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Prial J, El-Shibiny H, El-Dib M, Benjamin J, Erdei C, Dodrill P, Szakmar E, Bell KA. Growth trajectories and need for oral feeding support among infants with neonatal encephalopathy treated with therapeutic hypothermia. J Perinatol 2024; 44:1163-1171. [PMID: 38702507 DOI: 10.1038/s41372-024-01983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE Identify feeding supports required among infants with neonatal encephalopathy and determine growth trajectories to 3 years. STUDY DESIGN Single-center retrospective cohort study of 120 infants undergoing therapeutic hypothermia. Logistic regression and stratified analyses identified whether clinical factors, EEG-determined encephalopathy severity, and MRI-based brain injury predict feeding supports (nasogastric tube, oral feeding compensations) and growth. RESULTS 50.8% of infants required feeding supports in the hospital, decreasing to 14% at discharge. Moderate-to-severe encephalopathy and basal ganglia injury predicted feeding support needs. Yet, 35% of mildly encephalopathic infants required gavage tubes. Growth trajectories approximated expected growth of healthy infants. CONCLUSION Infants with neonatal encephalopathy-even if mild-frequently experience feeding difficulties during initial hospitalization. With support, most achieve full oral feeds by discharge and adequate early childhood growth. Clinical factors may help identify infants requiring feeding support, but do not detect all at-risk infants, supporting routine screening of this high-risk population.
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Affiliation(s)
- Jennifer Prial
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Hoda El-Shibiny
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
| | - Mohamed El-Dib
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer Benjamin
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Carmina Erdei
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Pamela Dodrill
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eniko Szakmar
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Katherine A Bell
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Ventura GC, Dyshliuk N, Dmytriyeva O, Nordsten MJB, Haugaard MM, Christiansen LI, Thymann T, Sangild PT, Pankratova S. Enteral plasma supports brain repair in newborn pigs after birth asphyxia. Brain Behav Immun 2024; 119:693-708. [PMID: 38677626 DOI: 10.1016/j.bbi.2024.04.032] [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] [Received: 12/18/2023] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024] Open
Abstract
Newborns exposed to birth asphyxia transiently experience deficient blood flow and a lack of oxygen, potentially inducing hypoxic-ischaemic encephalopathy and subsequent neurological damage. Immunomodulatory components in plasma may dampen these responses. Using caesarean-delivered pigs as a model, we hypothesized that dietary plasma supplementation improves brain outcomes in pigs exposed to birth asphyxia. Mild birth asphyxia was induced by temporary occlusion of the umbilical cord prior to caesarean delivery. Motor development was assessed in asphyxiated (ASP) and control (CON) piglets using neonatal arousal, physical activity and gait test parameters before euthanasia on Day 4. The ASP pigs exhibited increased plasma lactate at birth, deficient motor skills and increased glial fibrillary acidic protein levels in CSF and astrogliosis in the putamen. The expression of genes related to oxidative stress, inflammation and synaptic functions was transiently altered in the motor cortex and caudate nucleus. The number of apoptotic cells among CTIP2-positive neurons in the motor cortex and striatal medium spiny neurons was increased, and maturation of preoligodendrocytes in the internal capsule was delayed. Plasma supplementation improved gait performance in the beam test, attenuated neuronal apoptosis and affected gene expression related to neuroinflammation, neurotransmission and antioxidants (motor cortex, caudate). We present a new clinically relevant animal model of moderate birth asphyxia inducing structural and functional brain damage. The components in plasma that support brain repair remain to be identified but may represent a therapeutic potential for infants and animals after birth asphyxia.
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Affiliation(s)
- Gemma Chavarria Ventura
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nadiya Dyshliuk
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; National University of Life and Environmental Sciences of Ukraine, Kyiv, Ukraine
| | - Oksana Dmytriyeva
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Jacob Bagi Nordsten
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria Mathilde Haugaard
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Line Iadsatian Christiansen
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Thymann
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Torp Sangild
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics, Odense University Hospital, Odense, Denmark
| | - Stanislava Pankratova
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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J A, S S, P W, S W, P B, K M. Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives. Semin Perinatol 2024; 48:151904. [PMID: 38688744 DOI: 10.1053/j.semperi.2024.151904] [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: 05/02/2024]
Abstract
Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.
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Affiliation(s)
- Afifi J
- Department of Pediatrics, Neonatal-Perinatal Medicine, Dalhousie University, 5980 University Avenue, Halifax B3K6R8, Nova Scotia, Canada.
| | - Shivananda S
- Department of Pediatrics, Neonatal-Perinatal Medicine, University of British Columbia, Canada
| | - Wintermark P
- Department of Pediatrics, Neonatal-Perinatal Medicine, McGill University, Canada
| | - Wood S
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Brain P
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Mohammad K
- Department of Pediatrics, Section of Newborn Intensive Care, University of Calgary, Canada
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Kumar J, Anne RP, Meena J, Sundaram V, Dutta S, Kumar P. To feed or not to feed during therapeutic hypothermia in asphyxiated neonates: a systematic review and meta-analysis. Eur J Pediatr 2023:10.1007/s00431-023-04950-0. [PMID: 37014443 DOI: 10.1007/s00431-023-04950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/05/2023]
Abstract
The practice of withholding feed during therapeutic hypothermia (TH) in neonates with hypoxemic ischemic encephalopathy (HIE) is based on conventions rather than evidence. Recent studies suggest that enteral feeding might be safe during TH. We systematically compared the benefits and harms of enteral feeding in infants undergoing TH for HIE. We searched electronic databases and trial registries (MEDLINE, CINAHL, Embase, Web of Science, and CENTRAL) until December 15, 2022, for studies comparing enteral feeding and non-feeding strategies. We performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was the incidence of stage II/III necrotizing enterocolitis (NEC). Other outcomes included the incidence of any stage NEC, mortality, sepsis, feed intolerance, time to full enteral feeds, and hospital stay. Six studies ((two randomized controlled trials (RCTs) and four nonrandomized studies of intervention (NRSIs)) enrolling 3693 participants were included. The overall incidence of stage II/III NEC was very low (0.6%). There was no significant difference in the incidence of stage II/III NEC in RCTs (2 trials, 192 participants; RR, 1.20; 95% CI: 0.53 to 2.71, I2, 0%) and NRSIs (3 studies, no events in either group). In the NRSIs, infants in the enteral feeding group had significantly lower sepsis rates (four studies, 3500 participants, RR, 0.59; 95% CI: 0.51 to 0.67, I2-0%) and lower all-cause mortality (three studies, 3465 participants, RR: 0.43; 95% CI: 0.33 to 0.57, I2-0%) than the infants in the "no feeding" group. However, no significant difference in mortality was observed in RCTs (RR: 0.70; 95% CI: 0.28 to 1.74, I2-0%). Infants in the enteral feeding group achieved full enteral feeding earlier, had higher breastfeeding rates at discharge, received parenteral nutrition for a shorter duration, and had shorter hospital stays than the control group. Conclusion: In late preterm and term infants with HIE, enteral feeding appears safe and feasible during the cooling phase of TH. However, there is insufficient evidence to guide the timing of initiation, volume, and feed advancement. What is Known: • Many neonatal units withhold enteral feeding during therapeutic hypothermia, fearing an increased risk of complications (feed intolerance and necrotizing enterocolitis). • The overall risk of necrotizing enterocolitis in late-preterm and term infants is extremely low (< 1%). What is New: • Enteral feeding during therapeutic hypothermia is safe and does not increase the risk of necrotizing enterocolitis, hypoglycemia, or feed intolerance. It may reduce the incidence of sepsis and all-cause mortality until discharge.
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Affiliation(s)
- Jogender Kumar
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajendra Prasad Anne
- Department of Pediatrics, All India Institute of Medical Sciences, Bibi Nagar, Telangana, India
| | - Jitendra Meena
- Department of Pediatrics, All India Institute of Medical Science, Jodhpur, Rajasthan, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Department of Pediatrics, Neonatal Unit, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Alene T, Feleke MG, Yeshambel A, Amare AT, Tigabu A, Birlie TA, Aynalem YA, Kerebeh G, Eshetu K, Tsega TD, Wassihun B, Adella GA, Chichiabellu TY. Time to occurrence of necrotizing enterocolitis and its predictors among low birth weight neonates admitted at neonatal intensive care unit of felege hiwot compressive specialized hospital BahirDar, Ethiopia, 2021: A retrospective follow-up study. Front Pediatr 2022; 10:959631. [PMID: 36172392 PMCID: PMC9512154 DOI: 10.3389/fped.2022.959631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/22/2022] [Indexed: 11/15/2022] Open
Abstract
Background Globally, the incidence of necrotizing enterocolitis (NEC) varies between 6 and 15% of all neonates admitted to the neonatal intensive care unit (NICU). Though necrotizing enterocolitis is a multifactorial and life-threatening disease, low birth prematurity is the single cause. Therefore, determining the time to presentation and its predictors of necrotizing enterocolitis were the main goals of this investigation. Materials and methods An institution-based retrospective follow-up study was conducted among 747 low birth weight (LBW) neonates admitted to the neonatal intensive care unit of Felege Hiwot comprehensive specialized Hospital from 1 January 2017 to 30 December 2019. The sample size was calculated by using the STATA package. Data were entered into Epi data version 3.1 and exported to STATA version 14 for analysis. The log-rank test and the Kaplan-Meier estimator were used to display the survival probability and differences between groups. At a significance threshold of 5%, Cox proportional hazard regression was performed to determine the net independent predictors of necrotizing enterocolitis. Result The overall incidence rate was 0.86 per 1,000 person-days (95% CI: 0.67, 1.14) with a 6.8% (95% i: 5.2, 8.9) proportion of necrotizing enterocolitis among low birth weight neonates. Preeclampsia [adjusted hazard ratio (AHR);1.92 (95% CI: 1.03-3.58)], premature rapture of membrane [AHR; 2.36 (95%, CI: 1.19-4.69)], perinatal asphyxia [AHR; 4.05 (95%, CI: 2.04-8.60)], gestational age between 28 and 32 weeks [AHR; 3.59 (95% CI: 1.01-8.83)], and birth weigh less than 1,000 g [AHR; 5.45 (95% CI: 3.84-9.12) were the independent predictors of necrotizing enterocolitis. Conclusion Within the first 1-7 days of a newborn's life, necrotizing enterocolitis was most common. It was discovered that preeclampsia, premature rupture of membrane, perinatal asphyxia, gestational age of 28-32 weeks, and birth weight less than 1,000 g were predictors of its occurrence.
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Affiliation(s)
- Tamiru Alene
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Science, Injibara University, Injibara, Ethiopia
| | - Mulualem Gete Feleke
- Department of Generic Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Addisu Yeshambel
- Department of Midwifery, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | | | - Agimasie Tigabu
- Department of Adult Health Nursing, Debre Tabor University, Debra Tabor, Ethiopia
| | | | - Yared Asmare Aynalem
- Department of Pediatrics and Child Health Nursing, Debre Berhan University, Debre Berhan, Ethiopia
| | - Gashaw Kerebeh
- Department of Pediatrics and Child Health Nursing, College of Health Science, Debre Tabor University, Debra Tabor, Ethiopia
| | - Kirubel Eshetu
- Department of Generic Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
| | - Tilahun Degu Tsega
- Department of Epidemiology, College of Medicine and Health Science, Injibara University, Injibara, Ethiopia
| | - Biresaw Wassihun
- Department of Midwifery, College of Medicine and Health Science, Injibara University, Injibara, Ethiopia
| | - Getachew Asmare Adella
- Department of Reproductive Health, School of Public Health, Wolaita Sodo University, Sodo, Ethiopia
| | - Tesfaye Yitna Chichiabellu
- Department of Generic Nursing, College of Health Science and Medicine, Wolaita Sodo University, Sodo, Ethiopia
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Hu Y, Chen F, Xiang X, Wang F, Hua Z, Wei H. Early versus delayed enteral nutrition for neonatal hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: a randomized controlled trial. Ital J Pediatr 2022; 48:146. [PMID: 35971138 PMCID: PMC9380332 DOI: 10.1186/s13052-022-01342-2] [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: 01/25/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background The practice of therapeutic hypothermia (TH) is widely used for neonatal hypoxic-ischemic encephalopathy (HIE) despite its corresponding feeding strategies are still controversial. This randomized controlled trial (RCT) demonstrated to evaluate the effect of early vs. delayed enteral nutrition on the incidence of feeding intolerance (FI) and other association during TH. Methods This single center, parallel-group, and no-blinded RCT was processed in a level III, and academic neonatal intensive care unit. Infants who were diagnosed with HIE and undertaken TH from September 2020 to August 2021 were enrolled. Participants were randomized to receive enteral nutrition either during TH/rewarming (early enteral nutrition, EEN) or after TH (delayed enteral nutrition, DEN) according to a recommend enteral feeding protocol. All data were analyzed using SPSS 26.0 software with a p-value< 0.05 was considered statistically significant. Results Ninety-two infants were enrolled after randomization, but 12 (13.04%) cases including 3 (3.26%) deaths were excluded from eventually analyzed, who did not initiate or discontinue the intervention. 80 cases (42 and 38 in the EEN and DEN group, respectively) who completed the interventions were eventually analyzed. Besides initial time of enteral feeds, two groups had processed the same feeding method. Total 23 (25.0%) cases developed FI, and no difference of morbidity was found between two groups (23.4% vs 26.7%, p = 0.595; Log Rank, p = 0.803). There was no case died or developed late-onset bloodstream and no difference of the incidence of hypoglycemia or weight gain was found (p > 0.05). The percentage of infants who had not reaching the goal of full enteral feeding volume between the two groups was similar (21.43% vs 23.68%, p = 0.809). The average time of parenteral nutrition, reaching full enteral feeds and hospital stay were shorter in the EEN group compared with the DEN group with significant differences (8.81 ± 1.67 vs 10.61 ± 2.06 days, p < 0.001; 9.91 ± 1.88 vs 12.24 ± 2.50 days, p < 0.001; 12.55 ± 4.57 vs 16.47 ± 5.27 days, p = 0.001 respectively). Conclusions Compared with delayed enteral nutrition, introduction of early enteral nutrition according to a recommend feeding strategy for neonatal HIE undergoing TH may be feasible and safe.FI is frequent in this high-risk group of infants which should not be ignored during feeding process. Trial registration The Chinese Clinical Trial Registry,ChiCTR2000038193, 2020-9-13, https://www.chictr.org.cn.
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Affiliation(s)
- Ya Hu
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China
| | - Xinyu Xiang
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China
| | - Fang Wang
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China
| | - Ziyu Hua
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hong Wei
- Department of Neonatology, Children's Hospital of Chongqing Medical University (The institution is also validated by Ringgold as 'Chongqing Medical University Affiliated Children's Hospital'), Chongqing, China. .,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China. .,National Clinical Research Center for Child Health and Disorders, Chongqing, China. .,China International Science and Technology Cooperation base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Wintermark P, Mohammad K, Bonifacio SL. Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101303. [PMID: 34711527 DOI: 10.1016/j.siny.2021.101303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.
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Affiliation(s)
- Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, T3B 6A8, Calgary, AB, Canada.
| | - Sonia L Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, 94304, Palo Alto, CA, USA.
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- Newborn Brain Society, PO Box 200783, Roxbury Crossing, 02120, MA, USA
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