Cerebral function monitoring: a new scoring system for the evaluation of brain maturation in neonates

Assessment of neural function recovery in premature infants at high risk of brain injury using amplitude integrated electroencephalography and GMs scales

Preterm infants are a high-risk group for brain injury, and it is important to evaluate the neurological recovery of preterm infants. Therefore, this paper evaluates the neurological recovery in preterm infants at high risk of brain injury by amplitude-integrated EEG and GMs scale. The study collected basic information on preterm infants and performed amplitude integrated EEG examination and GMs scale evaluation. Amplitude integrated EEG examination attaches electrodes using multielectrode arrays onto specific areas of the premature head to record brain wave activity to monitor electrical activity in the preterm brain in real time and amplify and process through the signals received by the electrodes to obtain more detailed EEG data. The GMs scale evaluates the developmental and functional status of the child and allows an objective assessment of the development and recovery of neurological function by observing their performance in motor, language, cognition, and social interaction. Analysis of the data by statistical processing. The results showed that early brain injury was evident in high-risk infants. Amplitude integrated EEG parameters can have some predictive value for brain injury. There were also differences in GMs scale assessment between brain injury and non-brain injury. Amplitude integrated EEG combined with GMs scale has certain value in predicting brain injury and can provide an important basis for early intervention in children with preterm brain injury and help to improve their neurodevelopmental outcome.

The clinical value of amplitude-integrated electroencephalography in a historical cohort with neonatal encephalopathy: A comparison of short-term versus prolonged-period monitoring

BACKGROUND

To compare the amplitude-integrated electroencephalography (aEEG) monitoring (short-term versus prolonged-period) for neonatal seizure detection and outcome.

METHODS

The aEEG monitoring in a historical cohort (n = 88, preterm:42, and term:46) with neonatal encephalopathy between 2010-2022 was re-evaluated for neonatal seizures (electrographic, electro-clinical, and clinical seizures) and EEG background scoring. The cohort was dichotomized: group I (short-period with 6-12 h, n = 36) and group II (prolonged-period with 24-48 h, n = 52). Both monitoring types were evaluated for the diagnostic accuracy of the "patients with seizures" and for outcome characteristics (early death as well as adverse outcomes at 12 months of age).

RESULTS

A total of 67 (76 %) neonates of the cohort were diagnosed as "patients with seizures": electrographic-only seizures in 10 (15 %), electro-clinical seizures in 22 (33 %), and clinical-only seizures in 35 (52 %). The aEEG provides the "patients with seizures" in neonates with a 36.5 % rate with both types of monitoring: 17/36 (47.2 %) with short-term and 15/52 (28.8 %) with prolonged-period monitoring. The prolonged period aEEG had higher diagnostic values for seizure detection (sensitivity = 0.73 and negative predictivity value = 0.81). However, the aEEG background scores were similar for both types of aEEG monitoring, respectively (the mean ± SD: 4.73 ± 2.9 versus 4.4 ± 4. p = 0.837). The aEEG scoring was correlated with the magnitude of brain injury documented with MRI, the early death, and the adverse outcome at 12 months of age.

CONCLUSIONS

Both aEEG types are valuable for monitoring the "patients with seizures" and outcome characteristics.

aEEG in the first 3 days after extremely preterm delivery relates to neurodevelopmental outcomes

OBJECTIVES

Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age.

METHODS

Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5-7 years.

RESULTS

Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5-7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures.

CONCLUSION

Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5-7 years.

Amplitude-integrated electroencephalography showed no differences in cerebral activity between preterm singletons and twins in the first 4 weeks of life

AIM

Genetic influences on cerebral activity have been described previously, but data are scarce in preterms. We aimed to investigate whether a genetic influence causes amplitude-integrated electroencephalography (aEEG) signals to differ between singletons and twin preterm newborns.

METHODS

This was a retrospective single-centre study conducted at Innsbruck Medical University Hospital, Austria. Preterm infants born before 32 weeks of gestation between 6 November 2010 and 6 December 2022 were eligible for the study. The aEEG was analysed for the total maturation score, its component scores and the number of sleep-wake cycles per hour.

RESULTS

We enrolled 240 preterm twin infants (57.5% male) with a mean gestational age of 30 (range: 24-32) weeks and a mean birth weight of 1324 (range: 600-2116) grams. We compared 240 singleton matched preterms. No differences were found between preterm singletons and twin preterm infants regarding the total maturation and component scores, or the number of sleep-wake cycles. aEEG showed no difference between monozygotic and dizygotic twins.

CONCLUSION

Compared to singletons, twin infants born preterm showed no differences in aEEG signals in the first 4 weeks of life. Future studies should include more complex non-invasive functional neuroimaging methods to gain more insight into this important topic.

Trends in Amplitude-Integrated Electroencephalography in the Smallest Preterm Neonates

BACKGROUND

Amplitude-integrated electroencephalography is increasingly used for the neuromonitoring of premature infants. However, it is still not clear how bioelectrical activity changes in the smallest gestational age newborns. The aim of our study was to evaluate the bioelectrical activity of amplitude-integrated electroencephalograms in premature newborns of different gestational age to assess how gestational age and postnatal age influence patterns of amplitude-integrated electroencephalograms and to test the hypothesis of whether the bioelectrical activity of the brain matures faster after the birth of premature newborns than in utero.

METHODS

We prospectively included infants born before 32 weeks of gestational age between June 2020 and July 2022. Serial recordings of amplitude-integrated electroencephalograms were performed at three time points of age (days 1-3, 13-15, and 27-29). Recordings were analyzed for background patterns, the onset and appearance of cyclicity, and lower amplitude border and bandwidth, which were used to derive a composite Burdjalov score.

RESULTS

In total, 140 premature neonates were included in the study, and 112 of them completed the study. The median gestational age of the newborns enrolled in the study was 29 (27-30) weeks, and the mean weight was 1206 (350) g. Burdjalov scores increased with increasing gestational age. Higher scores were observed in every dimension of the amplitude-integrated electroencephalograms for newborns of lower gestational age when compared to newborns of higher gestational age of the same postmenstrual age. There was a significant correlation between gestational age and parameters of amplitude-integrated electroencephalograms at all time points.

CONCLUSIONS

A higher gestational age has a positive effect on the bioelectrical activity of amplitude-integrated electroencephalograms. Increasing postnatal age affected amplitude-integrated electroencephalograms more than gestational age. Our hypothesis that the bioelectrical activity of the brain matures faster for premature newborns after birth than in the womb was confirmed.

An Amplitude-Integrated EEG Evaluation of Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

Infants with neonatal opioid withdrawal syndrome (NOWS) have disrupted neurobehavior that requires hospitalization and treatment. This article aimed to evaluate electroencephalography (EEG) abnormalities using amplitude-integrated EEG (aEEG) in NOWS.

STUDY DESIGN

Eighteen term born infants with NOWS were recruited prospectively for an observational pilot study. aEEG monitoring was started within 24 hours of recruitment and twice weekly through discharge. aEEG data were analyzed for background and seizures. Severity of withdrawal was monitored using the modified Finnegan scoring (MFS) system.

RESULTS

Fifteen neonates had complete datasets. Thirteen (87%) had continuous aEEG background in all recordings. None had sleep-wake cyclicity (SWC) at initial recording. Brief seizures were noted in 9 of 15 (60%) infants. Lack of SWC was associated with higher MFS scores. At discharge, 8 of 15 (53%) had absent or emerging SWC.

CONCLUSION

aEEG abnormalities (absent SWC) are frequent and persist despite treatment at the time of discharge in the majority of patients with NOWS. Brief electrographic seizures are common. Neonates with persistent aEEG abnormalities at discharge warrant close follow-up.

KEY POINTS

· EEG abnormalities are common and persist after clinical signs resolve in patients with NOWS.. · Short subclinical seizures may be seen.. · aEEG may identify neonates who need follow-up..

Predictive Ability of Amplitude Integrated Electroencephalography for Adverse Outcomes in Neonates with Sepsis-Associated Encephalopathy: A Cohort Study

The authors examined the prevalence of abnormal amplitude integrated electroencephalography (aEEG) patterns in neonates diagnosed with sepsis-associated encephalopathy (SAE). They recorded 36626 min of aEEG in 75 study neonates. Encephalopathy was defined by the Brighton Collaboration Neonatal Encephalopathy criteria. Neonates with primary outcome [either non-survivors or survivors with abnormal neurological examination at discharge using Amiel-Tison assessment tool, n = 58, (77%)] were compared with 17 survivors having normal neurological examination at discharge. Severely abnormal aEEG patterns (isoelectric voltage, continuous low voltage, burst suppression) collectively represented 31% of total 36626 min aEEG tracings. Neonates experiencing primary outcome had significantly higher Burdjalov scores than survivors with normal neurological exam (p value 0.01). After adjusting for gestational age, birth weight, and invasive ventilation, severely abnormal aEEG (aOR 5.8, 95% CI 1.7-19.5, p value 0.005) and Burdjalov score (aOR 0.77, 95% CI 0.63-0.95, p value 0.01) were independently associated with death or abnormal neurological examination at discharge.

[Effects of antenatal corticosteroid therapy in pregnant women on the brain development of preterm infants as assessed by amplitude-integrated electroencephalography]

OBJECTIVES

To investigate the effects of antenatal corticosteroid (ACS) therapy in pregnant women on the brain development of preterm infants using amplitude-integrated electroencephalography (aEEG).

METHODS

A retrospective analysis was conducted on 211 preterm infants with a gestational age of 28 to 34+6 weeks. The infants were divided into an ACS group (131 cases) and a control group (80 cases) based on whether antenatal dexamethasone was given for promoting fetal lung maturity. The first aEEG monitoring (referred to as aEEG1) was performed within 24 hours after birth, and the second aEEG monitoring (referred to as aEEG2) was performed between 5 to 7 days after birth. The aEEG results were compared between the two groups.

RESULTS

In preterm infants with a gestational age of 28 to 31+6 weeks, the ACS group showed a more mature periodic pattern and higher lower amplitude boundary in aEEG1 compared to the control group (P<0.05). In preterm infants with a gestational age of 32 to 33+6 weeks and 34 to 34+6 weeks, the ACS group showed a higher proportion of continuous patterns, more mature periodic patterns and higher Burdjalov scores in aEEG1 (P<0.05). And the ACS group exhibited a higher proportion of continuous patterns, more mature periodic patterns, higher lower amplitude boundaries, narrower bandwidths, and higher Burdjalov scores in aEEG2 (P<0.05).

CONCLUSIONS

ACS-treated preterm infants have more mature aEEG patterns compared to those not treated with ACS, suggesting a beneficial effect of ACS on the brain development of preterm infants.

The net impact of clinical seizures on outcome characteristics in infants with neonatal encephalopathies at 12 months of age

PURPOSE

To assess the impact of clinical neonatal seizures on outcome characteristics of preterm and term newborns with neonatal encephalopathy (NE).

METHODS

We designed a prospective comparative study with 53 babies (preterm neonates: 26 and term neonates: 27) with NE: group 1 (preterm neonates with seizures, n = 13), group 2 (preterm neonates without seizures, n = 13), group 3 (term neonates with seizures, n = 13) and group 4 (term neonates without seizures, n = 14). The functional outcome characteristics of the survivors were assessed by the Ankara Developmental Screening Inventory (ADSI) and the Guide for Monitoring Child Development (GMCD) at 12 months of age.

RESULTS

Clinically defined acute symptomatic seizures were diagnosed with prompt conventional EEG / amplitude-integrated EEG in preterm (92.3%) and term neonates (81.4%) with etiology-specific diagnoses of NE. There were no differences between the study groups regarding seizure semiology and EEG characteristics. A primary adverse outcome was defined in 22 (41.5%) of the cohort. However, only 15.3% of infants had an unfavorable functional outcome with ADSI at 12 months. Among the survivors, there was no significant difference between the study groups regarding ADSI scores. The GMDC test revealed normal development in 50% of survivors with seizures in the preterm group and 83% in the term group.

CONCLUSION

There was no significant difference between the characteristics of functional outcomes at 12 months in preterm and term neonates with NE for clinical seizures.

Early Brain Activity in Very Preterm Infants of Mothers with Gestational Diabetes Mellitus: A Pilot Study

INTRODUCTION

Neurological consequences of preterm infants born to mothers with gestational diabetes mellitus (GDM) are unclear. In this pilot study, we investigated the effect of GDM on brain activity in very preterm infants.

METHODS

Preterm infants <32 gestational weeks of mothers with GDM compared to gestational age- and sex-matched controls born between 2011 and 2018 were included. Amplitude-integrated electroencephalography (aEEG) was assessed for total maturation and individual component scores according to Burdjalov and colleagues, the dominating visual background, and the presence of sleep-wake cycles per hour in the first 72 h of life and weekly at days 7, 14, 21, and 28.

RESULTS

We included 47 infants of mothers with GDM and 94 control infants. Both the aEEG total maturation score and its individual component scores, as well as the percentage of continuous background pattern, increased equally during the first 4 weeks after birth in both groups. GDM-exposed infants showed a slightly but significantly higher number of sleep-wake cycles per hour.

CONCLUSION

We found normal maturation of brain activity in the first 4 weeks after birth in very preterm infants born to mothers with GDM, not differing from a very preterm control group. The higher number of sleep-wake cycles per hour in GDM-exposed infants could indicate transiently enhanced maturation. Further studies on brain activity and brain development in very preterm infants of mothers with GDM are needed to validate our results.

Association of aEEG and brain injury severity on MRI at term-equivalent age in preterm infants

AIM

Measures to detect and monitor brain injury in preterm infants are amplitude-integrated electroencephalography (aEEG) and magnetic resonance imaging (MRI). To investigate the association between aEEG and MRI in a large cohort of preterm infants. Five hundred and twenty-three preterm infants were included in the study.

METHODS

AEEG was interpreted for the total maturation score (TMS) according to Burdjalov. Cerebral MRI was evaluated using a validated scoring system by Kidokoro.

RESULTS

One hundred and forty-six infants (27.9%) showed some form of brain injury, with 111 infants (21.2%) showing mild injury and 35 (6.7%) showing severe injury. TMS were significantly higher in infants without injury compared to severe injury. When comparing infants with isolated intraventricular haemorrhage  to infants without brain injury, TMS were significantly lower.

CONCLUSION

Prediction of adverse outcome is an important aspect of neonatal care. The combination of diagnostic measures evaluating brain injury might enhance our abilities in neonatal care to provide accurate information about later outcome. Early aEEG is predictive for the severity of brain injury detected by MRI at term-equivalent age. Whether aEEG is also predictive for neurodevelopmental outcome needs to be further investigated in relation to the various patterns of preterm brain injury.

The prognostic value of the NPT test combined with amplitude integrated electroencephalogram in children with VE and its bioreliability analysis

Background

Viral encephalitis (VE) is one of the common diseases of children with intracranial infection, it has come on urgent, progress is fast, and the clinical features of severe cases may even lead to disability, death, and other serious adverse prognostic outcomes, so seek in early diagnosis and prognosis of efficiency of the relevant indicators to stop in time and take effective means to prevent the further development is of great significance. Neopterin (NPT), as a factor that plays an important role in the process of validation development, has been relatively rarely studied in children with VE.

Methods

In this study, 127 cases of children with VE were retrieved from the TCGA database by bioinformatics, and their amplitude integrated electroencephalogram (AEEG) related information was collected at the same time. The neurodevelopmental status of VE children was evaluated according to the Gesell scale and divided into the good group (n=88) and the poor group (n=39). The differences in NPT expression and AEEG score between them were observed. In addition, the clinical data of 100 children without VE were screened from the database, and the differences in NPT expression and AEEG score between VE children and non-VE children were compared. The ROC curve was used to evaluate the clinical efficacy of NPT combined with AEEG in diagnosis and prognosis prediction. Kaplan-Meier was used to observe the effect of NPT high expression and low expression on poor prognosis of VE children.

Multisensory stimulation bundles on sleep and neurobehavioral development in the first year after birth in very preterm infants: a randomized crossover controlled study protocol

BACKGROUND

Disrupted sleep is believed to contribute to short- and long-term neurodevelopmental problems in very preterm infants (VPIs). This study presents a protocol for an evaluator-blinded, randomized crossover trial. It aims to assess the sleep efficiency of hospitalized VPIs by providing multisensory stimulation bundles. Furthermore, it aims to observe the intervention impacts on sleep during hospitalization of the VPIs and their sleep and neurodevelopmental outcomes during the first year of post-discharge follow-up.

METHODS

The study will be conducted in the neonatology department of a tertiary pediatric teaching hospital. All the eligible VPIs will undergo two types of care in random order: "standard care" (2 weeks) and "standard care plus multisensory stimulation bundles," each lasting 2 weeks. A generated list of random numbers will be used for case sequence allocation. Sleep outcomes will be evaluated using the Actiwatch-2 Actigraph. Moreover, the amplitude-integrated electroencephalography and the Griffiths Mental Development Scales will be used to measure the neurodevelopmental outcomes during hospitalization and in the first year of follow-up of the VPIs.

DISCUSSION

The intervention protocol of this study differs from that of other traditional interventions by producing precise and consistent supportive stimulations, similar to maternal tactile, auditory, posture, and visual effects for hospitalized VPIs. This protocol could be an effective measure to facilitate sleep and early neurodevelopment of VPIs. The expected outcomes will help confirm the implementation and generalization of the multisensory stimulation bundles' care protocol in neonatology departments. We expect that the study will positively impact hospitalized VPIs, especially in their sleep and early neurodevelopmental outcomes. It will also provide a new perspective regarding parent and infant interaction strategies, particularly for newborn intensive care units that limit visits because of the global spread of COVID-19.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR 2200059099. Registered on 25 April 2022, https://www.chictr.org.cn/showproj.html?proj=166980 ; the Hospital Research Ethics Committee (approval number: SCMCIRB-K2021086-1, Version 01), approved on 21 January 2022.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic role of optic nerve sheath diameter and brain blood flow in neonates with hypoxic-ischemic encephalopathy

PURPOSE

The primary aim was to study the optic nerve sheath diameter (ONSD) measurements and cerebral blood flows in neonates with hypoxic-ischemic encephalopathy (HIE) who were at risk of cerebral edema and to compare the measurements with healthy neonates.

METHODS

Neonates diagnosed as Stage II and III HIE patients were enrolled in the study group. ONSD measurements and blood flow Doppler studies in the first 24-48 h of life during hypothermia and following hypothermia treatment. Magnetic resonance imaging (MRI) and transfontanelle ultrasonography were performed within the first 4-7 days of life in all HIE patients. Saved US and MRI images were assessed by a blind pediatric radiologist later on.

RESULTS

Data from a total of 63 infants (42 in the HIE group and 21 in the control group) were analyzed. Both the right and left ONSD measurements were comparable between HIE and control groups. However, both resistive index (RI) and pulsatility index (PI) of the middle cerebral artery were found to be significantly lower in HIE (0.69 ± 0.09 and 1.14 (0.98-1.30)) group when compared with controls (0.75 ± 0.04 and 1.41 (1.25-1.52)) (p < 0.01). Ultrasonographic ONSD measurements were significant and strongly correlated with MRI ONSD measurements for both sides (r = 0.91 and r = 0.93, p < 0.01). Doppler studies during normothermia were comparable with the control group and significantly increased following therapeutic hypothermia.

CONCLUSION

Ultrasonographic ONSD measurements can be reliably performed in term neonates with high compatibility to MRI. No significant effect on ONSD measurements was found related to asphyxia and therapeutic hypothermia despite the significant alteration observed in Doppler studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep assessment in preterm infants: Use of actigraphy and aEEG

OBJECTIVE

Objective methods to monitor the sleep of preterm infants at the neonatal intensive care unit (NICU) are required to prevent potentially adverse neurodevelopmental outcomes. This study aimed to determine the concordance of actigraphy and amplitude-integrated electroencephalogram (aEEG) against gold standard direct observation (DO) in assessing sleep/wake states of typically developing preterm infants.

METHODS

This prospective observational study was conducted in a single center level III NICU. Sleep variables were measured using Philips Respironics Mini-Mitter® Actiwatch-2 for 24 h and compared with 8-h matched data of aEEG and DO. Sensitivity-specificity analysis, Cohen's kappa, prevalence-adjusted and bias-adjusted kappa (PABAK), and Bland Altman plots were generated.

RESULTS

Seventeen preterm infants were recruited. A total of 11252 epochs were studied. Sensitivity (86.4%), agreement rate (67.9%), and predictive value for wake (47.9%) for the actigraphy were highest at the automatic activity threshold whereas specificity (54.5%) and predictive value for sleep (75.5%) were highest at low threshold. The sensitivity of aEEG was 79.3% and the specificity was 54.3%. At all thresholds, the agreement was largely equivalent with low kappas (0.14-0.17) and PABAK coefficients (0.22-0.35) for actigraphy and DO. Moderate agreement was observed between aEEG and DO according to the PABAK coefficient (0.44). Mean differences in sleep parameters were not different between DO and aEEG as well as DO/aEEG and actigraphy at medium threshold (p > 0.05).

CONCLUSIONS

Actigraphy at medium threshold can be used in depicting sleep in typically developing preterm infants at NICU. aEEG may be an alternative adjunctive method to actigraphy for the evaluation of sleep/wake states in the NICU setting.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04145362.

Neuromonitoring in neonatal critical care part I: neonatal encephalopathy and neonates with possible seizures

The blooming of neonatal neurocritical care over the last decade reflects substantial advances in neuromonitoring and neuroprotection. The most commonly used brain monitoring tools in the neonatal intensive care unit (NICU) are amplitude integrated EEG (aEEG), full multichannel continuous EEG (cEEG), and near-infrared spectroscopy (NIRS). While some published guidelines address individual tools, there is no consensus on consistent, efficient, and beneficial use of these modalities in common NICU scenarios. This work reviews current evidence to assist decision making for best utilization of neuromonitoring modalities in neonates with encephalopathy or with possible seizures. Neuromonitoring approaches in extremely premature and critically ill neonates are discussed separately in the companion paper. IMPACT: Neuromonitoring techniques hold promise for improving neonatal care. For neonatal encephalopathy, aEEG can assist in screening for eligibility for therapeutic hypothermia, though should not be used to exclude otherwise eligible neonates. Continuous cEEG, aEEG and NIRS through rewarming can assist in prognostication. For neonates with possible seizures, cEEG is the gold standard for detection and diagnosis. If not available, aEEG as a screening tool is superior to clinical assessment alone. The use of seizure detection algorithms can help with timely seizures detection at the bedside.

The effects of betamethasone on the amplitude integrated EEG of infants born at 34- or 35-weeks gestation

OBJECTIVE

Assess if maternal betamethasone administration at 34-35 weeks accelerated neonatal amplitude integrated EEG (aEEG) maturation.

STUDY DESIGN

Nested, observational cohort in 7 centers participating in the Antenatal Late Preterm Steroid randomized trial. Up to 2 aEEGs were obtained in neonates born from 34⁰-35⁶ weeks gestation before 72 h (aEEG 1) and at 5-7 days (aEEG 2) if hospitalized. Personnel and aEEG central readers were masked to the intervention. The primary outcome was maturation reflected by cycle frequency; secondary outcomes were border voltage, span, and discontinuity.

RESULTS

58 neonates were enrolled (betamethasone, 28, placebo, 30). On aEEG 1, cycle frequency did not differ, but betamethasone exposed infants had a greater lower border voltage and a broader span. On aEEG 2, both groups displayed increases in lower border voltage.

CONCLUSIONS

Betamethasone associated changes in lower border voltage support accelerated electrical activity. Further investigation is needed to understand the broader span.

Neuromonitoring in neonatal critical care part II: extremely premature infants and critically ill neonates

Neonatal intensive care has expanded from cardiorespiratory care to a holistic approach emphasizing brain health. To best understand and monitor brain function and physiology in the neonatal intensive care unit (NICU), the most commonly used tools are amplitude-integrated EEG, full multichannel continuous EEG, and near-infrared spectroscopy. Each of these modalities has unique characteristics and functions. While some of these tools have been the subject of expert consensus statements or guidelines, there is no overarching agreement on the optimal approach to neuromonitoring in the NICU. This work reviews current evidence to assist decision making for the best utilization of these neuromonitoring tools to promote neuroprotective care in extremely premature infants and in critically ill neonates. Neuromonitoring approaches in neonatal encephalopathy and neonates with possible seizures are discussed separately in the companion paper. IMPACT: For extremely premature infants, NIRS monitoring has a potential role in individualized brain-oriented care, and selective use of aEEG and cEEG can assist in seizure detection and prognostication. For critically ill neonates, NIRS can monitor cerebral perfusion, oxygen delivery, and extraction associated with disease processes as well as respiratory and hypodynamic management. Selective use of aEEG and cEEG is important in those with a high risk of seizures and brain injury. Continuous multimodal monitoring as well as monitoring of sleep, sleep-wake cycling, and autonomic nervous system have a promising role in neonatal neurocritical care.

Newborns at high risk for brain injury: the role of the amplitude-integrated electroencephalography

OBJECTIVE

Amplitude-integrated electroencephalography (aEEG) is a simplified bedside neurophysiology tool that has been implemented in the neonatal intensive care unit and studied in an extensive range of clinical applications in the past decade. This critical review aimed to evaluate a variety of clinical applications of aEEG monitoring in diagnosis, clinical management, and prognosis assessment in critically ill neonates.

SOURCES

The databases of Pubmed, SciELO, Lilacs, and Cochrane, books, and other online resources were consulted, as well as sources of professional experiences.

SUMMARY OF FINDINGS

The clinical use of aEEG to access real-time brain function, background activity, and utility in seizures detection has been described. A critical review was realized considering the authors' professional experience. Newborns with hypoxic-ischemic encephalopathy and seizures screening represent the most common studied population. However, several studies have shown interesting applications on preterm infants, newborns with congenital heart disease, and other clinical situations of high risk of injury to the developing brain.

CONCLUSION

The aEEG has shown to be a useful non-invasive bedside monitor that aids in evaluating brain function, background activity, and cyclicity. aEEG findings have also demonstrated good prognostic value in a group of critically ill neonates. The aEEG seizure diagnosis capability has limitations, which have been already well established. The use of neonatal brain monitoring such as aEEG was shown to give valuable information in several high-risk clinical situations.

The impact of age and electrode position on amplitude-integrated EEGs in children from 1 month to 17 years of age

Aim

Amplitude-integrated electroencephalography (aEEG) is used to monitor electrocortical activity in critically ill children but age-specific reference values are lacking. We aimed to assess the impact of age and electrode position on aEEG amplitudes and derive normal values for pediatric aEEGs from neurologically healthy children.

Methods

Normal EEGs from awake children aged 1 month to 17 years (213 female, 237 male) without neurological disease or neuroactive medication were retrospectively converted into aEEGs. Two observers manually measured the upper and lower amplitude borders of the C3 – P3, C4 – P4, C3 – C4, P3 – P4, and Fp1 – Fp2 channels of the 10–20 system. Percentiles (10th, 25th, 50th, 75th, 90th) were calculated for each age group (&lt;1 year, 1 year, 2–5 years, 6–9 years, 10–13 years, 14–17 years).

Results

Amplitude heights and curves differed between channels without sex-specific differences. During the first 2 years of life, upper and lower amplitudes of all but the Fp1–Fp2 channel increased and then declined until 17 years. The decline of the upper Fp1–Fp2 amplitude began at 4 years, while the lower amplitude declined from the 1st year of life.

Conclusions

aEEG interpretation must account for age and electrode positions but not for sex in infants and children.

Amplitude-integrated EEG recorded at 32 weeks postconceptional age. Correlation with MRI at term

OBJECTIVE

The study aims to establish the role of late aEEG (scored by Burdjalov) in predicting brain maturation as well as abnormalities evaluated at term equivalent age (TEA) by brain MRI.

METHODS

91 infants born before 30 wks gestation underwent an aEEG monitoring at 32 wks postconceptional age (PCA). aEEG, was correlated with TEA MRI, scored by Kidokoro.

RESULTS

A significant correlation between the aEEG score and the MRI scores was found. The same results were obtained for the aEEG continuity score; cyclicity and bandwidth scores were associated with grey matter and cerebellar MRI items. Moreover, a correlation between aEEG and cEEG recorded both at 32 and 40 wks PCA, was found.

CONCLUSIONS

aEEG monitoring can be predictive of MRI findings at TEA, suggesting that it could be implemented as a useful tool to support ultrasound to help identify neonates who will benefit from early intervention services.

A practical approach toward interpretation of amplitude integrated electroencephalography in preterm infants

The developing preterm brain is vulnerable to injury, especially during periods of clinical instability; therefore, monitoring the brain may provide important information on brain health. Over the last 2 decades, a growing body of literature has been reported on preterm amplitude integrated electroencephalography (aEEG) with regards to normative data and associations with adverse outcomes. Despite this, the use of aEEG for preterm infants remains mostly a research tool with limited clinical applicability. In this article, we review the literature on normal and abnormal aEEG patterns in preterm infants and propose a stepwise clinical algorithm for aEEG assessment at the bedside that takes into account assessment of maturation and identification of pathological patterns.

CONCLUSION

This algorithm may be used by clinicians at the bedside for interpretation to integrate it in clinical practice for neurological surveillance of preterm infants.

WHAT IS KNOWN

• Studies have reported normative data on aEEG in preterm infants for different gestational ages. • Burst suppression pattern and absent sleep-wake cycling have been described to be associated with brain pathology and adverse outcomes in preterm infants.

WHAT IS NEW

• We have synthesized aEEG characteristics in preterm infants across the spectrum of prematurity reported in the literature. • We present a stepwise approach for clinically applicable interpretation of aEEG in preterm infants.

Amplitude-Integrated EEG Monitoring in Pediatric Intensive Care: Prognostic Value in Meningitis before One Year of Age

Pediatric morbidity from meningitis remains considerable. Preventing complications is a major challenge to improve neurological outcome. Seizures may reveal the meningitis itself or some complications of this disease. Amplitude-integrated electroencephalography (aEEG) is gaining interest for the management of patients with acute neurological distress, beyond the neonatal age. This study aimed at evaluating the predictive value of aEEG monitoring during the acute phase in meningitis among a population of infants hospitalized in the pediatric intensive care unit (PICU), and at assessing the practicability of the technique. AEEG records of 25 infants younger than one year of age hospitalized for meningitis were retrospectively analyzed and correlated to clinical data and outcome. Recording was initiated, on average, within the first six hours for n = 18 (72%) patients, and overall quality was considered as good. Occurrence of seizure, of status epilepticus, and the background pattern were significantly associated with unfavorable neurological outcomes. AEEG may help in the management and prognostic assessment of pediatric meningitis. It is an easily achievable, reliable technique, and allows detection of subclinical seizures with minimal training. However, it is important to consider the limitations of aEEG, and combinate it with conventional EEG for the best accuracy.

Amplitude-Integrated Electroencephalography: A Primer for Neonatologists and Practitioners in the NICU

Amplitude-integrated electroencephalography (aEEG) is an essential tool used in the NICU to monitor infants with central nervous system pathology and encephalopathy. This review provides a summary of aEEG, including clinical indications, interpretation of different tracing patterns, and seizure identification, which are essential skills for teams caring for sick newborns. We also discuss the limitations of the clinical application of aEEG in this population.

Electroencephalographic studies in growth-restricted and small-for-gestational-age neonates

Foetal growth restriction (FGR) and being born small for gestational age (SGA) are associated with neurodevelopmental delay. Early diagnosis of neurological damage is difficult in FGR and SGA neonates. Electroencephalography (EEG) has the potential as a tool for the assessment of brain development in FGR/SGA neonates. In this review, we analyse the evidence base on the use of EEG for the assessment of neonates with FGR or SGA. We found consistent findings that FGR/SGA is associated with measurable changes in the EEG that present immediately after birth and persist into childhood. Early manifestations of FGR/SGA in the EEG include changes in spectral power, symmetry/synchrony, sleep-wake cycling, and the continuity of EEG amplitude. Later manifestations of FGR/SGA into infancy and early childhood include changes in spectral power, sleep architecture, and EEG amplitude. FGR/SGA infants had poorer neurodevelopmental outcomes than appropriate for gestational age controls. The EEG has the potential to identify FGR/SGA infants and assess the functional correlates of neurological damage. IMPACT: FGR/SGA neonates have significantly different EEG activity compared to AGA neonates. EEG differences persist into childhood and are associated with adverse neurodevelopmental outcomes. EEG has the potential for early identification of brain impairment in FGR/SGA neonates.

Prophylactic Low-Dose Paracetamol Administration for Ductal Closure and Amplitude-Integrated Electroencephalography in Preterm Infants

INTRODUCTION

Prophylactic low-dose paracetamol administration is used to induce closure of the ductus arteriosus in preterm infants. In our recent study we found no impairment on microstructural maturation processes in the brain of preterm infants at term-equivalent age following prophylactic low-dose paracetamol administration. We now assessed amplitude-integrated electroencephalography (aEEG) signals in preterm infants with and without exposure to prophylactic low-dose paracetamol administration.

METHODS

Infants <32 gestational weeks born between 10/2014 and 12/2018 received prophylactic paracetamol (10 mg/kg intravenously every 8 h until echocardiography after at least 72 h) and form the paracetamol group; infants born between 02/2011 and 09/2014 formed the control group. Four single parameters (continuity, cyclicity, amplitude of lower border, bandwidth span) together with their sum (Burdjalov total score) and presence of sleep-wake cycles were compared between the groups.

RESULTS

Included in the study were 338 infants. Two-hundred and seventeen infants received prophylactic paracetamol and 121 formed the control group. The paracetamol group showed a significantly higher number of sleep-wake cycles per hour and a significantly higher total scores compared to the control group (p < 0.05).

CONCLUSION

Paracetamol exposure has been regarded critically with respect to safety in preterm infants in recent years. We found no impairment on amplitude-integrated electroencephalography signals in preterm infants receiving low-dose prophylactic paracetamol compared to controls. Growing awareness and greater availability of data may encourage the clinicians to administer prophylactic paracetamol for ductal closure in preterm infants. The clinical relevance of our findings has to be evaluated in long-term follow up studies on neurodevelopmental outcome.

The impact of perinatal inflammation on the electroencephalogram in preterm infants: a systematic review

BACKGROUND

To summarise the association between perinatal inflammation (PI) exposure and electroencephalography (EEG) features in preterm infants.

METHODS

This systematic review included clinical studies of preterm infants born <37 weeks of gestational age (GA), who had both a PI exposure and an EEG assessment performed during the neonatal period. Studies were identified from Medline and Embase databases on the 15th of September 2021. PI was defined by histological chorioamnionitis, clinical chorioamnionitis, or early-onset neonatal infection (EONI). The risk of bias in included studies was assessed using the Joanna Briggs Institute (JBI) appraisal tool. A narrative approach was used to synthesise results. This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement.

RESULTS

Two cross-sectional studies enrolling 130 preterm children born <32 weeks of GA assessed with one-channel amplitude-integrated EEG (aEEG) during the first four days of life were included. A PI exposure was described in 39 (30%) infants and was associated with a decrease in amplitude and a reduced incidence of sleep-wake cycling patterns.

CONCLUSION

These results should be interpreted with caution because of the small number of included studies and their heterogeneity. Further clinical studies evaluating the association of PI with EEG findings are needed.

IMPACT

A method to assess developmental trajectories following perinatal inflammation is required. Insufficient data exist to determine EEG features associated with perinatal inflammation. Further clinical studies evaluating this association are needed.

Randomized controlled trial of early arachidonic acid and docosahexaenoic acid enteral supplementation in very preterm infants

OBJECTIVE

To evaluate changes in blood long-chain polyunsaturated fatty acid (LCPUFA) and oxylipin concentrations in very preterm infants from birth to 36 weeks' postmenstrual age (WPA) after providing an emulsified arachidonic acid (ARA):docosahexaenoic acid (DHA) supplement at two different concentrations.

STUDY DESIGN

This prospective, randomized trial assigned infants to receive a supplement (1) 80:40 group (80 mg/kg/day ARA and 40 mg/kg/day DHA, n = 9) or (2) 120:60 group (120 mg/kg/day ARA and 60 mg/kg/day DHA, n = 9). Infants received supplement daily from birth until 36 WPA. At baseline, 21 days of life and 36 WPA, the LCPUFAs were measured in plasma by gas chromatography/mass spectrophotometry. Additionally, LCPUFAs and oxylipins were analyzed in whole blood by ultra-high-performance liquid chromatography-tandem mass spectrometry. Furthermore, a sample of oral mucosa was obtained to analyze single-nucleotide polymorphism located in the FADS1 gene by PCR.

RESULTS

Gestational age was similar between groups (80:40 = 28⁺⁶ [27⁺³; 30⁺³] completed weeks^+days ; 120:60 = 29⁺⁶ [27⁺³; 30⁺⁵] completed weeks^+days , p = 0.83). At 36 WPA, the change in plasma ARA was significantly different between groups (80:40 group = 0.15 [-0.67; 0.69] %nmol, 120:60 = 1.68 [1.38; 3.16] %nmol, p = 0.031). In whole blood, the levels of ARA-derived oxylipins (5-, 8-, 9-, 11-, 15-HETE and 8,9-EET) and EPA-derived oxylipins (18-HEPE) significantly increase from baseline to 36 WPA in the 120:60 group than the 80:40 group.

CONCLUSION

Supplementation at high doses (120:60 mg/kg/day) increased levels of ARA, and EPA- and ARA-derived oxylipins compared to low doses (80:40 mg/kg/day). Differences were detected in EPA metabolites without a significant increase in plasma DHA.

Early aEEG can predict neurodevelopmental outcomes at 12 to 18 month of age in VLBWI with necrotizing enterocolitis: a cohort study

Background

Studies have shown that neurological damage is common in necrotizing enterocolitis (NEC) survivors. The purpose of the study was to investigate the predictive value of amplitude-integrated electroencephalogram (aEEG) for neurodevelopmental outcomes in preterm infants with NEC.

Methods

Infants with NEC were selected, and the control group was selected based on 1:1–2 pairing by gestational age. We performed single-channel (P3–P4) aEEG in the two groups. The Burdjalov scores were compared between the two groups. Cranial magnetic resonance imaging (MRI) was performed several months after birth. The neurological outcomes at 12 to 18 months of age were compared with the Gesell Developmental Schedules (GDS). The predictive value of aEEG scores for neurodevelopmental delay was calculated.

Results

There was good consistency between the two groups regarding general conditions. In the 1st aEEG examination, the patients in NEC group had lower Co (1.0 (0.0, 2.0) vs. 2.0 (2.0, 2.0), P = 0.001), Cy (1.0 (0.0, 2.0) vs. 3.0 (3.0, 4.0), P < 0.001), LB (1.0 (0.0, 2.0) vs. 2.0 (2.0, 2.0), P < 0.001), B (1.0 (1.0, 2.0) vs. 3.0 (3.0, 3.5), P < 0.001) and T (3.0 (2.0, 8.0) vs. 10.0 (10.0, 11.5), P < 0.001), than the control group. Cranial MRI in NEC group revealed a widened interparenchymal space with decreased myelination. The abnormality rate of cranial MRI in the NEC group was higher than that in the control group (P = 0.001). The GDS assessment indicated that NEC children had inferior performance and lower mean scores than the control group in the subdomains of gross motor (71 (SD = 6.41) vs. 92 (SD = 11.37), P < 0.001), fine motor (67 (SD = 9.34) vs. 96 (SD = 13.69), adaptive behavior (76 (SD = 9.85) vs. 95 (SD = 14.38), P = 0.001), language (68 (SD = 12.65) vs. 95 (SD = 11.41), P < 0.001), personal-social responses (80 (SD = 15.15) vs. 93(SD = 14.75), P = 0.037) and in overall DQ (72 (SD = 8.66) vs. 95 (SD = 11.07), P < 0.001). The logistic binary regression analysis revealed that the NEC patients had a significantly greater risk of neurodevelopmental delay than the control group (aOR = 27.00, 95% CI = 2.561–284.696, P = 0.006). Confirmed by Spearman’s rank correlation analysis, neurodevelopmental outcomes were significantly predicted by the 1st aEEG Burdjalov score (r = 0.603, P = 0.001). An abnormal 1st Burdjalov score has predictive value for neurodevelopmental delay with high specificity (84.62%) and positive predictive value (80.00%).

Conclusions

Children with NEC are more likely to develop neurodevelopmental delay. There is high specificity and PPV of early aEEG in predicting neurodevelopmental delay.

Association Between Increased Seizures During Rewarming After Hypothermia for Neonatal Hypoxic Ischemic Encephalopathy and Abnormal Neurodevelopmental Outcomes at 2-Year Follow-up: A Nested Multisite Cohort Study

Importance

Compared with normothermia, hypothermia has been shown to reduce death or disability in neonatal hypoxic ischemic encephalopathy but data on seizures during rewarming and associated outcomes are scarce.

Objective

To determine whether electrographic seizures are more likely to occur during rewarming compared with the preceding period and whether they are associated with abnormal outcomes in asphyxiated neonates receiving hypothermia therapy.

Design, Setting, and Participants

This prespecified nested cohort study of infants enrolled in the Optimizing Cooling (OC) multicenter Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network trial from December 2011 to December 2013 with 2 years' follow-up randomized infants to either 72 hours of cooling (group A) or 120 hours (group B). The main trial included 364 infants. Of these, 194 were screened, 10 declined consent, and 120 met all predefined inclusion criteria. A total of 112 (90%) had complete data for death or disability. Data were analyzed from January 2018 to January 2020.

Interventions

Serial amplitude electroencephalography recordings were compared in the 12 hours prior and 12 hours during rewarming for evidence of electrographic seizure activity by 2 central amplitude-integrated electroencephalography readers blinded to treatment arm and rewarming epoch. Odds ratios and 95% CIs were evaluated following adjustment for center, prior seizures, depth of cooling, and encephalopathy severity.

Main Outcomes and Measures

The primary outcome was the occurrence of electrographic seizures during rewarming initiated at 72 or 120 hours compared with the preceding 12-hour epoch. Secondary outcomes included death or moderate or severe disability at age 18 to 22 months. The hypothesis was that seizures during rewarming were associated with higher odds of abnormal neurodevelopmental outcomes.

Results

A total of 120 newborns (70 male [58%]) were enrolled (66 in group A and 54 in group B). The mean (SD) gestational age was 39 (1) weeks. There was excellent interrater agreement (κ, 0.99) in detection of seizures. More infants had electrographic seizures during the rewarming epoch compared with the preceding epoch (group A, 27% vs 14%; P = .001; group B, 21% vs 10%; P = .03). Adjusted odd ratios (95% CIs) for seizure frequency during rewarming were 2.7 (1.0-7.5) for group A and 3.2 (0.9-11.6) for group B. The composite death or moderate to severe disability outcome at 2 years was significantly higher in infants with electrographic seizures during rewarming (relative risk [95% CI], 1.7 [1.25-2.37]) after adjusting for baseline clinical encephalopathy and seizures as well as center.

Conclusions and Relevance

Findings that higher odds of electrographic seizures during rewarming are associated with death or disability at 2 years highlight the necessity of electroencephalography monitoring during rewarming in infants at risk.

Trial Registration

ClinicalTrials.gov Identifier: NCT01192776.

Evaluation of the suitability and clinical applicability of different electrodes for aEEG/cEEG monitoring in the extremely premature infant

INTRODUCTION

Monitoring of brain function using continuous electroencephalography (aEEG/cEEG) is an essential tool in the standard care of the term infant, and its use is growing in the premature infant as a biomarker of lesion and brain maturity. However, the placing of the electrodes is a great challenge, particularly in the extremely premature infant, which often discourages neuromonitoring. The aim of this study is to assess the different electrodes available, to select the one that best suits the peculiarities of the extremely premature infant, and evaluate its applicability in clinical practice.

POPULATION AND METHODS

With the aim of designing a neuromonitoring study protocol using aEEG/cEEG in <28 weeks premature infants, an analysis was made of our experience with the type of electrodes available. The electrode that was considered most suitable for this population was chosen by assessing: the need of preparing the scalp, speed in positioning the electrodes, if the application was invasive or not, the possibility of repositioning, risk of skin injuries, sterility of the technique, and durability. The electrode chosen was used for continuous electroencephalographic monitoring started in the first 24 h of life, and maintained until at least 72 h of life.

RESULTS

The electrodes evaluated were: subdermal needles, silver cups, and 2 types of self-adhesive electrodes (solid hydrogel and wet gel). The wet gel electrodes were chosen. They were used on 41 neonates with a mean gestational age of 25.8 ± 1.1 weeks. Good stable impedance was rapidly obtained, without the need of excessive manipulations, and no skin injuries were observed. The satisfaction of the staff involved in positioning them was very high.

CONCLUSION

The self-adhesive disposable electrodes with wet gel and integrated cable enabled the electrodes to be positioned rapidly and provided continuous non-invasive and good quality aEEG/cEEG monitoring in the extremely premature infant.

Value of amplitude-integrated electroencephalogram combined with quantitative indices of cranial magnetic resonance imaging in predicting short-term neurodevelopment in moderately and late preterm infants: a prospective study

OBJECTIVES

To study the association of amplitude-integrated electroencephalogram (aEEG) and the quantitative indices biparietal width (BPW) and interhemispheric distance (IHD) of cranial magnetic resonance imaging (cMRI) with short-term neurodevelopment in moderately and late preterm infants.

METHODS

A total of 104 moderately and late preterm infants who were admitted to the neonatal intensive care unit from September 2018 to April 2020 were selected as the subjects for this prospective study. The Naqeeb method and sleep-wake cycling (SWC) were used for aEEG assessment within 72 hours after birth. cMRI was performed at the corrected gestational age of 37 weeks. BPW and IHD were measured at the T2 coronal position. At the corrected age of 6 months, the Developmental Screening Test for Child Under Six (DST) was used to follow up neurodevelopment. According to developmental quotient (DQ), the infants were divided into a normal DST group (78 infants with DQ≥85) and an abnormal DST group (26 infants with DQ<85). Related indices were compared between the two groups. The association between aEEG and cMRI was evaluated.

RESULTS

Compared with the normal DST group, the abnormal DST group had significantly lower aEEG normal rate and SWC maturation rate (P<0.05), as well as a significantly larger IHD and a significantly smaller BPW (P<0.05). Immature SWC, aEEG abnormality, and a relatively large IHD were the risk factors for abnormal DST (P<0.05), and a relatively large BPW was a protective factor against abnormal DST (P<0.05).

CONCLUSIONS

For moderately and late preterm infants, aEEG within 72 hours after birth and the quantitative indices BPW and IHD of cMRI at the corrected gestational age of 37 weeks may affect their neurodevelopmental outcome at the corrected age of 6 months.

Aberrant gut-microbiota-immune-brain axis development in premature neonates with brain damage

Premature infants are at substantial risk for suffering from perinatal white matter injury. Though the gut microbiota has been implicated in early-life development, a detailed understanding of the gut-microbiota-immune-brain axis in premature neonates is lacking. Here, we profiled the gut microbiota, immunological, and neurophysiological development of 60 extremely premature infants, which received standard hospital care including antibiotics and probiotics. We found that maturation of electrocortical activity is suppressed in infants with severe brain damage. This is accompanied by elevated γδ T cell levels and increased T cell secretion of vascular endothelial growth factor and reduced secretion of neuroprotectants. Notably, Klebsiella overgrowth in the gut is highly predictive for brain damage and is associated with a pro-inflammatory immunological tone. These results suggest that aberrant development of the gut-microbiota-immune-brain axis may drive or exacerbate brain injury in extremely premature neonates and represents a promising target for novel intervention strategies.

Fully automated simultaneous peripheral arteriovenous exchange transfusion not seen to aggravate brain function and the disorder of the internal environment in neonates with severe hyperbilirubinemia

BACKGROUND

The acute changes in brain function in newborn infants undergoing ET remain unclear. This study aimed to determine whether fully automated simultaneous peripheral arteriovenous ET would influence the brain function.

METHODS

A retrospective analysis was conducted on the clinical data of 39 neonates with hyperbilirubinemia who received ET. Seventeen patients were in the encephalopathy group, and the other 22 patients were in the non-encephalopathy group. Changes in amplitude-integrated electroencephalogram (aEEG) during ETs were analyzed, including background activities, sleep-wake cycling (SWC), and seizures. Before and after the ET, routine blood test parameters, electrolytes, blood glucose, and blood gas parameters were measured.

RESULTS

After ETs, there were no significant changes in the levels of pH, PaO₂, PaCO₂, lactate, and red blood cells, while the levels of total bilirubin, indirect bilirubin, blood potassium, blood sodium, serum calcium, while blood cells, and platelets were significantly lower and the level of blood glucose was significantly higher compared to those before therapy. There was no significant difference in the changes of electroencephalographic activities during ETs, including background activities, SWC, and seizures. However, there were significant differences in suppressions on background activities, while there were no significant statistical differences in SWC or seizures between the 2 groups.

CONCLUSION

Fully automated simultaneous peripheral arteriovenous ET is safe and efficient without significant influence on the disorder of the internal environment and electroencephalographic activities after ET in neonates. However, background activities are more significantly depressed in infants of bilirubin encephalopathy than infants of non-encephalopathy during ET.

[Effect of oral motor intervention in improving brain function development in preterm infants: a randomized controlled trial]

OBJECTIVE

To study the effect of oral motor intervention (OMI) on brain function development in preterm infants.

METHODS

A total of 112 preterm infants were stratified into small-gestational-age (30-31⁺⁶ weeks) and large-gestational-age (32-33⁺⁶ weeks) according to gestational age at birth. The preterm infants were randomly divided into a control group and an intervention group, with 56 infants in each group. The infants in the control group were given routine treatment and nursing, while those in the intervention group were given OMI in addition to the treatment and nursing in the control group. Amplitude-integrated EEG (aEEG) and Neonatal Behavioral Neurological Assessment (NBNA) were performed on days 1, 7, and 14 of enrollment, and the level of brain function development was compared before and after intervention.

RESULTS

On day 7 of OMI, the small-gestational-age intervention group had lower upper bounds of voltage and bandwidth and a higher aEEG score than the small-gestational-age control group (P < 0.05). Compared with the small-gestational-age control group, the small-gestational-age intervention group had higher upper bound of voltage, percentage of mature sleep-wake cycle, aEEG score, and NBNA score and a lower narrow bandwidth on day 14 of OMI (P < 0.05). Compared with the large-gestational-age control group, the large-gestational-age intervention group had lower upper voltage and voltage difference and higher lower bound of voltage and aEEG score on days 7 and 14 of OMI (P < 0.05). On day 7 of OMI, the large-gestational-age intervention group had a higher NBNA score than the large-gestational-age control group (P < 0.05).

CONCLUSIONS

OMI can promote the maturation of aEEG background activities, improve neurobehavioral manifestations, and accelerate brain function development in preterm infants.

The effect of kangaroo mother care on aEEG activity and neurobehavior in preterm infants: a randomized controlled trial

OBJECTIVE

To evaluate the effect of kangaroo mother care (KMC) versus traditional care (TC) on aEEG activity and neurobehavior in preterm infants.

METHODS

A prospective randomized control single-blinded trial conducted in a tertiary level neonatal intensive care unit between October 2019 and October 2020. Preterm infants with gestational age of 31-33 weeks were randomly divided into either a KMC group or a TC group. Outcomes were compared between the groups including aEEG scores, the percentage of mature sleep-wake cycling (SWC) and background activity continuity, narrowband upper and lower bound amplitude, narrowband bandwidth, and neonatal behavioral neurological assessment (NBNA) scores on day 1, day 7, and day 14 after randomization.

RESULTS

A total of 65 infants (32 in KMC group and 33 in TC group) completed protocol. No significant differences were observed in outcomes on day 1. aEEG scores (p = .027 and p = .007, respectively) and the percentage of mature SWC (p = .034 and p = .039, respectively) were significantly higher in KMC group on day 7 and day 14. Compared to the TC group, KMC group had a narrower bandwidth on day 7 (p = .003) and day 14 (p = .016) and higher lower bound amplitude on day 14 (p = .002). Upper bound amplitude and the percentage of continuity were comparable between the groups on day 7 and day 14. The NBNA scores in the KMC group were significantly higher than that of the TC group on day 7 (p < .001) and day 14 (p < .001).

CONCLUSIONS

Preterm infants submitted to the KMC, compared to those non-submitted, have more mature aEEG activity and better neurobehavior performance on day 7 and day 14 after random.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900026363.

The Effect of Music on aEEG Cyclicity in Preterm Neonates

Several methods can be used in the neonatal intensive care unit (NICU) to reduce stress and optimize the quality of life during this period of hospitalization. Among these, music could play an important role. We investigated the effect of different kinds of music therapies on the brain activity of very preterm infants using amplitude-integrated EEG. Sixty-four patients were included and randomly assigned to three different groups: live music group, recorded music group, and control group. In both intervention groups, music was started after the appearance of the first quiet-sleep phase, with a subsequent duration of 20 min. Changes between the first and second quiet-sleep epochs were analyzed using the amplitude-integrated EEG. When looking at single parameters of the amplitude-integrated EEG trace, no differences could be found between the groups when comparing their first and second quiet-sleep phase regarding the parameters of change from baseline, quality of the quiet-sleep epoch, and duration. However, when looking at the total cyclicity score of the second quiet-sleep phase, a difference between both intervention groups and the control group could be found (live music therapy vs. control, p = 0.003; recorded music therapy vs. control, p = 0.006). Improvement within the first and second quiet-sleep epochs were detected in both music groups, but not in the control group. We concluded that our study added evidence of the beneficial effect of music on the amplitude-integrated EEG activity in preterm infants.

Factors associated with neurodevelopment in preterm infants with systematic inflammation

Background

Several studies have suggested that adverse neurodevelopment could be induced by systemic inflammation in preterm infants. We aimed to investigate whether preterm infants with systemic inflammation would have impaired neurodevelopment and which biomarkers and neurophysiologic studies during inflammation are associated with poor neurodevelopment.

Methods

This prospective cohort study enrolled infants born before 30 weeks of gestation or with birth weight < 1250 g. Infants were grouped according to the presence of systemic inflammation: Control (no inflammation, n = 49), I (systemic inflammation, n = 45). Blood and cerebrospinal fluid samples for markers of brain injury and inflammation were collected and amplitude-integrated electroencephalography (aEEG) was performed within 4 h of septic workup. We evaluated aEEG at 35 weeks postmenstrual age (PMA), head circumference at 36 weeks PMA, and brain MRI at discharge. The Bayley Scales of Infant and Toddler Development III (Bayley-III) was performed at a corrected age (CA) of 18 months.

Results

The I group had more white matter injuries (2 vs. 26.7%, Control vs. I, respectively) at the time of discharge, lower brain functional maturation (9.5 vs. 8), and smaller head size (z-score − 1.45 vs. -2.12) at near-term age and poorer neurodevelopment at a CA of 18 months than the control (p < 0.05). Among the I group, the proportion of immature neutrophils (I/T ratios) and IL-1 beta levels in the CSF were associated with aEEG measures at the day of symptom onset (D0). Seizure spike on aEEG at D0 was significantly correlated with motor and social-emotional domains of Bayley-III (p < 0.05). The I/T ratio and CRP and TNF-α levels of blood at D0, white matter injury on MRI at discharge, head circumference and seizure spikes on aEEG at near-term age were associated with Bayley-III scores at a CA of 18 months.

Conclusions

Systemic inflammation induced by clinical infection and NEC are associated with neurodevelopmental impairment in preterm infants. The seizure spike on aEEG, elevated I/T ratio, CRP, and plasma TNF-alpha during inflammatory episodes are associated with poor neurodevelopment.

Influence of Intensive Care Unit Enlightenment on Premature Infants on Functional Brain Maturation Assessed by Amplitude-Integrated Electroencephalograph

OBJECTIVE

Amplitude-integrated electroencephalograph (aEEG) presents a valuable tool for functional brain maturation of preterm infants. However, the effect of enlightenment on functional brain maturation of premature infants has not been investigated. We aimed to do this with aEEG.

STUDY DESIGN

A total of 32 infants, 30 to 35 gestational weeks, were involved in the study. They were randomly distributed into three groups in which different lighting protocols were applied. In group 1, the infants' incubators were covered for 24 hours. In group 2, the infants' incubators were open for 24 hours. In group 3, the infants' incubators were covered for 12 hours and open for another 12 hours. The infants are evaluated with aEEG recordings done on the 3rd (first measurement) and 10th days (second measurement) along with the Burdjalov scoring. Analysis of aEEG recordings was performed, based on sleep-wake cycles (SWCs), upper and lower margin amplitudes, narrowband and broadband of SWC, and bandwidth of SWC.

RESULTS

At first, the narrowband lower amplitudes in group 1 were higher than those of the other groups (p = 0.042), but the difference was not significant in the second measurement (p = 0.110). The Burdjalov scores were higher in group 1 and group 3 on 10th day, though not statistically significant (p = 0.871). When the infants were re-evaluated according to the gestational weeks, the Burdjalov scores of the two groups less than 34 weeks (30-31 and 32-33 weeks) were similar, whereas 34 to 35 weeks were higher when compared with those of the two groups.

CONCLUSION

The difference observed between groups in terms of narrowband lower amplitude in the first measurement may reflect the effect of intrauterine environment rather than enlightenment at the same gestational age because it was made on the third day. However, the fact that all groups have similar results on day 10 suggests that other factors in the intensive care setting may diminish the effect of enlightenment. Burdjalov scores are associated with maturation, and high scores found in the 34- to 35-week group suggest that the 34-week maturation might be a threshold for SWC and development in our group sample.

Amplitude-integrated electroencephalography improves the predictive ability of acute bilirubin encephalopathy

BACKGROUND

To establish a clinical prediction model of acute bilirubin encephalopathy (ABE) using amplitude-integrated electroencephalography (aEEG).

METHODS

A total of 114 neonatal hyperbilirubinemia patients in the Beijing Chaoyang Hospital from August 2015 to October 2018 were enrolled in this study. There were 62 (54.38%) males, and the age of patients undergoing aEEG examination was 2-23 days, with an average of 7.61±4.08 days. Participant clinical information, peak bilirubin value, albumin value, hyperbilirubinemia, and the graphic indicators of aEEG were extracted from medical records, and ABE was diagnosed according to a bilirubin-induced neurological dysfunction (BIND) score >0. Multivariable logistic regression was used to establish a clinical prediction model of ABE. Furthermore, decision curve analysis (DCA) was performed to evaluate the model's predictive value.

RESULTS

According to the BIND score, there were a total of 23 (20.18%) ABE cases. The multivariable logistic regression analysis showed that the value of bilirubin/albumin (B/A), presence of hyperbilirubinemia risk factors, number of sleep-wake cycling (SWC) within 3 hours, widest bandwidth, duration of SWC, and type of SWC were significantly associated with ABE. A clinical prediction model was developed as: p=ex/ (1+ex), X=0.278+0.713*B/A+2.602*with risk factors (with risk factors equals 1) - 1.500*SWC number within 3 hours + 0.219*the widest bandwidth-0.065*the duration of one SWC + 1.491* SWC (mature SWC equals 0, immature SWC equals 1). The area under the curve (AUC) was 0.85 [95% confidence interval (CI): 0.75-0.94], which was significantly higher than the AUC only based on conventional clinical information of B/A (AUC: 0.58, 95% CI: 0.45-0.72). The DCA also showed good predictive ability compared to B/A.

CONCLUSIONS

A clinical prediction model can be established based on the patients' B/A, presence of risk factors for hyperbilirubinemia, number of SWC within 3 hours, widest bandwidth, duration of 1 SWC, and the type of SWC. It has good predictive ability and may improve the diagnostic accuracy of ABE.

Amplitude-integrated electroencephalography signals in preterm infants with cerebral hemorrhage

OBJECTIVE

To evaluate whether preterm infants with cerebral hemorrhage show alterations of aEEG signals in the first four weeks of life.

STUDY DESIGN

Preterm infants (n = 536) born before 32 completed weeks of pregnancy at Innsbruck Medical University Hospital were included in the study. AEEG recordings were evaluated for the Burdjalov score and cerebral hemorrhage was diagnosed by cerebral ultrasound.

RESULTS

Eighty preterm infants with cerebral hemorrhage (median gestational age 28.9 weeks, median birth weight 1157 g) and 456 preterm infants without cerebral hemorrhage (median gestational age 30.0 weeks, median birth weight 1300 g) were investigated. Burdjalov total scores were significantly lower in infants with cerebral hemorrhage. Infants with mild cerebral hemorrhage showed higher Burdjalov total scores compared to infants with severe cerebral hemorrhage in the first days of life. A Burdjalov total score of seven or more was predictive for no development of a cerebral hemorrhage, with a highest area under the curve (0.613) at postnatal day three.

CONCLUSION

Preterm infants with cerebral hemorrhage show alterations in aEEG signals in the newborn period. In future aEEG could be used as a supplemental method to monitor preterm infants at risk for cerebral hemorrhage. The use of aEEG in early life could reduce the number of ultrasound examinations and limit cumulative stress and discomfort in preterm infants.

[Clinical significance of amplitude-integrated electroencephalography in preterm infants with bronchopulmonary dysplasia]

OBJECTIVE

To study the changes and clinical significance of amplitude-integrated electroencephalography (aEEG) in preterm infants with bronchopulmonary dysplasia (BPD).

METHODS

A total of 156 preterm infants with a gestational age of ≤ 32⁺⁶ weeks who were diagnosed with BPD were enrolled as the BPD group, and 156 preterm infants without BPD who were hospitalized during the same period of time were enrolled as the control group. The aEEG scoring system for preterm infants was used to compare aEEG results between the two groups during hospitalization. A stratified analysis was conducted based on the examination time (at the corrected gestational age of ≤ 28⁺⁶ weeks, 29-30⁺⁶ weeks, 31-32⁺⁶ weeks, 33-34⁺⁶ weeks, 35-36⁺⁶ weeks, and 37-38⁺⁶ weeks).

RESULTS

Compared with the non-BPD group, the BPD group had a significantly lower total aEEG score at the corrected gestational age of 33-34⁺⁶ weeks (P < 0.001). The mild BPD group had a significantly lower total aEEG score than the non-BPD group at the corrected gestational age of 33-34⁺⁶ weeks (P < 0.05); the moderate BPD group had a significantly lower total aEEG score than the non-BPD group at the corrected gestational ages of 31-32⁺⁶ weeks, 33-34⁺⁶ weeks, and 35-36⁺⁶ weeks (P < 0.05); the severe BPD group had a significantly lower total aEEG score than the non-BPD group at all corrected gestational ages except ≤ 28⁺⁶ weeks and 29-30⁺⁶ weeks (P < 0.05).

CONCLUSIONS

Preterm infants with BPD (especially moderate to severe BPD) have a lower aEEG score than those without BPD, suggesting that their nervous system development may lag behind that of non-BPD preterm infants with the same gestational age. Therefore, early nervous system evaluation and intervention are necessary for preterm infants with BPD.

Characterization of aEEG During Sleep and Wakefulness in Healthy Children

INTRODUCTION

Interpretation of amplitude-integrated EEG (aEEG) is hindered by lacking knowledge on physiological background patterns in children. The aim of this study was to find out whether aEEG differs between wakefulness and sleep in children.

METHODS

Forty continuous full-channel EEGs (cEEG) recorded during the afternoon and overnight in patients <18 years of age without pathologies or only solitary interictal epileptiform discharges were converted into aEEGs. Upper and lower amplitudes of the C3-C4, P3-P4, C3-P3, C4-P4, and Fp1-Fp2 channels were measured during wakefulness and sleep by two investigators and bandwidths (BW) calculated. Sleep states were assessed according to the American Academy of Sleep Medicine. Median and interquartile ranges (IQR) were calculated to compare the values of amplitudes and bandwidth between wakefulness and sleep.

RESULTS

Median age was 9.9 years (IQR 6.1-14.7). All patients displayed continuous background patterns. Amplitudes and BW differed between wakefulness and sleep with median amplitude values of the C3-C4 channel 35 μV (IQR: 27-49) for the upper and 13 μV (10-19) for the lower amplitude. The BW was 29 μV (21-34). During sleep, episodes with high amplitudes [upper: 99 μV (71-125), lower: 35 μV (25-44), BW 63 μV (44-81)] corresponded to sleep states N2-N3. High amplitude-sections were interrupted by low amplitude-sections, which became the longer toward the morning [upper amplitude: 39 μV (30-51), lower: 16 μV (11-20), BW 23 μV (19-31)]. Low amplitude-sections were associated with sleep states REM, N1, and N2. With increasing age, amplitudes and bandwidths declined.

CONCLUSION

aEEGs in non-critically ill children displayed a wide range of amplitudes and bandwidths. Amplitudes were low during wakefulness and light sleep and high during deep sleep. Interpretation of pediatric aEEG background patterns must take into account the state of wakefulness in in clinical practice and research.

Effect of morphine on cerebral activity of extremely premature infants

BACKGROUND

Morphine is widely used for sedation in premature infants and may have long-term effects on neurodevelopmental outcome.

AIMS

To assess its effect on cerebral activity of extremely preterm infants.

METHODS

Retrospective study in infants less than 28 weeks of gestational age (GA), treated with morphine and monitored with amplitude integrated EEG (aEEG), that were assessed at baseline and 6 consecutive 2 h periods. At each period, the background activity score and presence of cycling were determined.

RESULTS

A total of 140 infants were included. Background aEEG activity score worsened in 40% of the infants by 6 h after morphine initiation and cycling, initially present in 70% of the infants, could be detected in only 10% after 10 h. On multivariable analysis, adjusted for baseline aEEG score and GA, the background activity decreased by 0.85 (95% confidence interval (CI): 0.74-0.97) immediately after morphine initiation, 0.72 (CI: 0.63-0.83) at 2 h later and on average by 0.64 (CI: 0.57-0.71) at each subsequent 2 h periods. The relative risk of cycling loss at 2 h and 4 h after morphine administration was 1.58 (CI: 1.15-2.16) and 3.37 (CI: 2.23-5.08), respectively.

CONCLUSIONS

Continuous infusion of morphine in extremely preterm infants significantly depresses their cerebral activity soon after its commencement.

Technical recommendations and interpretation guidelines for electroencephalography for premature and full-term newborns

Electroencephalography (EEG) of neonatal patients is amongst the most valuable diagnostic and prognostic tool. EEG recordings, acquired at the bedside of infants, evaluate brain function and the maturation of premature and extremely premature infants. Strict conditions of acquisition and interpretation must be respected to guarantee the quality of the EEG and ensure its safety for fragile children. This article provides guidance for EEG acquisition including: (1) the required equipment and devices, (2) the modalities of installation and asepsis precautions, and (3) the digital signal acquisition parameters to use during the recording. The fundamental role of a well-trained technician in supervising the EEG recording is emphasized. In parallel to the acquisition recommendations, we present a guideline for EEG interpretation and reporting. The successive steps of EEG interpretation, from reading the EEG to writing the report, are described. The complexity of the EEG signal in neonates makes artefact detection difficult. Thus, we provide an overview of certain characteristic artefacts and detail the methods for eliminating them.

WU-NEAT: A clinically validated, open-source MATLAB toolbox for limited-channel neonatal EEG analysis

BACKGROUND

Limited-channel EEG research in neonates is hindered by lack of open, accessible analytic tools. To overcome this limitation, we have created the Washington University-Neonatal EEG Analysis Toolbox (WU-NEAT), containing two of the most commonly used tools, provided in an open-source, clinically-validated package running within MATLAB.

METHODS

The first algorithm is the amplitude-integrated EEG (aEEG), which is generated by filtering, rectifying and time-compressing the original EEG recording, with subsequent semi-logarithmic display. The second algorithm is the spectral edge frequency (SEF), calculated as the critical frequency below which a user-defined proportion of the EEG spectral power is located. The aEEG algorithm was validated by three experienced reviewers. Reviewers evaluated aEEG recordings of fourteen preterm/term infants, displayed twice in random order, once using a reference algorithm and again using the WU-NEAT aEEG algorithm. Using standard methodology, reviewers assigned a background pattern classification. Inter/intra-rater reliability was assessed. For the SEF, calculations were made using the same fourteen recordings, first with the reference and then with the WU-NEAT algorithm. Results were compared using Pearson's correlation coefficient.

RESULTS

For the aEEG algorithm, intra- and inter-rater reliability was 100% and 98%, respectively. For the SEF, the mean±SD Pearson correlation coefficient between algorithms was 0.96±0.04.

CONCLUSION

We have demonstrated a clinically-validated toolbox for generating the aEEG as well as calculating the SEF from EEG data. Open-source access will enable widespread use of common analytic algorithms which are device-independent and unlikely to become outdated as technology changes, thereby facilitating future collaborative research in neonatal EEG.

[Evaluation of the suitability and clinical applicability of different electrodes for aEEG/cEEG monitoring in the extremely premature infant]

INTRODUCTION

Monitoring of brain function using continuous electroencephalography (aEEG/cEEG) is an essential tool in the standard care of the term infant, and its use is growing in the premature infant as a biomarker of lesion and brain maturity. However, the placing of the electrodes is a great challenge, particularly in the extremely premature infant, which often discourages neuromonitoring. The aim of this study is to assess the different electrodes available, to select the one that best suits the peculiarities of the extremely premature infant, and evaluate its applicability in clinical practice.

POPULATION AND METHODS

With the aim of designing a neuromonitoring study protocol using aEEG/cEEG in<28 weeks premature infants, an analysis was made of our experience with the type of electrodes available. The electrode that was considered most suitable for this population was chosen by assessing: the need of preparing the scalp, speed in positioning the electrodes, if the application was invasive or not, the possibility of repositioning, risk of skin injuries, sterility of the technique, and durability. The electrode chosen was used for continuous electroencephalographic monitoring started in the first 24h of life, and maintained until at least 72h of life.

RESULTS

The electrodes evaluated were: subdermal needles, silver cups, and 2 types of self-adhesive electrodes (solid hydrogel and wet gel). The wet gel electrodes were chosen. They were used on 41 neonates with a mean gestational age of 25.8±1.1 weeks. Good stable impedance was rapidly obtained, without the need of excessive manipulations, and no skin injuries were observed. The satisfaction of the staff involved in positioning them was very high.

CONCLUSION

The self-adhesive disposable electrodes with wet gel and integrated cable enabled the electrodes to be positioned rapidly and provided continuous non-invasive and good quality aEEG/cEEG monitoring in the extremely premature infant.