25 (68%), p = 0.38), intravenous bicarbonate (5/25 (20%) and 3/25 (12%), p = 0.70) or treatment with fresh frozen plasma (10/25 (40%) and 8/25 (32%), p = 0.56)) in cooled and non-cooled infants, respectively. Urine output < 1 ml/kg/h was less common in cooled infants compared to non-cooled infants at 0-24 h (7/25 (28%) vs. 16/23 (70%) respectively, p = 0.004). CONCLUSIONS This post hoc analysis of the THIN study support that cooling of infants with hypoxic-ischemic encephalopathy in a level III neonatal intensive care unit in India was safe. Cooled infants had slightly lower pH, but better renal function during the first day compared to non-cooled infants. More research is needed to identify the necessary level of intensive care during cooling to guide further implementation of this neuroprotective treatment in low-resource settings. TRIAL REGISTRATION Data from this article was collected during the THIN-study (Therapeutic Hypothermia in India; ref. CTRI/2013/05/003693 Clinical Trials Registry - India).
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Affiliation(s)
- Karen Haugvik Francke
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Ragnhild Støen
- Department of Pediatrics, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
| | - Niranjan Thomas
- Department of Neonatology, Christian Medical College, Vellore, India
- Department of Neonatology, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, 3021, Australia
| | - Karoline Aker
- Department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
- Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Melemed AL, Slaughter JL, Benninger KL, Conroy S. Is erythropoietin beneficial and safe as an adjunctive therapy to therapeutic hypothermia in newborns with hypoxic ischemic injury? J Perinatol 2023; 43:1552-1555. [PMID: 37773520 DOI: 10.1038/s41372-023-01773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/17/2023] [Accepted: 08/30/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Abigail L Melemed
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Jonathan L Slaughter
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio Perinatal Research Network, Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Kristen L Benninger
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio Perinatal Research Network, Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Sara Conroy
- The Ohio Perinatal Research Network, Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Biostatistics Resource at Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Peeples ES. MicroRNA therapeutic targets in neonatal hypoxic-ischemic brain injury: a narrative review. Pediatr Res 2023; 93:780-788. [PMID: 35854090 DOI: 10.1038/s41390-022-02196-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/25/2022] [Accepted: 06/28/2022] [Indexed: 11/11/2022]
Abstract
Neonatal hypoxic-ischemic brain injury (HIBI) is a devastating injury resulting from impaired blood flow and oxygen delivery to the brain at or around the time of birth. Despite the use of therapeutic hypothermia, more than one in four survivors suffer from major developmental disabilities-an indication of the critical need for more effective therapies. MicroRNAs (miRNA) have the potential to act as biomarkers and/or therapeutic targets in neonatal HIBI as a step toward improving outcomes in this high-risk population. This review summarizes the current literature around the use of cord blood and postnatal circulating blood miRNA expression for diagnosis or prognosis in human infants with hypoxic-ischemic encephalopathy, as well as animal studies assessing endogenous brain miRNA expression and potential for therapeutic targeting of miRNA expression for neuroprotection. Ultimately, the lack of knowledge regarding brain specificity of circulating miRNAs and the temporal variability in expression currently limit the use of miRNAs as biomarkers. However, given their broad effect profile, ease of administration, and small size allowing for effective blood-brain barrier crossing, miRNAs represent promising therapeutic targets for improving brain injury and reducing developmental impairments in neonates after HIBI. IMPACT: The high morbidity and mortality of neonatal hypoxic-ischemic brain injury (HIBI) despite current therapies demonstrates a need for developing more sensitive biomarkers and superior therapeutic options. MicroRNAs have been evaluated both as biomarkers and therapeutic options after neonatal HIBI. The limited knowledge regarding brain specificity of circulating microRNAs and temporal variability in expression currently limit the use of microRNAs as biomarkers. Future studies comparing the neuroprotective effects of modulating microRNA expression must consider temporal changes in the endogenous expression to determine appropriate timing of therapy, while also optimizing techniques for delivery.
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Affiliation(s)
- Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
- Children's Hospital & Medical Center, Omaha, NE, USA.
- Child Health Research Institute, Omaha, NE, USA.
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Foglia EE, Davis PG, Guinsburg R, Kapadia V, Liley HG, Rüdiger M, Schmölzer GM, Strand ML, Wyckoff MH, Wyllie J, Weiner GM. Recommended Guideline for Uniform Reporting of Neonatal Resuscitation: The Neonatal Utstein Style. Pediatrics 2023; 151:190463. [PMID: 36632729 DOI: 10.1542/peds.2022-059631] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 01/13/2023] Open
Abstract
Clinical research on neonatal resuscitation has accelerated over recent decades. However, an important methodologic limitation is that there are no standardized definitions or reporting guidelines for neonatal resuscitation clinical studies. To address this, the International Liaison Committee on Resuscitation Neonatal Life Support Task Force established a working group to develop the first Utstein-style reporting guideline for neonatal resuscitation. The working group modeled this approach on previous Utstein-style guidelines for other populations. This reporting guideline focuses on resuscitation of newborns immediately after birth for respiratory failure, bradycardia, severe bradycardia, or cardiac arrest. We identified 7 relevant domains: setting, patient, antepartum, birth/preresuscitation, resuscitation process, postresuscitation process, and outcomes. Within each domain, relevant data elements were identified as core versus supplemental. Core data elements should be collected and reported for all neonatal resuscitation studies, while supplemental data elements may be collected and reported using standard definitions when possible. The Neonatal Utstein template includes both core and supplemental elements across the 7 domains, and the associated Data Table provides detailed information and reporting standards for each data element. The Neonatal Utstein reporting guideline is anticipated to assist investigators engaged in neonatal resuscitation research by standardizing data definitions. The guideline will facilitate data pooling in meta-analyses, enhancing the strength of neonatal resuscitation treatment recommendations and subsequent guidelines.
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Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Peter G Davis
- Newborn Research Center, the Royal Women's Hospital and the University of Melbourne, Victoria, Australia
| | - Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vishal Kapadia
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Mario Rüdiger
- Saxony Center for Fetal-Neonatal Health.,Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Medizinische Fakultät TU Dresden, Dresden, Germany
| | - Georg M Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Marya L Strand
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Wyllie
- Department of Paediatrics and Neonatology, James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Gary M Weiner
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Kukka AJ, Waheddoost S, Brown N, Litorp H, Wrammert J, KC A. Incidence and outcomes of intrapartum-related neonatal encephalopathy in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob Health 2022; 7:bmjgh-2022-010294. [PMID: 36581333 PMCID: PMC9806096 DOI: 10.1136/bmjgh-2022-010294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/23/2022] [Indexed: 12/30/2022] Open
Abstract
AIM To examine the incidence of intrapartum-related neonatal encephalopathy, and neonatal mortality and neurodevelopmental outcomes associated with it in low-income and middle-income countries. METHODS Reports were included when neonatal encephalopathy diagnosed clinically within 24 hours of birth in term or near-term infants born after intrapartum hypoxia-ischaemia defined as any of the following: (1) pH≤7.1 or base excess ≤-12 or lactate ≥6, (2) Apgar score ≤5 at 5 or 10 min, (3) continuing resuscitation at 5 or 10 min or (4) no cry from baby at 5 or 10 min. Peer-reviewed articles were searched from Ovid MEDLINE, Cochrane, Web of Science and WHO Global Index Medicus with date limits 1 November 2009 to 17 November 2021. Risk of bias was assessed using modified Newcastle Ottawa Scale. Inverse variance of heterogenicity was used for meta-analyses. RESULTS There were 53 reports from 51 studies presenting data on 4181 children with intrapartum-related neonatal encephalopathy included in the review. Only five studies had data on incidence, which ranged from 1.5 to 20.3 per 1000 live births. Neonatal mortality was examined in 45 studies and in total 636 of the 3307 (19.2%) infants died. Combined outcome of death or moderate to severe neurodevelopmental disability was reported in 19 studies and occurred in 712 out of 1595 children (44.6%) with follow-up 1 to 3.5 years. CONCLUSION Though there has been progress in some regions, incidence, case mortality and morbidity in intrapartum-related neonatal encephalopathy has been static in the last 10 years. PROSPERO REGISTRATION NUMBER CRD42020177928.
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Affiliation(s)
- Antti Juhani Kukka
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden .,Department of Pediatrics, Region Gävleborg, Gävle, Sweden
| | | | - Nick Brown
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden,Department of Pediatrics, Region Gävleborg, Gävle, Sweden
| | - Helena Litorp
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan Wrammert
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Ashish KC
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
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12
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Andersen HB, Andersen M, Bennedsgaard K, Kerrn-Jespersen S, Kyng KJ, Holm IE, Henriksen TB. No Differences in Cerebral Immunohistochemical Markers following Remote Ischemic Postconditioning in Newborn Piglets with Hypoxia-Ischemia. Neuropediatrics 2022; 53:423-431. [PMID: 35777661 PMCID: PMC9643070 DOI: 10.1055/a-1889-8544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Despite therapeutic hypothermia, neonates with hypoxic-ischemic encephalopathy still develop neurological disabilities. We have previously investigated neuroprotection by remote ischemic postconditioning (RIPC) in newborn piglets following hypoxia-ischemia (HI). The aim of this study was to further investigate potential effects of RIPC on cerebral immunohistochemical markers related to edema, apoptosis, and angiogenesis. METHODS Brain expression of aquaporin 4, caspase-3, B-cell lymphoma 2, and vascular endothelial growth factor was analyzed by immunohistochemistry in 23 piglets, randomly selected from a larger study of RIPC after HI. Twenty animals were subjected to 45 minutes of HI and randomized to treatment with and without RIPC, while three animals were randomized to sham procedures. RIPC was conducted by four conditioning cycles of 5-minute ischemia and reperfusion. Piglets were euthanized 72 hours after the HI insult. RESULTS Piglets subjected to HI treated with and without RIPC were similar at baseline and following the HI insult. However, piglets randomized to HI alone had longer duration of low blood pressure during the insult. We found no differences in the brain expression of the immunohistochemical markers in any regions of interest or the whole brain between the two HI groups. CONCLUSION RIPC did not influence brain expression of markers related to edema, apoptosis, or angiogenesis in newborn piglets at 72 hours after HI. These results support previous findings of limited neuroprotective effect by this RIPC protocol. Our results may have been affected by the time of assessment, use of fentanyl as anesthetic, or limitations related to our immunohistochemical methods.
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Affiliation(s)
- Hannah B. Andersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Andersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristine Bennedsgaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sigrid Kerrn-Jespersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper J. Kyng
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ida E. Holm
- Department of Pathology, Randers Regional Hospital, Randers, Denmark
| | - Tine B. Henriksen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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13
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Christidis P, Vij A, Petousis S, Ghaemmaghami J, Shah BV, Koutroulis I, Kratimenos P. Neuroprotective effect of Src kinase in hypoxia-ischemia: A systematic review. Front Neurosci 2022; 16:1049655. [PMID: 36507364 PMCID: PMC9730728 DOI: 10.3389/fnins.2022.1049655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Hypoxic-ischemic encephalopathy (HIE) is a major cause of neonatal morbidity and mortality worldwide. While the application of therapeutic hypothermia has improved neurodevelopmental outcomes for some survivors of HIE, this lone treatment option is only available to a subset of affected neonates. Src kinase, an enzyme central to the apoptotic cascade, is a potential pharmacologic target to preserve typical brain development after HIE. Here, we present evidence of the neuroprotective effects of targeting Src kinase in preclinical models of HIE. Methods We performed a comprehensive literature search using the National Library of Medicine's MEDLINE database to compile studies examining the impact of Src kinase regulation on neurodevelopment in animal models. Each eligible study was assessed for bias. Results Twenty studies met the inclusion criteria, and most studies had an intermediate risk for bias. Together, these studies showed that targeting Src kinase resulted in a neuroprotective effect as assessed by neuropathology, enzymatic activity, and neurobehavioral outcomes. Conclusion Src kinase is an effective neuroprotective target in the setting of acute hypoxic injury. Src kinase inhibition triggers multiple signaling pathways of the sub-membranous focal adhesions and the nucleus, resulting in modulation of calcium signaling and prevention of cell death. Despite the significant heterogeneity of the research studies that we examined, the available evidence can serve as proof-of-concept for further studies on this promising therapeutic strategy.
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Affiliation(s)
- Panagiotis Christidis
- Laboratory of Physiology, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Abhya Vij
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Stamatios Petousis
- 2nd Department of Obstetrics and Gynecology, “Hippokrateion” General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Javid Ghaemmaghami
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC, United States
| | - Bhairav V. Shah
- Division of Pediatric Surgery, Department of Pediatrics, School of Medicine, Prisma Health Children's Hospital-Midlands, University of South Carolina, Columbia, SC, United States
| | - Ioannis Koutroulis
- Department of Pediatrics, Division of Emergency Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Panagiotis Kratimenos
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC, United States,Division of Neonatology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, United States,*Correspondence: Panagiotis Kratimenos
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14
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Cochrane Database Syst Rev 2022; 11:CD015023. [PMID: 36354070 PMCID: PMC9647594 DOI: 10.1002/14651858.cd015023.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life. OBJECTIVES To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. SEARCH METHODS We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine. AUTHORS' CONCLUSIONS We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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15
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Pang R, Mujuni BM, Martinello KA, Webb EL, Nalwoga A, Ssekyewa J, Musoke M, Kurinczuk JJ, Sewegaba M, Cowan FM, Cose S, Nakakeeto M, Elliott AM, Sebire NJ, Klein N, Robertson NJ, Tann CJ. Elevated serum IL-10 is associated with severity of neonatal encephalopathy and adverse early childhood outcomes. Pediatr Res 2022; 92:180-189. [PMID: 33674741 PMCID: PMC9411052 DOI: 10.1038/s41390-021-01438-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neonatal encephalopathy (NE) contributes substantially to child mortality and disability globally. We compared cytokine profiles in term Ugandan neonates with and without NE, with and without perinatal infection or inflammation and identified biomarkers predicting neonatal and early childhood outcomes. METHODS In this exploratory biomarker study, serum IL-1α, IL-6, IL-8, IL-10, TNFα, and VEGF (<12 h) were compared between NE and non-NE infants with and without perinatal infection/inflammation. Neonatal (severity of NE, mortality) and early childhood (death or neurodevelopmental impairment to 2.5 years) outcomes were assessed. Predictors of outcomes were explored with multivariable linear and logistic regression and receiver-operating characteristic analyses. RESULTS Cytokine assays on 159 NE and 157 non-NE infants were performed; data on early childhood outcomes were available for 150 and 129, respectively. NE infants had higher IL-10 (p < 0.001), higher IL-6 (p < 0.017), and lower VEGF (p < 0.001) levels. Moderate and severe NE was associated with higher IL-10 levels compared to non-NE infants (p < 0.001). Elevated IL-1α was associated with perinatal infection/inflammation (p = 0.013). Among NE infants, IL-10 predicted neonatal mortality (p = 0.01) and adverse early childhood outcome (adjusted OR 2.28, 95% CI 1.35-3.86, p = 0.002). CONCLUSIONS Our findings support a potential role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy. IMPACT Neonatal encephalopathy is a common cause of child death and disability globally. Inflammatory cytokines are potential biomarkers of encephalopathy severity and outcome. In this Ugandan health facility-based cohort, neonatal encephalopathy was associated with elevated serum IL-10 and IL-6, and reduced VEGF at birth. Elevated serum IL-10 within 12 h after birth predicted severity of neonatal encephalopathy, neonatal mortality, and adverse early childhood developmental outcomes, independent of perinatal infection or inflammation, and provides evidence to the contribution of the inflammatory processes. Our findings support a role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy in a sub-Saharan African cohort.
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Affiliation(s)
- Raymand Pang
- Institute for Women's Health, University College London, London, UK
| | - Brian M Mujuni
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Emily L Webb
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Angela Nalwoga
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Julius Ssekyewa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Margaret Musoke
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Margaret Sewegaba
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Frances M Cowan
- Department of Pediatrics, Imperial College London, London, UK
| | - Stephen Cose
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Margaret Nakakeeto
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Alison M Elliott
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Neil J Sebire
- UCL Institute of Child Health and GOSH BRC, UCL, London, UK
| | - Nigel Klein
- UCL Institute of Child Health and GOSH BRC, UCL, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Cally J Tann
- Institute for Women's Health, University College London, London, UK.
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
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16
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Martinello KA, Meehan C, Avdic-Belltheus A, Lingam I, Mutshiya T, Yang Q, Akin MA, Price D, Sokolska M, Bainbridge A, Hristova M, Tachtsidis I, Tann CJ, Peebles D, Hagberg H, Wolfs TGAM, Klein N, Kramer BW, Fleiss B, Gressens P, Golay X, Robertson NJ. Hypothermia is not therapeutic in a neonatal piglet model of inflammation-sensitized hypoxia-ischemia. Pediatr Res 2022; 91:1416-1427. [PMID: 34050269 PMCID: PMC8160560 DOI: 10.1038/s41390-021-01584-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perinatal inflammation combined with hypoxia-ischemia (HI) exacerbates injury in the developing brain. Therapeutic hypothermia (HT) is standard care for neonatal encephalopathy; however, its benefit in inflammation-sensitized HI (IS-HI) is unknown. METHODS Twelve newborn piglets received a 2 µg/kg bolus and 1 µg/kg/h infusion over 52 h of Escherichia coli lipopolysaccharide (LPS). HI was induced 4 h after LPS bolus. After HI, piglets were randomized to HT (33.5 °C 1-25 h after HI, n = 6) or normothermia (NT, n = 6). Amplitude-integrated electroencephalogram (aEEG) was recorded and magnetic resonance spectroscopy (MRS) was acquired at 24 and 48 h. At 48 h, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive brain cell death, microglial activation/proliferation, astrogliosis, and cleaved caspase-3 (CC3) were quantified. Hematology and plasma cytokines were serially measured. RESULTS Two HT piglets died. aEEG recovery, thalamic and white matter MRS lactate/N-acetylaspartate, and TUNEL-positive cell death were similar between groups. HT increased microglial activation in the caudate, but had no other effect on glial activation/proliferation. HT reduced CC3 overall. HT suppressed platelet count and attenuated leukocytosis. Cytokine profile was unchanged by HT. CONCLUSIONS We did not observe protection with HT in this piglet IS-HI model based on aEEG, MRS, and immunohistochemistry. Immunosuppressive effects of HT and countering neuroinflammation by LPS may contribute to the observed lack of HT efficacy. Other immunomodulatory strategies may be more effective in IS-HI. IMPACT Acute infection/inflammation is known to exacerbate perinatal brain injury and can worsen the outcomes in neonatal encephalopathy. Therapeutic HT is the current standard of care for all infants with NE, but the benefit in infants with coinfection/inflammation is unknown. In a piglet model of inflammation (LPS)-sensitized HI, we observed no evidence of neuroprotection with cooling for 24 h, based on our primary outcome measures: aEEG, MRS Lac/NAA, and histological brain cell death. Additional neuroprotective agents, with beneficial immunomodulatory effects, require exploration in IS-HI models.
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Affiliation(s)
- Kathryn A Martinello
- Institute for Women's Health, University College London, London, UK
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | | | - Ingran Lingam
- Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Institute for Women's Health, University College London, London, UK
| | - Mustafa Ali Akin
- Department of Paediatrics, Ondokuz Mayıs University, Samsun, Turkey
| | - David Price
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Magdalena Sokolska
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Alan Bainbridge
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Mariya Hristova
- Institute for Women's Health, University College London, London, UK
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Cally J Tann
- Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Donald Peebles
- Institute for Women's Health, University College London, London, UK
| | - Henrik Hagberg
- Department of Clinical Sciences, Centre of Perinatal Medicine and Health, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Centre for the Developing Brain, Kings College London, London, UK
| | - Tim G A M Wolfs
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Nigel Klein
- Paediatric Infectious Diseases and Immunology, Institute of Child Health, University College London, London, UK
| | - Boris W Kramer
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- Université de Paris, NeuroDiderot, Inserm, Paris, France
| | | | - Xavier Golay
- Institute of Neurology, University College London, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK.
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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Mathew JL, Kaur N, Dsouza JM. Therapeutic hypothermia in neonatal hypoxic encephalopathy: A systematic review and meta-analysis. J Glob Health 2022; 12:04030. [PMID: 35444799 PMCID: PMC8994481 DOI: 10.7189/jogh.12.04030] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is regarded as the most efficacious therapy for neonatal hypoxic encephalopathy. However, limitations in previous systematic reviews and the publication of new data necessitate updating the evidence. We conducted this up-to-date systematic review to evaluate the effects of TH in neonatal encephalopathy on clinical outcomes. Methods In this systematic review and meta-analysis, we searched Medline, Cochrane Library, Embase, LIVIVO, Web of Science, Scopus, CINAHL, major trial registries, and grey literature (from inception to October 31, 2021), for randomized controlled trials (RCT) comparing TH vs normothermia in neonatal encephalopathy. We included RCTs enrolling neonates (gestation ≥35 weeks) with perinatal asphyxia and encephalopathy, who received either TH (temperature ≤34°C) initiated within 6 hours of birth for ≥48 hours, vs no cooling. We excluded non-RCTs, those with delayed cooling, or cooling to >34°C. Two authors independently appraised risk-of-bias and extracted data on mortality and neurologic disability at four time points: neonatal (from randomization to discharge/death), infancy (18-24 months), childhood (5-10 years), and long-term (>10 years). Other outcomes included seizures, EEG abnormalities, and MRI findings. Summary data from published RCTs were pooled through fixed-effect meta-analysis. Results We identified 36 863 citations and included 39 publications representing 29 RCTs with 2926 participants. Thirteen studies each had low, moderate, and high risk-of-bias. The pooled risk ratios (95% confidence interval, CI) were as follows: neonatal mortality: 0.87 (95% CI = 0.75, 1.00), n = 2434, I2 = 38%; mortality at 18-24 months: 0.88 (95% CI = 0.78, 1.01), n = 2042, I2 = 51%; mortality at 5-10 years: 0.81 (95% CI = 0.62, 1.04), n = 515, I2 = 59%; disability at 18-24 months: 0.62 (95% CI = 0.52, 0.75), n = 1440, I2 = 26%; disability at 5-10 years: 0.68 (95% CI = 0.52, 0.90), n = 442, I2 = 3%; mortality or disability at 18-24 months: 0.78 (95% CI = 0.72, 0.86), n = 1914, I2 = 54%; cerebral palsy at 18-24 months: 0.63 (95% CI = 0.50, 0.78), n = 1136, I2 = 39%; and childhood cerebral palsy: 0.63 (95% CI = 0.46, 0.85), n = 449, I2 = 0%. Some outcomes showed significant differences by study-setting; the risk ratio (95% CI) for mortality at 18-24 months was 0.79 (95% CI = 0.66,0.93), n = 1212, I2 = 7% in high-income countries, 0.67 (95% CI = 0.41, 1.09), n = 276, I2 = 0% in upper-middle-income countries, and 1.18 (95% CI = 0.94, 1.47), n = 554, I2 = 75% in lower-middle-income countries. The corresponding pooled risk ratios for ‘mortality or disability at 18-24 months’ were 0.77 (95% CI = 0.69, 0.86), n = 1089, I2 = 0%; 0.56 (95% CI = 0.41, 0.78), n = 276, I2 = 30%; and 0.92 (95% CI = 0.77, 1.09), n = 549, I2 = 86% respectively. Trials with low risk of bias showed risk ratio of 0.97 (95% CI = 0.80, 1.16, n = 1475, I2 = 62%) for neonatal mortality, whereas trials with higher risk of bias showed 0.71 (95% CI = 0.55, 0.91), n = 959, I2 = 0%. Likewise, risk ratio for mortality at 18-24 months was 0.96 (95% CI = 0.83, 1.13), n = 1336, I2 = 58% among low risk-of-bias trials, but 0.72 (95% CI = 0.56, 0.92), n = 706, I2 = 0%, among higher risk of bias trials. Conclusions Therapeutic hypothermia for neonatal encephalopathy reduces neurologic disability and cerebral palsy, but its effect on neonatal, infantile and childhood mortality is uncertain. The setting where it is implemented affects the outcomes. Low(er) quality trials overestimated the potential benefit of TH.
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Affiliation(s)
- Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Navneet Kaur
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
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18
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Rise and Fall of Therapeutic Hypothermia in Low-Resource Settings: Lessons from the HELIX Trial: Correspondence. Indian J Pediatr 2022; 89:295-296. [PMID: 34561766 DOI: 10.1007/s12098-021-03961-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
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19
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Rise and Fall of Therapeutic Hypothermia in Low-Resource Settings: Lessons from the HELIX Trial: Correspondence. Indian J Pediatr 2022; 89:293-294. [PMID: 34562191 DOI: 10.1007/s12098-021-03964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
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Kalyanasundaram S, Kaushal M, Sharma R. Rise and Fall of Therapeutic Hypothermia in Low-Resource Settings: Lessons from the HELIX Trial: Correspondence. Indian J Pediatr 2022; 89:301-302. [PMID: 34674111 DOI: 10.1007/s12098-021-03977-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Monika Kaushal
- Department of Neonatology, DHCC, Emirates Specialty Hospital, Dubai, 505240, UAE.
| | - Rajesh Sharma
- Department of Neonatology, Corniche Hospital, Abu Dhabi, UAE
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21
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Car KP, Nakwa F, Solomon F, Velaphi SC, Tann CJ, Izu A, Lala SG, Madhi SA, Dangor Z. The association between early-onset sepsis and neonatal encephalopathy. J Perinatol 2022; 42:354-358. [PMID: 35001084 DOI: 10.1038/s41372-021-01290-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/18/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We evaluated the association between early-onset sepsis and neonatal encephalopathy in a low-middle-income setting. METHODS We undertook a retrospective study in newborns with gestational age ≥35 weeks and/or birth weight ≥2500 grams, diagnosed with neonatal encephalopathy. Early-onset sepsis was defined as culture-confirmed sepsis or probable sepsis. RESULTS Of 10,182 hospitalised newborns, 1027 (10.1%) were diagnosed with neonatal encephalopathy, of whom 52 (5.1%) had culture-confirmed and 129 (12.5%) probable sepsis. The case fatality rate for culture-confirmed sepsis associated neonatal encephalopathy was threefold higher compared to neonatal encephalopathy without sepsis (30.8% vs. 10.5%, p < 0.001). Predictors of mortality for culture-confirmed sepsis associated neonatal encephalopathy included severe neonatal encephalopathy (aOR 6.51, 95%CI: 1.03-41.44) and seizures (aOR 10.64, 95%CI: 1.05-107.39). CONCLUSION In this setting, 5% of neonatal encephalopathy cases was associated with culture-confirmed sepsis and a high case fatality rate.
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Affiliation(s)
- Kathleen P Car
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Firdose Nakwa
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fatima Solomon
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso C Velaphi
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cally J Tann
- Department of Infectious Disease Epidemiology, School of Hygiene and Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Institute for Women's Health, University College London, London, UK
| | - Alane Izu
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sanjay G Lala
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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22
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Roumes H, Sanchez S, Benkhaled I, Fernandez V, Goudeneche P, Perrin F, Pellerin L, Guillard J, Bouzier-Sore AK. Neuroprotective Effect of Eco-Sustainably Extracted Grape Polyphenols in Neonatal Hypoxia-Ischemia. Nutrients 2022; 14:773. [PMID: 35215424 PMCID: PMC8877633 DOI: 10.3390/nu14040773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 02/05/2023] Open
Abstract
Polyphenols are natural compounds with promising prophylactic and therapeutic applications. However, their methods of extraction, using organic solvents, may prove to be unsuitable for daily consumption or for certain medical indications. Here, we describe the neuroprotective effects of grape polyphenols extracted in an eco-sustainable manner in a rat model of neonatal hypoxia-ischemia (NHI). Polyphenols (resveratrol, pterostilben and viniferin) were obtained using a subcritical water extraction technology to avoid organic solvents and heavy metals associated with chemical synthesis processes. A resveratrol or a polyphenol cocktail were administered to pregnant females at a nutritional dose and different time windows, prior to induction of NHI in pups. Reduced brain edema and lesion volumes were observed in rat pups whose mothers were supplemented with polyphenols. Moreover, the preservation of motor and cognitive functions (including learning and memory) was evidenced in the same animals. Our results pave the way to the use of polyphenols to prevent brain lesions and their associated deficits that follow NHI, which is a major cause of neonatal death and disabilities.
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Affiliation(s)
- Hélène Roumes
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
| | - Stéphane Sanchez
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
| | - Imad Benkhaled
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
- I3M, Common Laboratory CNRS-Siemens, University of Poitiers and Poitiers University Hospital, F-86073 Poitiers, France
| | - Valentin Fernandez
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
| | - Pierre Goudeneche
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
| | - Flavie Perrin
- IC2MP, UMR 7285, Team 5 Chemistry, University of Poitiers and CNRS, F-86000 Poitiers, France;
| | - Luc Pellerin
- IRMETIST, Inserm U1313, University of Poitiers and CHU Poitiers, F-86021 Poitiers, France;
| | - Jérôme Guillard
- IC2MP, UMR 7285, Team 5 Chemistry, University of Poitiers and CNRS, F-86000 Poitiers, France;
| | - Anne-Karine Bouzier-Sore
- CRMSB, UMR 5536, University of Bordeaux and CNRS, F-33000 Bordeaux, France; (H.R.); (S.S.); (I.B.); (V.F.); (P.G.)
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23
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Short-term Outcome and Predictors of Survival Among Neonates With Moderate or Severe Hypoxic Ischemic Encephalopathy: Data From the Indian Neonatal Collaborative. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2413-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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24
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Diggikar S, Krishnegowda R. Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Literature Review. J Trop Pediatr 2022; 68:6534393. [PMID: 35191983 DOI: 10.1093/tropej/fmac016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS This structured review aimed to discuss the existing literature on therapeutic hypothermia for moderate to severe neonatal encephalopathy exclusively in low- and middle-income countries (LMICs). METHODS Medline, Embase, CINHAL and Cochrane Registry were searched for original papers with therapeutic hypothermia (TH) for treating neonatal encephalopathy in LMIC with no language restrictions. The search identified 1413 papers from 1990 to 31 August 2021. RESULTS Twenty-one original papers were included after duplicates removal and full-text screening in the final review. Fourteen randomized control studies and seven non-randomized studies were discussed with various modes of cooling (servo-controlled, phase changing material, traditional methods), complications during cooling, mortality and long-term neurodevelopmental assessment. Although there is sufficient evidence in LMIC favouring cooling for the reduction in mortality and improving the neurodevelopmental outcomes, nonetheless these studies were widely heterogeneous in terms of method of cooling, tools for assessing developmental outcomes, age at assessment and variations in neuroimaging tools and reporting. CONCLUSION Therapeutic hypothermia is beneficial in LMICs with low certainty of evidence in reducing mortality and improving neurodevelopmental outcomes.
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Affiliation(s)
- Shivashankar Diggikar
- Department of Pediatrics, Ovum Woman and Child Specialty Hospital, Banaswadi, Bengaluru 560043, India
| | - Roshani Krishnegowda
- Department of Pediatrics, SDM College of Medical Sciences, Dharwad 580009, India
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25
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Variane GFT, Magalhães M, Pietrobom RFR, Netto A, Rodrigues DP, Gasperini R, Sant’Anna GM. Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil. PLoS One 2022; 17:e0262581. [PMID: 35020756 PMCID: PMC8754327 DOI: 10.1371/journal.pone.0262581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 12/29/2021] [Indexed: 11/19/2022] Open
Abstract
Background
Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs.
Methods
A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up.
Discussion
The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring.
Trial registration
NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Neonatal Division, Grupo Santa Joana, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- * E-mail:
| | - Maurício Magalhães
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Rafaela Fabri Rodrigues Pietrobom
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Alexandre Netto
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Gasperini
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
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26
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Peeples ES, Sahar NE, Snyder W, Mirnics K. Temporal brain microRNA expression changes in a mouse model of neonatal hypoxic-ischemic injury. Pediatr Res 2022; 91:92-100. [PMID: 34465878 PMCID: PMC9620396 DOI: 10.1038/s41390-021-01701-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/10/2021] [Accepted: 08/04/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neonatal hypoxic-ischemic brain injury (HIBI) results in significant morbidity and mortality despite current standard therapies. MicroRNAs (miRNAs) are a promising therapeutic target; however, there is a paucity of data on endogenous miRNA expression of the brain after HIBI during the primary therapeutic window (6-72 h after injury). METHODS Postnatal day 9 mouse pups underwent unilateral carotid ligation+hypoxia (HIBI), sham surgery+hypoxia, or sham surgery+normoxia (controls). miRNA sequencing was performed on the ipsilateral brain of each of the three groups plus the contralateral HIBI brain at 24 and 72 h after injury. Findings were validated in eight key miRNAs by quantitative polymerase chain reaction. RESULTS Hypoxia resulted in significant differential expression of 38 miRNAs at both time points. Mir-2137, -335, -137, and -376c were significantly altered by neonatal HIBI at 24 and 72 h, with 3 of the 4 demonstrating multiphasic expression (different direction of differential expression at 24 versus 72 h). CONCLUSIONS Our global assessment of subacute changes in brain miRNA expression after hypoxia or HIBI will advance research into targeted miRNA-based interventions. It will be important to consider the multiphasic miRNA expression patterns after HIBI to identify optimal timing for individual interventions. IMPACT This study is the first to comprehensively define endogenous brain microRNA expression changes outside of the first hours after neonatal hypoxic-ischemic brain injury (HIBI). Mir-2137, -335, -137, and -376c were significantly altered by neonatal HIBI and therefore deserve further investigation as possible therapeutic targets. The expression profiles described will support the design of future studies attempting to develop miRNA-based interventions for infants with HIBI. At 24 h after injury, contralateral HIBI miRNA expression patterns were more similar to ipsilateral HIBI than to controls, suggesting that the contralateral brain is not an appropriate "internal control" for miRNA studies in this model.
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Affiliation(s)
- Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Namood-E Sahar
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - William Snyder
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Karoly Mirnics
- Department of Biochemistry & Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
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27
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Bellos I, Devi U, Pandita A. Therapeutic Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries: A Meta-Analysis. Neonatology 2022; 119:300-310. [PMID: 35340015 DOI: 10.1159/000522317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) represent substantial sources of neonatal morbidity and mortality in low- and middle-income countries (LMICs), leading to high rates of adverse long-term neurological outcomes. METHODS A systematic review with meta-analysis of randomized controlled trials in LMICs was conducted. PubMed, Scopus, Web of Science, CENTRAL, ClinicalTrials.gov, and Google Scholar were searched from inception to August 20, 2021. The population of the study consisted of neonates with gestational age ≥34 weeks and HIE. The main endpoints were overall mortality and the composite outcome of death or severe disability. The certainty of evidence was evaluated with the GRADE approach. RESULTS Ten studies were included comprising 1,293 neonates. Some concerns of bias were raised due to the nonblinded nature of the intervention. The risk of death was similar between the two groups (risk ratio [RR]: 0.78, 95% confidence interval [CI]: 0.52-1.18). No significant differences were observed in the composite outcome of death or severe disability between the two groups (RR: 0.78, 95% CI: 0.56-1.10, very low quality of evidence). Furthermore, no significant differences were observed in the endpoints of sepsis, shock, acute kidney injury, major arrhythmia, and length of hospital stay. Therapeutic hypothermia was associated with significantly higher risk of thrombocytopenia (RR: 2.13, 95% CI: 1.34-3.38) and clinically significant hemorrhage (RR: 1.57, 95% CI: 1.25-1.97). CONCLUSION Therapeutic hypothermia probably results in little to no difference in clinical outcomes among neonates with HIE in LMICs. Further large-scale research targeting proper patient selection is needed to elucidate the utility of therapeutic hypothermia in resource-limited settings. PROTOCOL REGISTRATION The protocol of the study has been prospectively registered by Prospero, CRD42021272284.
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Affiliation(s)
- Ioannis Bellos
- National and Kapodistrian University of Athens, Athens, Greece
| | - Usha Devi
- Department of Neonatology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Kerrn-Jespersen S, Andersen M, Bennedsgaard K, Andelius TCK, Pedersen M, Kyng KJ, Henriksen TB. Remote ischemic postconditioning increased cerebral blood flow and oxygenation assessed by magnetic resonance imaging in newborn piglets after hypoxia-ischemia. Front Pediatr 2022; 10:933962. [PMID: 36245727 PMCID: PMC9559709 DOI: 10.3389/fped.2022.933962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We have previously investigated neurological outcomes following remote ischemic postconditioning (RIPC) in a newborn piglet model of hypoxic-ischemic encephalopathy. The aim of this study was to further investigate potential mechanisms of neuroprotection by comparing newborn piglets subjected to global hypoxia-ischemia (HI) treated with and without RIPC with regards to measures of cerebral blood flow and oxygenation assessed by functional magnetic resonance imaging. MATERIALS AND METHODS A total of 50 piglets were subjected to 45 min global HI and randomized to either no treatment or RIPC treatment. Magnetic resonance imaging was performed 72 h after the HI insult with perfusion-weighted (arterial spin labeling, ASL) and oxygenation-weighted (blood-oxygen-level-dependent, BOLD) sequences in the whole brain, basal ganglia, thalamus, and cortex. Four sham animals received anesthesia and mechanical ventilation only. RESULTS Piglets treated with RIPC had higher measures of cerebral blood flow in all regions of interest and the whole brain (mean difference: 2.6 ml/100 g/min, 95% CI: 0.1; 5.2) compared with the untreated controls. They also had higher BOLD values in the basal ganglia and the whole brain (mean difference: 4.2 T2*, 95% CI: 0.4; 7.9). Measures were similar between piglets treated with RIPC and sham animals. CONCLUSION Piglets treated with RIPC had higher measures of cerebral blood flow and oxygenation assessed by magnetic resonance imaging in the whole brain and several regions of interest compared with untreated controls 72 h after the HI insult. Whether this reflects a potential neuroprotective mechanism of RIPC requires further study.
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Affiliation(s)
- Sigrid Kerrn-Jespersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Andersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristine Bennedsgaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ted Carl Kejlberg Andelius
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Laboratory, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kasper Jacobsen Kyng
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tine Brink Henriksen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Thiamine as a Possible Neuroprotective Strategy in Neonatal Hypoxic-Ischemic Encephalopathy. Antioxidants (Basel) 2021; 11:antiox11010042. [PMID: 35052546 PMCID: PMC8772822 DOI: 10.3390/antiox11010042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 02/08/2023] Open
Abstract
On the basis that similar biochemical and histological sequences of events occur in the brain during thiamine deficiency and hypoxia/ischemia related brain damage, we have planned this review to discuss the possible therapeutic role of thiamine and its derivatives in the management of neonatal hypoxic-ischemic encephalopathy (HIE). Among the many benefits, thiamine per se as antioxidant, given intravenously (IV) at high doses, defined as dosage greater than 100 mg IV daily, should counteract the damaging effects of reactive oxygen and nitrogen species in the brain, including the reaction of peroxynitrite with the tyrosine residues of the major enzymes involved in intracellular glucose metabolism, which plays a key pathophysiological role in HIE in neonates. Accordingly, it is conceivable that, in neonatal HIE, the blockade of intracellular progressive oxidative stress and the rescue of mitochondrial function mediated by thiamine and its derivatives can lead to a definite neuroprotective effect. Because therapeutic hypothermia and thiamine may both act on the latent period of HIE damage, a synergistic effect of these therapeutic strategies is likely. Thiamine treatment may be especially important in mild HIE and in areas of the world where there is limited access to expensive hypothermia equipment.
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30
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Up-to-date Systematic Review and Meta-analysis of Therapeutic Hypothermia for Neonatal Encephalopathy: Is the Crown Losing Its Sheen? Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2406-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Mathew JL, Suman Rao PN, Vinayan KP. Randomized Controlled Trial Evaluating Hypothermia for Neonatal Encephalopathy in Low- and Middle-Income Countries. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2335-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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32
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Tran NT, Kelly SB, Snow RJ, Walker DW, Ellery SJ, Galinsky R. Assessing Creatine Supplementation for Neuroprotection against Perinatal Hypoxic-Ischaemic Encephalopathy: A Systematic Review of Perinatal and Adult Pre-Clinical Studies. Cells 2021; 10:cells10112902. [PMID: 34831126 PMCID: PMC8616304 DOI: 10.3390/cells10112902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/09/2022] Open
Abstract
There is an important unmet need to develop interventions that improve outcomes of hypoxic-ischaemic encephalopathy (HIE). Creatine has emerged as a promising neuroprotective agent. Our objective was to systematically evaluate the preclinical animal studies that used creatine for perinatal neuroprotection, and to identify knowledge gaps that need to be addressed before creatine can be considered for pragmatic clinical trials for HIE. Methods: We reviewed preclinical studies up to 20 September 2021 using PubMed, EMBASE and OVID MEDLINE databases. The SYRCLE risk of bias assessment tool was utilized. Results: Seventeen studies were identified. Dietary creatine was the most common administration route. Cerebral creatine loading was age-dependent with near term/term-equivalent studies reporting higher increases in creatine/phosphocreatine compared to adolescent-adult equivalent studies. Most studies did not control for sex, study long-term histological and functional outcomes, or test creatine post-HI. None of the perinatal studies that suggested benefit directly controlled core body temperature (a known confounder) and many did not clearly state controlling for potential study bias. Conclusion: Creatine is a promising neuroprotective intervention for HIE. However, this systematic review reveals key knowledge gaps and improvements to preclinical studies that must be addressed before creatine can be trailed for neuroprotection of the human fetus/neonate.
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Affiliation(s)
- Nhi Thao Tran
- School of Health & Biomedical Sciences, STEM College, RMIT University, Melbourne 3083, Australia; (N.T.T.); (D.W.W.)
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne 3168, Australia; (S.B.K.); (S.J.E.)
| | - Sharmony B. Kelly
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne 3168, Australia; (S.B.K.); (S.J.E.)
- Department of Obstetrics & Gynecology, Monash University, Melbourne 3168, Australia
| | - Rod J. Snow
- Institute for Physical Activity & Nutrition, Deakin University, Melbourne 3125, Australia;
| | - David W. Walker
- School of Health & Biomedical Sciences, STEM College, RMIT University, Melbourne 3083, Australia; (N.T.T.); (D.W.W.)
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne 3168, Australia; (S.B.K.); (S.J.E.)
| | - Stacey J. Ellery
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne 3168, Australia; (S.B.K.); (S.J.E.)
- Department of Obstetrics & Gynecology, Monash University, Melbourne 3168, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne 3168, Australia; (S.B.K.); (S.J.E.)
- Department of Obstetrics & Gynecology, Monash University, Melbourne 3168, Australia
- Correspondence:
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Weng B, Yan C, Chen Y, Gong X, Cai C. Efficiency Evaluation of Neuroprotection for Therapeutic Hypothermia to Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurosci 2021; 15:668909. [PMID: 34650397 PMCID: PMC8505668 DOI: 10.3389/fnins.2021.668909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background: To evaluate the safety and neurological outcomes of therapeutic hypothermia to neonatal hypoxic-ischemic encephalopathy (HIE). Materials and Methods: Medical records of 61 neonates with moderate to severe HIE were retrospectively enrolled and divided into a therapeutic hypothermia group (n = 36) and conventional therapy group (n = 25). Results: No significant difference in the incidence of severe adverse events was found between the two groups. Minimum and maximum voltages of amplitude-integrated electroencephalography (aEEG) recording results showed statistically significant differences in therapeutic hypothermia group after 72 h. The neonatal behavioral neurological assessment (NBNA) on the 28th day after birth and Bayley Scales of Infant Development, second edition (BSID II) scores at 18 months old were significant higher in the therapeutic hypothermia group than the conventional therapy group. Conclusion: Therapeutic hypothermia for neonates with moderate to severe HIE improved the development of the nervous system in 0–18-month-old infants and showed a predominant role in reducing death and major neuron development-associated disabilities.
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Affiliation(s)
- Bowen Weng
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chongbing Yan
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yihuan Chen
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Cheng Cai
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Thayyil S, Pant S, Montaldo P, Shukla D, Oliveira V, Ivain P, Bassett P, Swamy R, Mendoza J, Moreno-Morales M, Lally PJ, Benakappa N, Bandiya P, Shivarudhrappa I, Somanna J, Kantharajanna UB, Rajvanshi A, Krishnappa S, Joby PK, Jayaraman K, Chandramohan R, Kamalarathnam CN, Sebastian M, Tamilselvam IA, Rajendran UD, Soundrarajan R, Kumar V, Sudarsanan H, Vadakepat P, Gopalan K, Sundaram M, Seeralar A, Vinayagam P, Sajjid M, Baburaj M, Murugan KD, Sathyanathan BP, Kumaran ES, Mondkar J, Manerkar S, Joshi AR, Dewang K, Bhisikar SM, Kalamdani P, Bichkar V, Patra S, Jiwnani K, Shahidullah M, Moni SC, Jahan I, Mannan MA, Dey SK, Nahar MN, Islam MN, Shabuj KH, Rodrigo R, Sumanasena S, Abayabandara-Herath T, Chathurangika GK, Wanigasinghe J, Sujatha R, Saraswathy S, Rahul A, Radha SJ, Sarojam MK, Krishnan V, Nair MK, Devadas S, Chandriah S, Venkateswaran H, Burgod C, Chandrasekaran M, Atreja G, Muraleedharan P, Herberg JA, Kling Chong WK, Sebire NJ, Pressler R, Ramji S, Shankaran S. Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries (HELIX): a randomised controlled trial in India, Sri Lanka, and Bangladesh. LANCET GLOBAL HEALTH 2021; 9:e1273-e1285. [PMID: 34358491 PMCID: PMC8371331 DOI: 10.1016/s2214-109x(21)00264-3] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia. METHODS We did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18-22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385. FINDINGS We screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87-1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention. INTERPRETATION Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available. FUNDING National Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation. TRANSLATIONS For the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Deepika Shukla
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vania Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Ravi Swamy
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Naveen Benakappa
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Prathik Bandiya
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Indramma Shivarudhrappa
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Jagadish Somanna
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | | | - Ankur Rajvanshi
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sowmya Krishnappa
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | | | | | | | | | - Monica Sebastian
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Usha D Rajendran
- Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Vignesh Kumar
- Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Padmesh Vadakepat
- Institute of Child Health, Madras Medical College, Chennai, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Kavitha Gopalan
- Institute of Child Health, Madras Medical College, Chennai, India
| | - Mangalabharathi Sundaram
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Arasar Seeralar
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Prakash Vinayagam
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Mohamed Sajjid
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Mythili Baburaj
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Kanchana D Murugan
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | | | | | - Jayashree Mondkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Swati Manerkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Anagha R Joshi
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Kapil Dewang
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | | | - Pavan Kalamdani
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Vrushali Bichkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Saikat Patra
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Kapil Jiwnani
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | | | - Sadeka C Moni
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Ismat Jahan
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Sanjoy K Dey
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mst N Nahar
- National Institute of Neurosciences, Dhaka, Bangladesh
| | | | - Kamrul H Shabuj
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | | | | | | | | | - Radhika Sujatha
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sobhakumar Saraswathy
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Aswathy Rahul
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Saritha J Radha
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Manoj K Sarojam
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Vaisakh Krishnan
- Institute of Maternal and Child Health, Government Medical College, Kozhikode, Kerala, India
| | - Mohandas K Nair
- Institute of Maternal and Child Health, Government Medical College, Kozhikode, Kerala, India
| | - Sahana Devadas
- Vanivilas Hospital, Bangalore Medical College and Research Institute, Karnataka, India
| | - Savitha Chandriah
- Vanivilas Hospital, Bangalore Medical College and Research Institute, Karnataka, India
| | | | - Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Gaurav Atreja
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Jethro A Herberg
- Section of Paediatric Infectious Disease, Imperial College London, London, UK
| | - W K Kling Chong
- Centre for Perinatal Neuroscience, Imperial College London, London, UK; Department of Neuroradiology, Great Ormond Street Hospital, London, UK
| | - Neil J Sebire
- Perinatal Pathology, National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital for Children, University College London, London, UK
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, UK
| | | | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
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Aneja S, Sharma S. Hypoxic ischaemic encephalopathy in low resource settings-time to stop cooling? LANCET GLOBAL HEALTH 2021; 9:e1187-e1188. [PMID: 34358490 DOI: 10.1016/s2214-109x(21)00343-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Satinder Aneja
- Department of Paediatrics, School of Medical Sciences & Research, Sharda University, Greater Noida, India.
| | - Suvasini Sharma
- Department of Paediatrics, Lady Hardinge Medical College, New Delhi, India
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Mbatha S, Nakwa FL, Thandrayen K, Velaphi S. Neurodevelopmental outcome in neonates with hypoxic-ischaemic encephalopathy managed with therapeutic hypothermia in a tertiary-level public hospital outside an intensive care unit setting. Paediatr Int Child Health 2021; 41:171-176. [PMID: 34493152 DOI: 10.1080/20469047.2021.1967625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Management of hypoxic-ischaemic encephalopathy (HIE) by therapeutic hypothermia (TH) is a major challenge in low- and middle-income countries (LMIC) because of the limited resources. Clinicians in LMIC offer this intervention outside neonatal intensive care units (NICU). The effect of this practice on neurodevelopmental outcome is not well known. AIM To determine neurodevelopmental outcome in neonates with HIE managed with TH outside NICU settings. METHODS : This was a retrospective descriptive study of neonates with HIE managed with TH and followed up for neurodevelopmental assessment at 12 and 18-24 months postnatal age. Patients were reviewed over a 24-month period. Outcome at 12 and 18-24 months was compared. RESULTS Of 178 neonates with HIE attending the clinic, there was information on TH for 155 (87.1%), 113 of whom (72.9%) received TH. HIE was moderate in 88% and severe in 10%. Twenty-seven (23.9%) and 16 (14.1%) were assessed at one time-point at 12 or 18-24 months, respectively, 40 (35.3%) at both time-points, and 30 (26.6%) were not assessed. At 18-24 months, 32% had moderate-to-severe disability compared with 6% at 12 months, with the sensitivity and specificity of assessment at 12 months being 50% and 100%, respectively. The disability attrition rate at 18-24 months was 50%. CONCLUSIONS The relatively low prevalence of disability (32%) at 18-24 months suggests that use of TH in a Level 2 nursery is feasible and possibly beneficial. More studies are needed to confirm these findings. ABBREVIATIONS aEEG: amplitude electroencephalogram; CP: cerebral palsy; GMDS: Griffiths mental developmental scales; GQ: general quotient; HIC: high-income countries; HIE: hypoxic-ischaemic encephalopathy; LMIC: low- and middle-income countries; LTFU: loss to follow-up; NICU: neonatal intensive care unit; TH: therapeutic hypothermia; TOBY: total body hypothermia.
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Affiliation(s)
- S Mbatha
- Department of Paediatrics, Chris Hani Baragwanath Academic hospital. University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - F L Nakwa
- Department of Paediatrics, Chris Hani Baragwanath Academic hospital. University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - K Thandrayen
- Department of Paediatrics, Chris Hani Baragwanath Academic hospital. University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - S Velaphi
- Department of Paediatrics, Chris Hani Baragwanath Academic hospital. University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Hippokratia 2021. [DOI: 10.1002/14651858.cd015023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
- Cochrane Sweden; Lund University, Skåne University Hospital; Lund Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department; Poznan University of Medical Sciences; Poznan Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit; University Hospital; Uppsala Sweden
- Department of Women's and Children's Health; Uppsala University; Uppsala Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health; Örebro University; Örebro Sweden
- Faculty of Medicine and Health, School of Health Sciences; Örebro University; Örebro Sweden
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Bozkurt O, Yucesoy E. Acute Kidney Injury in Neonates with Perinatal Asphyxia Receiving Therapeutic Hypothermia. Am J Perinatol 2021; 38:922-929. [PMID: 31986537 DOI: 10.1055/s-0039-1701024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the incidence and severity of acute kidney injury (AKI) and evaluate risk factors that predict AKI in asphyxiated infants receiving therapeutic hypothermia. STUDY DESIGN Infants ≥36 weeks' gestation diagnosed with moderate-to-severe perinatal asphyxia and received therapeutic hypothermia were reviewed retrospectively (n = 166). Modified Acute Kidney Injury Network criteria were used to diagnose AKI. The results of infants with AKI were compared with the infants who did not develop AKI. RESULTS AKI developed in 49 (29.5%) infants, of whom 22 had stage I, 13 had stage II, and 14 had stage III AKI. The overall mortality rate was 15.7% and was significantly higher in infants with AKI when compared with infants without AKI (41 vs. 5%; p < 0.001). Asystole at birth (p = 0.044), placental abruption (p = 0.041), outborn status (p = 0.041), need for vasopressor support (p = 0.031), increased bleeding tendency (p = 0.031), initial lactate level (p = 0.015), and 12-hour lactate level (p = 0.029) were independent risk factors for the development of AKI. Receiver operating characteristic curve analysis demonstrated a good predictive value for initial lactate level (>15 mmol/L), with 69% sensitivity (95% CI: 55-82) and 82% specificity (95% CI: 74-89), and for 12-hour lactate level (>6 mmol/L), with 83.7% sensitivity (95% CI: 70-93) and 73.5% specificity (95% CI: 64.5-81), to predict AKI. CONCLUSION AKI is still a common complication of perinatal asphyxia despite treatment with therapeutic hypothermia. Identification of risk factors associated with the development of AKI in asphyxiated infants would be potentially beneficial to reduce morbidity and mortality. Besides perinatal risk factors, initial and 12-hour lactate concentrations can be used for the early prediction of AKI.
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Affiliation(s)
- Ozlem Bozkurt
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Demiroglu Bilim University, Istanbul, Turkey
| | - Ebru Yucesoy
- Division of Neonatology, Department of Pediatrics, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
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Wang Z, Zhang P, Zhou W, Xia S, Zhou W, Zhou X, Cheng X, Shi Y, Lin Z, Song D, Cheng G. Neonatal hypoxic-ischemic encephalopathy diagnosis and treatment: a National Survey in China. BMC Pediatr 2021; 21:261. [PMID: 34090355 PMCID: PMC8178820 DOI: 10.1186/s12887-021-02737-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022] Open
Abstract
Background Neonatal hypoxic-ischemic encephalopathy (HIE) affects as many as 100,000 infants each year in China. Therapeutic hypothermia reduces HIE related mortality and long-term neurodevelopmental disabilities. National guidelines for HIE management were published a decade ago. This study aimed to investigate the current status of HIE diagnosis and treatment in China. Method This prospective cross-sectional national survey used a questionnaire evaluating practices related to HIE management. Descriptive statistics and Chi-square or Fisher’s exact test were used, and a p-value of < 0.05 was considered significant. Results The 273 hospitals that completed the survey were located in 31 of the 34 provincial districts in China. Eighty-eight percent of the hospitals were Level III hospitals, and 74% treated 10 or more HIE cases annually. Awareness rates of the national guidelines for HIE diagnosis, HIE treatment, and therapeutic hypothermia protocol were 85, 63, and 78%, respectively. Neurological manifestations and blood gas were used as HIE diagnostic criteria by 96% (263/273) and 68% (186/273) of the hospitals, respectively. Therapeutic hypothermia was used in 54% (147/273) of hospitals. The percentage of general hospitals that implemented therapeutic hypothermia (43%, 71/165) was significantly lower than that in maternity and infant hospitals (67%, 49/73) (χ2 = 11.752, p = 0.001) and children’s hospitals (77%, 27/35) (χ2 = 13.446, p < 0.001). Reasons for not providing therapeutic hypothermia included reduction of HIE cases in recent years (39%), high cost of cooling devices and treatment (31%), lack of training (26%), and safety concerns (4%). Among the hospitals that provided therapeutic hypothermia, 27% (39/147) were in full compliance with the recommended protocol. Eighty-one percent (222/273) of the hospitals treated HIE infants with putative neuroprotective agents alone or in combination with cooling. Ninety-one percent of the hospitals had long-term neurodevelopmental follow-up programs for infants with HIE. Conclusions There is significant heterogeneity in HIE diagnosis and treatment in China. Therapeutic hypothermia has not become a standard of care for neonatal HIE nationwide. Unproven agents are widely used for HIE treatment. Nationwide standardization of HIE management and dissemination of therapeutic hypothermia represent the opportunities to reduce mortality and improve long-term neurodevelopmental outcomes of children affected by HIE. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02737-6.
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Affiliation(s)
- Zheng Wang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 200032, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 200032, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 200032, China
| | - Shiwen Xia
- Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Hubei, 430070, China
| | - Wei Zhou
- Guangzhou women and children's Medical Center, Guangdong, 510623, China
| | - Xiaoyu Zhou
- Children's Hospital of Nanjing Medical University, Jiangsu, 210093, China
| | - Xiuyong Cheng
- Department of Neonatology, The First Affiliated Hospital of Zhengzhou University, Henan, 450052, China
| | - Yuan Shi
- National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics Children's Hospital of Chongqing Medical University, Chongqing, 400014, China
| | - Zhenlang Lin
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Zhejiang, 325027, China
| | - Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA. .,Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Guoqiang Cheng
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 200032, China.
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Spiegel E, Nesbit KC, Altenor K, Nguyen HT, Tran L, Hermosa AQ, Martin H, Oettingen JV, Treleaven E, Partridge JC. Valuation of Life With Disability: An International Comparison Study in Vietnam, Peru, and Haiti. J Child Neurol 2021; 36:556-567. [PMID: 33432857 DOI: 10.1177/0883073820983262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors measured perceived quality of life for 4 disabilities among 450 adults in 3 resource-limited countries, measuring mean utilities using time trade-off, and surveying participants on 35 sociocultural characteristics to compare utilities for disabilities by country and examine associated sociocultural characteristics. Mean utilities were >0 for mild and moderate, but <0 for severe and profound. Utilities differed across countries (P = .007, .000, .017, .000 for mild, moderate, severe, profound, respectively). Vietnamese utilities correlated with residence (P = .03, moderate), education (P = .03, severe), and number of children (P = .03, moderate). Peruvian utilities correlated with education (P = .05, mild; P = .05, severe), experience with disability (P = .001, mild), gender (P = .04, moderate; P = .03, profound), number of hospitalizations (P = .04, severe). In Haiti, the only correlate was rejection (P = .02, moderate). Culture-specific variables differentially shape perceptions of disability in developing countries, thereby affecting cost-effectiveness calculations. Given substantially negative perceptions, reducing major disability would improve cost-effectiveness of health-policy decisions more than reducing mortality.
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Affiliation(s)
- Elizabeth Spiegel
- Department of Pediatrics, 8785University of California, San Francisco, San Francisco, CA, San Francisco, CA, USA
| | - Kathryn C Nesbit
- Graduate Program in Physical Therapy, 8785University of California, San Francisco/San Francisco State University, San Francisco, CA, USA
| | | | - Hoa Thi Nguyen
- Neonatology Department, Vietnam National Children's Hospital, Ha Noi, Viet Nam
| | - Ly Tran
- Neonatology Department, Vietnam National Children's Hospital, Ha Noi, Viet Nam
| | | | - Holly Martin
- Department of Pediatrics, 8785University of California, San Francisco, San Francisco, CA, San Francisco, CA, USA
| | - Julia von Oettingen
- Department of Pediatrics, 54473McGill University Health Centre, Montreal, Canada, USA
| | - Emily Treleaven
- Population Studies Center, University of Michigan, Ann Arbor, MI, USA
| | - John Colin Partridge
- Department of Pediatrics, 8785University of California, San Francisco, San Francisco, CA, San Francisco, CA, USA
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Melatonin for Neonatal Encephalopathy: From Bench to Bedside. Int J Mol Sci 2021; 22:ijms22115481. [PMID: 34067448 PMCID: PMC8196955 DOI: 10.3390/ijms22115481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022] Open
Abstract
Neonatal encephalopathy is a leading cause of morbidity and mortality worldwide. Although therapeutic hypothermia (HT) is now standard practice in most neonatal intensive care units in high resource settings, some infants still develop long-term adverse neurological sequelae. In low resource settings, HT may not be safe or efficacious. Therefore, additional neuroprotective interventions are urgently needed. Melatonin’s diverse neuroprotective properties include antioxidant, anti-inflammatory, and anti-apoptotic effects. Its strong safety profile and compelling preclinical data suggests that melatonin is a promising agent to improve the outcomes of infants with NE. Over the past decade, the safety and efficacy of melatonin to augment HT has been studied in the neonatal piglet model of perinatal asphyxia. From this model, we have observed that the neuroprotective effects of melatonin are time-critical and dose dependent. Therapeutic melatonin levels are likely to be 15–30 mg/L and for optimal effect, these need to be achieved within the first 2–3 h after birth. This review summarises the neuroprotective properties of melatonin, the key findings from the piglet and other animal studies to date, and the challenges we face to translate melatonin from bench to bedside.
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Konar MC, Islam K, Sil A, Nayek K, Barik K. Effect of Music on Outcomes of Birth Asphyxia: A Randomized Controlled Trial. J Trop Pediatr 2021; 67:6300031. [PMID: 34131763 DOI: 10.1093/tropej/fmab009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Birth asphyxia may cause neuro-developmental impairment in the affected newborns especially those who had hypoxic-ischemic encephalopathy. Music therapy has been observed to help in reducing pain and stress in newborns and improve neurodevelopmental outcome. OBJECTIVES The objective of this study is to determine the effects of music therapy on the outcomes of birth asphyxia. METHODS A randomized controlled trial involving 3095 newborns born between January 2013 and August 2019 with birth asphyxia was conducted in the neonatal intensive care unit of Burdwan Medical College. They were distributed in two groups-A (received music therapy along with coventional management) and B (only received conventional management), using computer-generated randomization. Pain score was assessed during any painful procedure and the neurodevelopmental outcome was measured at 3rd, 6th, 12th, 18th and 24th months. p < 0.01 was considered statistically significant. RESULTS A total of 3095 newborns were included with a mean gestation of 34.3 ± 2.1 weeks and 56.7% of them were male. Mean hospital stay, oxygen dependency, requirement of mechanical ventilation and incidence of apnea were significantly lesser among newborns of group A. Newborns of group B showed a significantly higher mean pain score, whereas newborns in Group A exhibited significantly greater mental and motor neurodevelopmental quotients. CONCLUSIONS Music therapy was observed to help in reducing hospital stay, oxygen dependency, incidences of apnea, pain during procedures and also resulted in better neurodevelopmental outcome. However, before generalizing the findings, further multi-centric research should be undertaken.
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Affiliation(s)
- Mithun Chandra Konar
- Pediatrics Department, Burdwan Medical College, Burdwan, West Bengal 713104, India
| | - Kamirul Islam
- Pediatrics Department, Burdwan Medical College, Burdwan, West Bengal 713104, India
| | - Archan Sil
- Pediatrics Department, Burdwan Medical College, Burdwan, West Bengal 713104, India
| | - Kaustav Nayek
- Pediatrics Department, Burdwan Medical College, Burdwan, West Bengal 713104, India
| | - Kanailal Barik
- Pediatrics Department, Burdwan Medical College, Burdwan, West Bengal 713104, India
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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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Effectiveness of reaching and maintaining therapeutic hypothermia target temperature using low‐cost devices in newborns with hypoxic–ischemic encephalopathy. Anat Rec (Hoboken) 2021; 304:1217-1223. [DOI: 10.1002/ar.24615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 11/07/2022]
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Abate BB, Bimerew M, Gebremichael B, Mengesha Kassie A, Kassaw M, Gebremeskel T, Bayih WA. Effects of therapeutic hypothermia on death among asphyxiated neonates with hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials. PLoS One 2021; 16:e0247229. [PMID: 33630892 PMCID: PMC7906350 DOI: 10.1371/journal.pone.0247229] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hypoxic perinatal brain injury is caused by lack of oxygen to baby’s brain and can lead to death or permanent brain damage. However, the effectiveness of therapeutic hypothermia in birth asphyxiated infants with encephalopathy is uncertain. This systematic review and meta-analysis was aimed to estimate the pooled relative risk of mortality among birth asphyxiated neonates with hypoxic-ischemic encephalopathy in a global context. Methods We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search randomized control trials from electronic databases (PubMed, Cochrane library, Google Scholar, MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and meta register of Current Controlled Trials (mCRT)). The authors extracted the author’s name, year of publication, country, method of cooling, the severity of encephalopathy, the sample size in the hypothermic, and non-hypothermic groups, and the number of deaths in the intervention and control groups. A weighted inverse variance fixed-effects model was used to estimate the pooled relative risk of mortality. The subgroup analysis was done by economic classification of countries, methods of cooling, and cooling devices. Publication bias was assessed with a funnel plot and Eggers test. A sensitivity analysis was also done. Results A total of 28 randomized control trials with a total sample of 35, 92 (1832 hypothermic 1760 non-hypothermic) patients with hypoxic-ischemic encephalopathy were used for the analysis. The pooled relative risk of mortality after implementation of therapeutic hypothermia was found to be 0.74 (95%CI; 0.67, 0.80; I2 = 0.0%; p<0.996). The subgroup analysis revealed that the pooled relative risk of mortality in low, low middle, upper-middle and high income countries was 0.32 (95%CI; -0.95, 1.60; I2 = 0.0%; p<0.813), 0.5 (95%CI; 0.14, 0.86; I2 = 0.0%; p<0.998), 0.62 (95%CI; 0.41–0.83; I2 = 0.0%; p<0.634) and 0.76 (95%CI; 0.69–0.83; I2 = 0.0%; p<0.975) respectively. The relative risk of mortality was the same in selective head cooling and whole-body cooling method which was 0.74. Regarding the cooling device, the pooled relative risk of mortality is the same between the cooling cap and cooling blanket (0.74). However, it is slightly lower (0.73) in a cold gel pack. Conclusions Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Both selective head cooling and whole-body cooling method are effective in reducing the mortality of infants with this condition. Moreover, low income countries benefit the most from the therapy. Therefore, health professionals should consider offering therapeutic hypothermia as part of routine clinical care to newborns with hypoxic-ischemic encephalopathy especially in low-income countries.
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Affiliation(s)
- Biruk Beletew Abate
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
- * E-mail:
| | - Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | | | | | - MesfinWudu Kassaw
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Teshome Gebremeskel
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
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Erythropoietin monotherapy for neuroprotection after neonatal encephalopathy in low-to-middle income countries: a systematic review and meta-analysis. J Perinatol 2021; 41:2134-2140. [PMID: 34175900 PMCID: PMC8440196 DOI: 10.1038/s41372-021-01132-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/21/2021] [Accepted: 06/04/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We examined whether erythropoietin monotherapy improves neurodevelopmental outcomes in near-term and term infants with neonatal encephalopathy (NE) in low-middle income countries (LMICs). METHODS We searched Pubmed, Embase, and Web of Science databases to identify studies that used erythropoietin (1500-12,500 units/kg/dose) or a derivative to treat NE. RESULTS Five studies, with a total of 348 infants in LMICs, were retrieved. However, only three of the five studies met the primary outcome of death or neuro-disability at 18 months of age or later. Erythropoietin reduced the risk of death (during the neonatal period and at follow-up) or neuro-disability at 18 months or later (p < 0.05). Death or neuro-disability occurred in 27.6% of the erythropoietin group and 49.7% of the comparison group (risk ratio 0.56 (95% CI: 0.42-0.75)). CONCLUSION The pooled data suggest that erythropoietin monotherapy may improve outcomes after NE in LMICs where therapeutic hypothermia is not available.
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Andersen M, Pedersen MV, Andelius TCK, Kyng KJ, Henriksen TB. Neurological Outcome Following Newborn Encephalopathy With and Without Perinatal Infection: A Systematic Review. Front Pediatr 2021; 9:787804. [PMID: 34988041 PMCID: PMC8721111 DOI: 10.3389/fped.2021.787804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Studies have suggested that neurological outcome may differ in newborns with encephalopathy with and without perinatal infection. We aimed to systematically review this association. Methods: We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were obtained from four databases including Pubmed, Embase, Web of Science, and The Cochrane Database. Newborns with encephalopathy with and without markers of perinatal infection were compared with regard to neurodevelopmental assessments, neurological disorders, and early biomarkers of brain damage. Risk of bias and quality of evidence were assessed by the Newcastle-Ottawa scale and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: We screened 4,284 studies of which eight cohort studies and one case-control study met inclusion criteria. A narrative synthesis was composed due to heterogeneity between studies. Six studies were classified as having low risk of bias, while three studies were classified as having high risk of bias. Across all outcomes, the quality of evidence was very low. The neurological outcome was similar in newborns with encephalopathy with and without markers of perinatal infection. Conclusions: Further studies of higher quality are needed to clarify whether perinatal infection may affect neurological outcome following newborn encephalopathy. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020185717.
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Affiliation(s)
- Mads Andersen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Kasper Jacobsen Kyng
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tine Brink Henriksen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Wyckoff MH, Weiner CGM. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics 2021; 147:peds.2020-038505C. [PMID: 33087553 DOI: 10.1542/peds.2020-038505c] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
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Phadke A, Kumble A, Ravikumar K. Early clinical outcome and complications associated in neonates with hypoxic ischemic encephalopathy grade II/III who underwent treatment with servo controlled whole-body therapeutic hypothermia: A prospective observational study. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_119_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A156-A187. [DOI: 10.1016/j.resuscitation.2020.09.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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