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Garegrat R, Londhe A, Manerkar S, Fattepur S, Deshmukh L, Joshi A, Chandriah S, Kariyappa M, Devadas S, Ethirajan T, Srivasan K, Kamalarathnam C, Balachandran A, Krishnan E, Sahayaraj D, Bandiya P, Shivanna N, Burgod C, Thayyil A, Alocious A, Lanza M, Muraleedharan P, Pant S, Venkateswaran H, Morales MM, Montaldo P, Krishnan V, Kalathingal T, Joshi AR, Vare A, Patil GC, Satyanathan BP, Hapat P, Deshmukh A, Shivarudhrappa I, Annayappa MK, Baburaj M, Muradi C, Fernandes E, Thale N, Jahan I, Shahidullah M, Choudhury SM, Dey SK, Neogi SB, Banerjee R, Rameh V, Alobeidi F, Grant E, Juul SE, Wilson M, Vita ED, Pressler R, Bassett P, Shankaran S, Thayyil S. Early and extended erythropoietin monotherapy after hypoxic ischaemic encephalopathy: a multicentre double-blind pilot randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327107. [PMID: 38729748 DOI: 10.1136/archdischild-2024-327107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/04/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To examine the feasibility of early and extended erythropoietin monotherapy after hypoxic ischaemic encephalopathy (HIE). DESIGN Double-blind pilot randomised controlled trial. SETTING Eight neonatal units in South Asia. PATIENTS Neonates (≥36 weeks) with moderate or severe HIE admitted between 31 December 2022 and 3 May 2023. INTERVENTIONS Erythropoietin (500 U/kg daily) or to the placebo (sham injections using a screen) within 6 hours of birth and continued for 9 days. MRI at 2 weeks of age. MAIN OUTCOMES AND MEASURES Feasibility of randomisation, drug administration and assessment of brain injury using MRI. RESULTS Of the 154 neonates screened, 56 were eligible; 6 declined consent and 50 were recruited; 43 (86%) were inborn. Mean (SD) age at first dose was 4.4 (1.2) hours in erythropoietin and 4.1 (1.0) hours in placebo. Overall mortality at hospital discharge occurred in 5 (19%) vs 11 (46%) (p=0.06), and 3 (13%) vs 9 (40.9%) (p=0.04) among those with moderate encephalopathy in the erythropoietin and placebo groups. Moderate or severe injury to basal ganglia, white matter and cortex occurred in 5 (25%) vs 5 (38.5%); 14 (70%) vs 11 (85%); and 6 (30%) vs 2 (15.4%) in the erythropoietin and placebo group, respectively. Sinus venous thrombosis was seen in two (10%) neonates in the erythropoietin group and none in the control group. CONCLUSIONS Brain injury and mortality after moderate or severe HIE are high in South Asia. Evaluation of erythropoietin monotherapy using MRI to examine treatment effects is feasible in these settings. TRIAL REGISTRATION NUMBER NCT05395195.
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Affiliation(s)
- Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Atul Londhe
- Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - Swati Manerkar
- Neonatology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | | | - Laxmikant Deshmukh
- Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - Amol Joshi
- Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | | | - Mallesh Kariyappa
- Pediatrics, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
| | - Sahana Devadas
- Pediatrics, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India
| | | | | | | | | | | | | | - Prathik Bandiya
- Neonatology, Indira Gandhi Institute of Child Health, Bangalore, India
| | - Niranjan Shivanna
- Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Annie Alocious
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Marianna Lanza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Pallavi Muraleedharan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Maria Moreno Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Thaslima Kalathingal
- Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Anagha Rajeev Joshi
- Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Ajay Vare
- Government Medical College and Hospital Aurangabad, Aurangabad, Maharashtra, India
| | - G C Patil
- Karnataka Institute of Medical Sciences Hubballi, Hubli, Karnataka, India
| | | | - Pavan Hapat
- Perinatal Brain Research Centre, Hisar, India
| | | | | | | | | | | | | | | | - Ismat Jahan
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Dhaka District, Bangladesh
| | | | | | - Sanjoy Kumer Dey
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Dhaka District, Bangladesh
| | - Sutapa B Neogi
- International Institute of Health Management Research-New Delhi, New Delhi, Delhi, India
| | - Rupsa Banerjee
- International Institute of Health Management Research-New Delhi, New Delhi, Delhi, India
| | - Vanessa Rameh
- Medicine and Radiology, Harvard University, Cambridge, Massachusetts, USA
| | | | - Ellen Grant
- Medicine and Radiology, Harvard University, Cambridge, Massachusetts, USA
| | | | | | - Enrico De Vita
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Seetha Shankaran
- Pediatrics/Neonatology, University of Texas at Austin Dell Seton Medical Center, Austin, Texas, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
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Montaldo P, Cirillo M, Burgod C, Caredda E, Ascione S, Carpentieri M, Puzone S, D'Amico A, Garegrat R, Lanza M, Moreno Morales M, Atreja G, Shivamurthappa V, Kariholu U, Aladangady N, Fleming P, Mathews A, Palanisami B, Windrow J, Harvey K, Soe A, Pattnayak S, Sashikumar P, Harigopal S, Pressler R, Wilson M, De Vita E, Shankaran S, Thayyil S. Whole-Body Hypothermia vs Targeted Normothermia for Neonates With Mild Encephalopathy: A Multicenter Pilot Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249119. [PMID: 38709535 DOI: 10.1001/jamanetworkopen.2024.9119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Importance Although whole-body hypothermia is widely used after mild neonatal hypoxic-ischemic encephalopathy (HIE), safety and efficacy have not been evaluated in randomized clinical trials (RCTs), to our knowledge. Objective To examine the effect of 48 and 72 hours of whole-body hypothermia after mild HIE on cerebral magnetic resonance (MR) biomarkers. Design, Setting, and Participants This open-label, 3-arm RCT was conducted between October 31, 2019, and April 28, 2023, with masked outcome analysis. Participants were neonates at 6 tertiary neonatal intensive care units in the UK and Italy born at or after 36 weeks' gestation with severe birth acidosis, requiring continued resuscitation, or with an Apgar score less than 6 at 10 minutes after birth and with evidence of mild HIE on modified Sarnat staging. Statistical analysis was per intention to treat. Interventions Random allocation to 1 of 3 groups (1:1:1) based on age: neonates younger than 6 hours were randomized to normothermia or 72-hour hypothermia (33.5 °C), and those 6 hours or older and already receiving whole-body hypothermia were randomized to rewarming after 48 or 72 hours of hypothermia. Main Outcomes and Measures Thalamic N-acetyl aspartate (NAA) concentration (mmol/kg wet weight), assessed by cerebral MR imaging and thalamic spectroscopy between 4 and 7 days after birth using harmonized sequences. Results Of 225 eligible neonates, 101 were recruited (54 males [53.5%]); 48 (47.5%) were younger than 6 hours and 53 (52.5%) were 6 hours or older at randomization. Mean (SD) gestational age and birth weight were 39.5 (1.1) weeks and 3378 (380) grams in the normothermia group (n = 34), 38.7 (0.5) weeks and 3017 (338) grams in the 48-hour hypothermia group (n = 31), and 39.0 (1.1) weeks and 3293 (252) grams in the 72-hour hypothermia group (n = 36). More neonates in the 48-hour (14 of 31 [45.2%]) and 72-hour (13 of 36 [36.1%]) groups required intubation at birth than in the normothermic group (3 of 34 [8.8%]). Ninety-nine neonates (98.0%) had MR imaging data and 87 (86.1%), NAA data. Injury scores on conventional MR biomarkers were similar across groups. The mean (SD) NAA level in the normothermia group was 10.98 (0.92) mmol/kg wet weight vs 8.36 (1.23) mmol/kg wet weight (mean difference [MD], -2.62 [95% CI, -3.34 to -1.89] mmol/kg wet weight) in the 48-hour and 9.02 (1.79) mmol/kg wet weight (MD, -1.96 [95% CI, -2.66 to -1.26] mmol/kg wet weight) in the 72-hour hypothermia group. Seizures occurred beyond 6 hours after birth in 4 neonates: 1 (2.9%) in the normothermia group, 1 (3.2%) in the 48-hour hypothermia group, and 2 (5.6%) in the 72-hour hypothermia group. Conclusions and Relevance In this pilot RCT, whole-body hypothermia did not improve cerebral MR biomarkers after mild HIE, although neonates in the hypothermia groups were sicker at baseline. Safety and efficacy of whole-body hypothermia should be evaluated in RCTs. Trial Registration ClinicalTrials.gov Identifier: NCT03409770.
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Mario Cirillo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Elisabetta Caredda
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Serena Ascione
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Mauro Carpentieri
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Simona Puzone
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Marianna Lanza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Maria Moreno Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Gaurav Atreja
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | | | - Ujwal Kariholu
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | - Narendra Aladangady
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Paul Fleming
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Asha Mathews
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | | | - Joanne Windrow
- Liverpool Women's NHS Foundation Trust, Liverpool, United Kingdom
| | - Karen Harvey
- Liverpool Women's NHS Foundation Trust, Liverpool, United Kingdom
| | - Aung Soe
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Santosh Pattnayak
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Palaniappan Sashikumar
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Sundeep Harigopal
- Neonatal Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, United Kingdom
| | - Martin Wilson
- Centre for Human Brain Health and School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Enrico De Vita
- MRI Physics, Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
- Department of Pediatrics, The University of Texas at Austin, Dell Children's Hospital, Austin, Texas
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
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Chawla S, Laptook AR, Smith EA, Tan S, Natarajan G, Wyckoff MH, Greenberg RG, Ambalavanan N, Bell EF, Van Meurs KP, Hintz SR, Vohr BR, Werner EF, Das A, Shankaran S. Association of maternal pre-pregnancy or first trimester body mass index with neurodevelopmental impairment or death in extremely low gestational age neonates. J Perinatol 2024:10.1038/s41372-024-01905-7. [PMID: 38396053 DOI: 10.1038/s41372-024-01905-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE To compare the rates of death or survival with severe neurodevelopmental impairment (sNDI) at 2 years among extremely preterm infants in relation to pre-pregnancy or first-trimester maternal body mass index (BMI). METHODS This retrospective cohort study included extremely preterm infants (gestational age 220/7-266/7 weeks). The study was conducted at National Institute of Child Health and Human Development Neonatal Research Network sites. The primary outcome was death or sNDI at 2 years. RESULTS Data on the primary outcome were available for 1208 children. Death or sNDI was not different among the three groups: 54.9% in normal, 56.1% in overweight, and 53.4% in obese group (p = 0.39). There was no significant difference in mortality, sNDI, moderate/severe cerebral palsy, Bayley Scales of Infant Development (BSID)-III cognitive composite score <70, BSID-III language composite score <70 in adjusted models. CONCLUSION Neurodevelopmental outcome was not significantly associated with maternal pre-pregnancy BMI among extreme preterm infants.
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Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Girija Natarajan
- Department of Pediatrics, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Myra H Wyckoff
- Department of Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | | | | | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Betty R Vohr
- Department of Pediatrics, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Erika F Werner
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA, USA
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MA, USA
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4
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Montaldo P, Burgod C, Herberg JA, Kaforou M, Cunnington AJ, Mejias A, Cirillo G, Miraglia Del Giudice E, Capristo C, Bandiya P, Kamalaratnam CN, Chandramohan R, Manerkar S, Rodrigo R, Sumanasena S, Krishnan V, Pant S, Shankaran S, Thayyil S. Whole-Blood Gene Expression Profile After Hypoxic-Ischemic Encephalopathy. JAMA Netw Open 2024; 7:e2354433. [PMID: 38306098 PMCID: PMC10837749 DOI: 10.1001/jamanetworkopen.2023.54433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024] Open
Abstract
Importance Induced hypothermia, the standard treatment for hypoxic-ischemic encephalopathy (HIE) in high-income countries (HICs), is less effective in the low-income populations in South Asia, who have the highest disease burden. Objective To investigate the differences in blood genome expression profiles of neonates with HIE from an HIC vs neonates with HIE from South Asia. Design, Setting, and Participants This case-control study analyzed data from (1) a prospective observational study involving neonates with moderate or severe HIE who underwent whole-body hypothermia between January 2017 and June 2019 and age-matched term healthy controls in Italy and (2) a randomized clinical trial involving neonates with moderate or severe HIE in India, Sri Lanka, and Bangladesh recruited between August 2015 and February 2019. Data were analyzed between October 2020 and August 2023. Exposure Whole-blood RNA that underwent next-generation sequencing. Main Outcome and Measures The primary outcomes were whole-blood genome expression profile at birth associated with adverse outcome (death or disability at 18 months) after HIE in the HIC and South Asia cohorts and changes in whole-genome expression profile during the first 72 hours after birth in neonates with HIE and healthy controls from the HIC cohort. Blood samples for RNA extraction were collected before whole-body hypothermia at 4 time points (6, 24, 48, and 72 hours after birth) for the HIC cohort. Only 1 blood sample was drawn within 6 hours after birth for the South Asia cohort. Results The HIC cohort was composed of 35 neonates (21 females [60.0%]) with a median (IQR) birth weight of 3.3 (3.0-3.6) kg and gestational age of 40.0 (39.0-40.6) weeks. The South Asia cohort consisted of 99 neonates (57 males [57.6%]) with a median (IQR) birth weight of 2.9 (2.7-3.3) kg and gestational age of 39.0 (38.0-40.0) weeks. Healthy controls included 14 neonates (9 females [64.3%]) with a median (IQR) birth weight of 3.4 (3.2-3.7) kg and gestational age of 39.2 (38.9-40.4) weeks. A total of 1793 significant genes in the HIC cohort and 99 significant genes in the South Asia cohort were associated with adverse outcome (false discovery rate <0.05). Only 11 of these genes were in common, and all had opposite direction in fold change. The most significant pathways associated with adverse outcome were downregulation of eukaryotic translation initiation factor 2 signaling in the HIC cohort (z score = -4.56; P < .001) and aldosterone signaling in epithelial cells in the South Asia cohort (z score = null; P < .001). The genome expression profile of neonates with HIE (n = 35) at birth, 24 hours, 48 hours, and 72 hours remained significantly different from that of age-matched healthy controls in the HIC cohort (n = 14). Conclusions and Relevance This case-control study found that disease mechanisms underlying HIE were primarily associated with acute hypoxia in the HIC cohort and nonacute hypoxia in the South Asia cohort. This finding might explain the lack of hypothermic neuroprotection.
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Women's and Children's Health and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Jethro A. Herberg
- Section of Paediatric Infectious Disease and Centre for Paediatrics and Child Health, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Myrsini Kaforou
- Section of Paediatric Infectious Disease and Centre for Paediatrics and Child Health, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Aubrey J. Cunnington
- Section of Paediatric Infectious Disease and Centre for Paediatrics and Child Health, Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Asuncion Mejias
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
- Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
| | - Grazia Cirillo
- Department of Women's and Children's Health and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Emanuele Miraglia Del Giudice
- Department of Women's and Children's Health and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlo Capristo
- Department of Women's and Children's Health and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | | | - Rema Chandramohan
- Institute of Child Health, Department of Neonatology, Madras Medical College, Chennai, India
| | - Swati Manerkar
- Department of Neonatology, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ranmali Rodrigo
- Department of Pediatrics, University of Kelaniya, Colombo, Sri Lanka
| | | | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
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5
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Burgod C, Mazlan M, Pant S, Krishnan V, Garegrat R, Montaldo P, Muraleedharan P, Bandiya P, Kamalaratnam CN, Chandramohan R, Manerkar S, Jahan I, Moni SC, Shahidullah M, Rodrigo R, Sumanasena S, Sujatha R, Sathyanathan BP, Joshi AR, Pressler RR, Bassett P, Shankaran S, Thayyil S. Duration of birth depression and neurodevelopmental outcomes after whole-body hypothermia for hypoxic ischemic encephalopathy in India, Sri Lanka and Bangladesh - an exploratory analysis of the HELIX trial. Lancet Reg Health Southeast Asia 2024; 20:100284. [PMID: 38234698 PMCID: PMC10794099 DOI: 10.1016/j.lansea.2023.100284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 01/19/2024]
Abstract
Background Effect of duration of birth depression on neurodevelopmental outcomes in low- and middle-income countries (LMICs) is not known. We examined the association of birth depression with brain injury, neurodevelopmental outcomes, and hypothermia after hypoxic ischemic encephalopathy (HIE) in south Asia. Methods We compared cerebral magnetic resonance (MR) at 2 weeks, and adverse outcomes (death or moderate or severe disability) at 18 months in 408 babies with moderate or severe HIE who had long birth depression (positive pressure ventilation (PPV) >10 min or Apgar score<6 at 10 min or cord pH < 7.0) and short birth depression (PPV for 5-10 min or Apgar score<6 at 5 min, but ≥6 at 10 min). Findings Long depression group (n = 201) had more severe HIE (32.8% versus 6.8%), mortality (47.5% versus 26.4%), death or disability at 18 months (62.2% versus 35.4%) (all p < 0.001), MR injury (Odds ratio; 95% CI) to basal ganglia (2.4 (1.3, 4.1); p = 0.003), posterior limb of internal capsule (2.3 (1.3, 4.3); p < 0.001) and white matter (1.7 (1.1, 2.7); p = 0.021), and lower thalamic N-acetylaspartate levels (7.69 ± 1.84 versus 8.29 ± 1.60); p = 0.031) than short depression group (n = 207). Three babies had no heartbeat at 5 min, of which 1 died and 2 survived with severe disability. No significant interaction between the duration of birth depression and whole-body hypothermia was seen for any of the MR biomarker or clinical outcomes. Interpretation Long birth depression was associated with more brain injury and adverse outcomes than short depression. Effect of hypothermia was not modified by duration of birth depression. Funding National Institute for Health Research.
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Affiliation(s)
- Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Munirah Mazlan
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Reema Garegrat
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Prathik Bandiya
- Neonatal Unit, Indira Gandhi Institute of Child Health, Bangalore, India
| | | | | | - Swati Manerkar
- Neonatal Unit and Radiology, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ismat Jahan
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Bangladesh
| | - Sadeka C. Moni
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Bangladesh
| | | | | | | | - Radhika Sujatha
- Neonatal Unit, Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, India
| | | | - Anagha R. Joshi
- Neonatal Unit and Radiology, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ronit R. Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, United Kingdom
| | | | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
- University of Texas at Austin, Dell Children's Hospital, Austin, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
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Lowe J, Bann CM, Dempsey AG, Fuller J, Taylor HG, Gustafson KE, Watson VE, Vohr BR, Das A, Shankaran S, Yolton K, Ball MB, Hintz SR. Do Bayley-III Composite Scores at 18-22 Months Corrected Age Predict Full-Scale IQ at 6-7 Years in Children Born Extremely Preterm? J Pediatr 2023; 263:113700. [PMID: 37640232 PMCID: PMC10840976 DOI: 10.1016/j.jpeds.2023.113700] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/31/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To determine the ability of the Bayley-III cognitive and language composite scores at 18-22 months corrected age to predict WISC-IV Full Scale IQ (FSIQ) at 6-7 years in infants born extremely preterm. STUDY DESIGN Children in this study were part of the Neuroimaging and Neurodevelopmental Outcome cohort, a secondary study to the SUPPORT trial and born 240/7-276/7 weeks gestational age. Bayley-III cognitive and language scores and WISC-IV FSIQ were compared with pairwise Pearson correlation coefficients and adjusted for medical and socioeconomic variables using linear mixed effect regression models. RESULTS Bayley-III cognitive (r = 0.33) and language scores (r = 0.44) were mildly correlated with WISC-IV FSIQ score. Of the children with Bayley-III cognitive scores of <70, 67% also had FSIQ of <70. There was less consistency for children with Bayley-III scores in the 85-100 range; 43% had an FSIQ of <85 and 10% an FSIQ of <70. Among those with Bayley-III language scores >100, approximately 1 in 5 had an FSIQ of <85. A cut point of 92 for the cognitive composite score resulted in sensitivity (0.60), specificity (0.64). A cut point of 88 for the language composite score produced sensitivity (0.61), specificity (0.70). CONCLUSIONS Findings indicate the Bayley-III cognitive and language scores correlate with later IQ, but may fail to predict delay or misclassify children who are not delayed at school age. The Bayley-III can be a useful tool to help identify children born extremely preterm who have below average cognitive scores and may be at the greatest risk for ongoing cognitive difficulties. TRIAL REGISTRATION Extended Follow-up at School Age for the SUPPORT Neuroimaging and Neurodevelopmental Outcomes (NEURO) Cohort: NCT00233324.
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Affiliation(s)
- Jean Lowe
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Carla M Bann
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Allison G Dempsey
- Department of Psychiatry, University of Colorado School of Medicine, University of Colorado Hospital, Denver, CO
| | - Janell Fuller
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM.
| | - H Gerry Taylor
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, OH
| | - Kathryn E Gustafson
- Department of Pediatrics, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | | | - Betty R Vohr
- Department of Pediatrics, Duke University, Durham, NC
| | - Abhik Das
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Seetha Shankaran
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Kimberly Yolton
- Department of Pediatrics, Wayne State University, Detroit, MI
| | - M Bethany Ball
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
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Bahr TM, Tan S, Smith E, Beauman SS, Schibler KR, Grisby CA, Lowe JR, Bell EF, Laptook AR, Shankaran S, Carlton DP, Rau C, Baserga MC, Flibotte J, Zaterka-Baxter K, Walsh MC, Das A, Christensen RD, Ohls RK. Serum ferritin values in neonates <29 weeks' gestation are highly variable and do not correlate with reticulocyte hemoglobin content. J Perinatol 2023; 43:1368-1373. [PMID: 37596391 PMCID: PMC10825191 DOI: 10.1038/s41372-023-01751-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/23/2023] [Accepted: 08/07/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVES To compare serum ferritin and RET-He values among extremely low gestational age neonates ELGANs with other markers of iron-deficient erythropoiesis. STUDY DESIGN This is a secondary analysis of the NICHD Darbepoetin Trial. Study data from placebo recipients who had a serum ferritin, a RET-He, and a mean corpuscular volume (MCV) measurement within a 24-hour period were analyzed for correlation. RESULTS Mixed linear regression models showed no association between ferritin and RET-He at both early (β = 0.0016, p = 0.40) and late (β = -0.0001, p = 0.96) time points. Positive associations were observed between RET-He and MCV at baseline, early, and late time points (p < 0.01, =0.01, <0.001, respectively), while ferritin was not associated with MCV at any time point. CONCLUSIONS Our study shows that RET-He is better correlated with MCV as a marker of iron-limited erythropoiesis than ferritin. The results suggest that ferritin is limited as a marker of iron sufficiency in premature infants. STUDY IDENTIFICATION FDA IND Number 100138; ClinicalTrials.gov number NCT03169881; NRN ID number NICHD-NRN-0058 (Darbe).
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA.
- Department of Neonatology, Intermountain Healthcare, Murray, UT, USA.
| | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Washington, DC, USA
| | - Emily Smith
- Social, Statistical and Environmental Sciences Unit, RTI International, Washington, DC, USA
| | - Sandra S Beauman
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Kurt R Schibler
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Cathy A Grisby
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jean R Lowe
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Brown University, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - David P Carlton
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Carrie Rau
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - Mariana C Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
| | - John Flibotte
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin Zaterka-Baxter
- Social, Statistical and Environmental Sciences Unit, RTI International, Washington, DC, USA
| | - Michele C Walsh
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Washington, DC, USA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
- Department of Neonatology, Intermountain Healthcare, Murray, UT, USA
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT, USA
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Sewell EK, Shankaran S, Natarajan G, Laptook A, Das A, McDonald SA, Hamrick S, Baack M, Rysavy M, Higgins RD, Chalak L, Patel RM. Evaluation of heterogeneity in effect of therapeutic hypothermia by sex among infants with neonatal encephalopathy. Pediatr Res 2023; 94:1380-1384. [PMID: 37012412 PMCID: PMC10843889 DOI: 10.1038/s41390-023-02586-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Our objective was to examine heterogeneity in the effect of therapeutic hypothermia by sex in infants with moderate or severe neonatal encephalopathy. METHODS We conducted a post hoc analysis of the Induced Hypothermia trial, which included infants born at gestational ages ≥36 weeks, admitted at ≤6 postnatal hours with evidence of severe acidosis or perinatal complications and moderate or severe neonatal encephalopathy. Multivariate modified Poisson regression models were used to compare the treatment effect of whole-body hypothermia versus control, with an evaluation of interaction by sex, on the primary outcome of death or moderate or severe disability at 18-22 months of corrected age. RESULTS A total of 101 infants (51 male, 50 female) were randomly assigned to hypothermia treatment and 104 infants (64 male, 40 female) to control. The primary outcome occurred in 45% of the hypothermia group and 63% of the control group (RR 0.73; 95% CI 0.56, 0.94). There was no significant difference (interaction P = 0.50) in the treatment effect of hypothermia on the primary outcome between females (RR 0.79; 95% CI 0.54, 1.17) compared to males (RR 0.63; 95% CI 0.44, 0.91). CONCLUSION We found no evidence that sex influences the treatment effect of hypothermia in infants with moderate or severe neonatal encephalopathy. IMPACT Preclinical evidence suggests a differential effect in response to cooling treatment of hypoxic-ischemic injury between males and females. We found no evidence of heterogeneity in the treatment effect of whole-body hypothermia by sex in this post hoc subgroup analysis of infants with moderate or severe neonatal encephalopathy from the National Institute of Child Health and Human Development Neonatal Research Network Induced Hypothermia trial.
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Affiliation(s)
- Elizabeth K Sewell
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | | | | | | | - Abhik Das
- RTI International, Rockville, MD, USA
| | | | - Shannon Hamrick
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Michelle Baack
- University of South Dakota - Sanford School of Medicine, Sioux Falls, SD, USA
| | - Matthew Rysavy
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Lina Chalak
- University of Texas Southwestern, Dallas, TX, USA
| | - Ravi Mangal Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
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Sewell EK, Shankaran S, McDonald SA, Hamrick S, Wusthoff CJ, Adams-Chapman I, Chalak LF, Davis AS, Van Meurs K, Das A, Maitre N, Laptook A, Patel RM. Antiseizure medication at discharge in infants with hypoxic-ischaemic encephalopathy: an observational study. Arch Dis Child Fetal Neonatal Ed 2023; 108:421-428. [PMID: 36732048 PMCID: PMC10293046 DOI: 10.1136/archdischild-2022-324612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/06/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess variability in continuation of antiseizure medication (ASM) at discharge and to evaluate if continuation of ASM at discharge is associated with death or disability among infants with hypoxic-ischaemic encephalopathy (HIE) and seizures. DESIGN Retrospective study of infants enrolled in three National Institute of Child Health and Human Development Neonatal Research Network Trials of therapeutic hypothermia. SETTING 22 US centres. PATIENTS Infants with HIE who survived to discharge and had clinical or electrographic seizures treated with ASM. EXPOSURES ASM continued or discontinued at discharge. OUTCOMES Death or moderate-to-severe disability at 18-22 months, using trial definitions. Multivariable logistic regression evaluated the association between continuation of ASM at discharge and the primary outcome, adjusting for severity of HIE, hypothermia trial treatment arm, use of electroencephalogram, discharge on gavage feeds, Apgar Score at 5 min, birth year and centre. RESULTS Of 302 infants included, 61% were continued on ASMs at discharge (range 13%-100% among 22 centres). Electroencephalogram use occurred in 92% of the cohort. Infants with severe HIE comprised 24% and 22% of those discharged with and without ASM, respectively. The risk of death or moderate-to-severe disability was greater for infants continued on ASM at discharge, compared with those infants discharged without ASM (44% vs 28%, adjusted OR 2.14; 95% CI 1.13 to 4.05). CONCLUSIONS In infants with HIE and seizures, continuation of ASM at discharge varies substantially among centres and may be associated with a higher risk of death or disability at 18-22 months of age.
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Affiliation(s)
- Elizabeth K Sewell
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Seetha Shankaran
- Pediatrics Neonatology, Wayne State University Childrens Hospital of MI, Detroit, Michigan, USA
| | | | - Shannon Hamrick
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | | | - Ira Adams-Chapman
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Lina F Chalak
- Pediatrics, UT Southwestern Dallas, dallas, Texas, USA
| | - Alexis S Davis
- Pediatrics, Stanford University, Palo Alto, California, USA
| | - Krisa Van Meurs
- Division of Neonatology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Abhik Das
- RTI International, Rockville, Maryland, USA
| | - Nathalie Maitre
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Abbott Laptook
- Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Ravi Mangal Patel
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
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Thayyil S, Montaldo P, Krishnan V, Ivain P, Pant S, Lally PJ, Bandiya P, Benkappa N, Kamalaratnam CN, Chandramohan R, Manerkar S, Mondkar J, Jahan I, Moni SC, Shahidullah M, Rodrigo R, Sumanasena S, Sujatha R, Burgod C, Garegrat R, Mazlan M, Chettri I, Babu Peter S, Joshi AR, Swamy R, Chong K, Pressler RR, Bassett P, Shankaran S. Whole-Body Hypothermia, Cerebral Magnetic Resonance Biomarkers, and Outcomes in Neonates With Moderate or Severe Hypoxic-Ischemic Encephalopathy Born at Tertiary Care Centers vs Other Facilities: A Nested Study Within a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2312152. [PMID: 37155168 PMCID: PMC10167567 DOI: 10.1001/jamanetworkopen.2023.12152] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Importance The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. Objective To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). Design, Setting, and Participants This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. Exposure 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. Main Outcomes and Measures Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. Results Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). Conclusions and Relevance In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs. Trial Registration ClinicalTrials.gov Identifier: NCT02387385.
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Affiliation(s)
- Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Neonatal Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Prathik Bandiya
- Neonatal Unit, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Naveen Benkappa
- Neonatal Unit, Indira Gandhi Institute of Child Health, Bengaluru, India
| | | | | | - Swati Manerkar
- Neonatal Unit, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Jayshree Mondkar
- Neonatal Unit, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ismat Jahan
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Sadeka C Moni
- Neonatal Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Ranmali Rodrigo
- Department of Pediatrics, University of Kelaniya, Kelaniya, Sri Lanka
| | | | - Radhika Sujatha
- Neonatal Unit, Sree Avittom Thirunal Hospital, Government Medical College, Thiruvananthapuram, India
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Munirah Mazlan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Ismita Chettri
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | | | - Anagha R Joshi
- Department of Radiology, Lokmanya Tilak Municipal Medical College, Mumbai, India
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Kling Chong
- Department of Neuroradiology, Great Ormond Street Hospital, London, United Kingdom
| | - Ronit R Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, United Kingdom
| | | | - Seetha Shankaran
- Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
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Chawla S, Natarajan G, Laptook AR, Chowdhury D, Bell EF, Ambalavanan N, Carlo WA, Gantz M, Das A, Tapia JL, Harmon HM, Shankaran S. Model for severe intracranial hemorrhage and role of early indomethacin in extreme preterm infants. Pediatr Res 2022; 92:1648-1656. [PMID: 35301420 PMCID: PMC9481746 DOI: 10.1038/s41390-022-02012-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND To develop a model for prediction of severe intracranial hemorrhage (ICH) or death based on variables from the first 12 h of age and to compare mortality and morbidities with and without exposure to early indomethacin. METHODS This retrospective cohort study included extreme preterm (220/7-266/7 weeks) infants born at National Institute of Child Health and Human Development Neonatal Research Network sites. Primary outcome was a composite of severe ICH and/or death. RESULTS Of 4624 infants, 1827 received early indomethacin. Lower gestation, lack of antenatal steroids exposure, lower 1-min Apgar, male sex, and receipt of epinephrine were associated with severe ICH or death. Early indomethacin was associated with a lower risk of patent ductus arteriosus, bronchopulmonary dysplasia, and higher risk of spontaneous intestinal perforation. CONCLUSIONS A model for early prediction of severe ICH/death was developed and validated. Early indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of spontaneous intestinal perforation. CLINICAL TRIAL REGISTRATION Not applicable. IMPACT Modern data on severe ICH and neonatal morbidities in relation to prophylactic indomethacin are scarce in the published literature. Prophylactic indomethacin was associated with a lower risk of patent ductus arteriosus and bronchopulmonary dysplasia and a higher risk of intestinal perforation. A risk estimator for severe intracranial hemorrhage/death was developed in a large cohort of extremely preterm infants. The risk estimator developed based on a large cohort of patients provides an estimate of severe intracranial bleeding for an individual infant.
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Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.
- Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
- Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Abbot R Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI, USA
| | - Dhuly Chowdhury
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marie Gantz
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD, USA
| | - Jose L Tapia
- Departamento de Neonatologia, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Heidi M Harmon
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
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12
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Laptook AR, Chalak L, Pappas A, Davis A, Sanchez PJ, Van Meurs KP, Oh W, Sommers R, Shankaran S, Hensman AM, Rouse DJ, McDonald S, Das A, Goldberg RN, Ambalavanan N, Gyamfi-Bannerman C, Thom EA, Higgins RD. The effects of betamethasone on the amplitude integrated EEG of infants born at 34- or 35-weeks gestation. J Perinatol 2022; 42:1615-1621. [PMID: 35618748 PMCID: PMC9699898 DOI: 10.1038/s41372-022-01415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/21/2022] [Accepted: 05/13/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI, USA
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Alexis Davis
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA, USA
| | - Pablo J. Sanchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State College of Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA, USA
| | - William Oh
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI, USA
| | - Ross Sommers
- Neonatology, Wellington Medical Center, Boca Raton, FL, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Angelita M. Hensman
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI, USA
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women and Infants Hospital, Brown University, Providence, RI, USA
| | - Scott McDonald
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle, NC, USA
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD, USA
| | | | | | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Elizabeth A. Thom
- Department of Biostatistics and Bioinformatics, George Washington University, Washington, DC, USA
| | - Rosemary D. Higgins
- Department of Global and Community Health, George Mason University, Fairfax, VA, USA
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Bonifacio SL, Chalak LF, Van Meurs KP, Laptook AR, Shankaran S. Neuroprotection for hypoxic-ischemic encephalopathy: Contributions from the neonatal research network. Semin Perinatol 2022; 46:151639. [PMID: 35835616 DOI: 10.1016/j.semperi.2022.151639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Therapeutic hypothermia (TH) is now well established as the standard of care treatment for moderate to severe neonatal encephalopathy secondary to perinatal hypoxic ischemic encephalopathy (HIE) in infants ≥36 weeks gestation in high income countries. The Neonatal Research Network (NRN) contributed greatly to the study of TH as a neuroprotectant with three trials now completed in infants ≥36 weeks gestation and the only large randomized-controlled trial of TH in preterm infants now in the follow-up phase. Data from the first NRN TH trial combined with data from other large trials of TH affirm the safety and neuroprotective qualities of TH and highlight the importance of providing TH to all infants who qualify. In this review we will highlight the findings of the three NRN trials of TH in the term infant population and the secondary analyses that continue to inform the care of patients with HIE.
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Affiliation(s)
- Sonia Lomeli Bonifacio
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Lina F Chalak
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
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Chawla S, Wyckoff MH, Rysavy MA, Patel RM, Chowdhury D, Natarajan G, Laptook AR, Lakshminrusimha S, Bell EF, Shankaran S, Van Meurs KP, Ambalavanan N, Greenberg RG, Younge N, Werner EF, Das A, Carlo WA. Association of Antenatal Steroid Exposure at 21 to 22 Weeks of Gestation With Neonatal Survival and Survival Without Morbidities. JAMA Netw Open 2022; 5:e2233331. [PMID: 36156145 PMCID: PMC9513645 DOI: 10.1001/jamanetworkopen.2022.33331] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/04/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The provision of antenatal corticosteroids to pregnant patients at gestational age (GA) 22 6/7 weeks or less remains controversial and lacks support from randomized clinical trials. Objective To compare rates of survival and survival without major morbidities among infants born at GA 22 0/7 to 23 6/7 weeks after exposure to antenatal steroids at 22 6/7 weeks' gestation or less vs no exposure to antenatal steroids. Design, Setting, and Participants This cohort study enrolled infants born at GA 22 0/7 to 23 6/7 weeks between January 1, 2016, and December 31, 2019, at centers in the National Institute of Child Health and Human Development Neonatal Research Network. Infants who did not receive intensive care and infants with antenatal steroid exposure after GA 22 6/7 weeks were excluded. Exposure Infants were classified as having no, partial, or complete exposure to antenatal steroids. Main Outcomes and Measures The primary outcome was survival to discharge. The main secondary outcome was survival without major neonatal morbidity. The associations of differential exposures to antenatal steroids with outcomes were evaluated using logistic regression, adjusting for GA, sex, race, maternal education, small for GA status, mode of delivery, multiple birth, prolonged rupture of membranes, year of birth, and Neonatal Research Network center. Results A total of 431 infants (mean [SD] GA, 22.6 [0.5] weeks; 232 [53.8%] boys) were included, with 110 infants (25.5%) receiving no antenatal steroids, 80 infants (18.6%) receiving partial antenatal steroids, and 241 infants (55.9%) receiving complete antenatal steroids. Seventeen infants were exposed to antenatal steroids at GA 21 weeks. Among infants exposed to complete antenatal steroids, 130 (53.9%) survived to discharge, compared with 30 infants (37.5%) with partial antenatal steroid exposure and 239 infants (35.5%) with no antenatal steroids. Infants born after complete antenatal steroid exposure, compared with those without antenatal steroid exposure, were more likely to survive to discharge (adjusted odds ratio [aOR], 1.95 [95% CI, 1.07-3.56]) and to survive without major morbidity (aOR, 2.74 [95% CI, 1.19-6.30]). Conclusions and Relevance In this retrospective cohort study, among infants born between GA 22 0/7 and 23 6/7 weeks who received intensive care, exposure to a complete course of antenatal steroids at GA 22 6/7 weeks or less was independently associated with greater odds of survival and survival without major morbidity. These data suggest that the use of antenatal steroids in patients at GA 22 6/7 weeks or less could be beneficial when active treatment is considered.
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Affiliation(s)
- Sanjay Chawla
- Departments of Pediatrics, Central Michigan University, Wayne State University, Children’s Hospital of Michigan, Detroit
| | - Myra H. Wyckoff
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
| | - Matthew A. Rysavy
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center, Houston
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Girija Natarajan
- Departments of Pediatrics, Central Michigan University, Wayne State University, Children’s Hospital of Michigan, Detroit
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
| | | | | | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | | | - Noelle Younge
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Erika F. Werner
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
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15
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Pappas A, Shankaran S, McDonald SA, Carlo WA, Laptook AR, Tyson JE, Das A, Skogstrand K, Hougaard DM, Higgins RD. Blood Biomarkers and 6- to 7-Year Childhood Outcomes Following Neonatal Encephalopathy. Am J Perinatol 2022; 39:732-749. [PMID: 33038899 PMCID: PMC8765716 DOI: 10.1055/s-0040-1717072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE This study aimed to profile the cytokine/chemokine response from day 0 to 7 in infants (≥36 weeks of gestational age) with neonatal encephalopathy (NE) and to explore the association with long-term outcomes. STUDY DESIGN This was a secondary study of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network randomized controlled trial of whole body hypothermia for NE. Eligible infants with moderate-severe NE were randomized to cooling or normothermia. Blood spots were collected on days 0 to 1, 2 to 4, and 6 to 7. Twenty-four cytokines/chemokines were measured using a multiplex platform. Surviving infants underwent neurodevelopmental assessment at 6 to 7 years. Primary outcome was death or moderate-severe impairment defined by any of the following: intelligence quotient <70, moderate-severe cerebral palsy (CP), blindness, hearing impairment, or epilepsy. RESULTS Cytokine blood spots were collected from 109 participants. In total 99 of 109 (91%) were assessed at 6 to 7 years; 54 of 99 (55%) developed death/impairment. Neonates who died or were impaired had lower early regulated upon activation normal T cell expressed and secreted (RANTES) and higher day 7 monocyte chemotactic protein (MCP)-1 levels than neonates who survived without impairment. Though TNF-α levels had no association with death/impairment, higher day 0 to 1 levels were observed among neonates who died/developed CP. On multiple regression analysis adjusted for center, treatment group, sex, race, and level of hypoxic ischemic encephalopathy, higher RANTES was inversely associated with death/impairment (odds ratio (OR): 0.31, 95% confidence interval [CI]: 0.13-0.74), while day seven MCP-1 level was directly associated with death/impairment (OR: 3.70, 95% CI: 1.42-9.61). Targeted cytokine/chemokine levels demonstrated little variation with hypothermia treatment. CONCLUSION RANTES and MCP-1 levels in the first week of life may provide potential targets for future therapies among neonates with encephalopathy. KEY POINTS · Elevation of specific cytokines and chemokines in neonates with encephalopathy has been noted along with increased risk of neurodevelopmental impairment in infancy.. · Cytokine/chemokines at <7 days were assessed among neonates in a trial of hypothermia for HIE.. · Neonates who died or were impaired at 6 to 7 years following hypoxic-ischemic encephalopathy had lower RANTES and higher MCP-1 levels than those who survived without impairment..
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Affiliation(s)
- Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, MI
| | | | - Scott A. McDonald
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham and Children’s Hospital of Alabama, Birmingham, AL
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infant’s Hospital, Brown University, Providence, RI
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Kristin Skogstrand
- Department for Congenital Disorders, Center for Neonatal Screening, Statens Serum Institut, Copenhagen
| | - David M. Hougaard
- Department for Congenital Disorders, Center for Neonatal Screening, Statens Serum Institut, Copenhagen
| | - Rosemary D. Higgins
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
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Shukla VV, Bann CM, Ramani M, Ambalavanan N, Peralta-Carcelen M, Hintz SR, Higgins RD, Natarajan G, Laptook AR, Shankaran S, Carlo WA. Predictive Ability of 10-Minute Apgar Scores for Mortality and Neurodevelopmental Disability. Pediatrics 2022; 149:185409. [PMID: 35296895 DOI: 10.1542/peds.2021-054992] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To test the hypothesis that an Apgar score at 10 minutes is independently predictive for death or moderate or severe disability. METHODS A secondary analysis of the Optimizing Cooling Trial (NCT01192776) including 347 infants with ≥36 weeks' gestational age at birth and hypoxic-ischemic encephalopathy and 18- to 22-month outcomes from 18 US centers in the National Institute of Child Health and Human Development Neonatal Research Network. The primary outcome was the composite of death or moderate/severe disability at 18 to 22 months of age. Generalized estimating equation models were used to examine the relationship between Apgar scores and outcomes, controlling for center, hypothermia treatment, and severity of hypoxic-ischemic encephalopathy (HIE). Classification and regression tree analyses were conducted to identify combinations of variables available during resuscitation that were most predictive for the composite outcome and death. RESULTS The study revealed that 50% (13 of 26) of infants with a 10-minute Apgar score of 0 survived; 46% (6 of 13) had no disability, 16% (2 of 13) had mild disability, and 38% (5 of 13) had moderate or severe disability. The 10-minute Apgar score of 0 was independently associated with death or moderate or severe disability (adjusted relative risk = 1.72, 95% confidence interval 1.11-2.68, P value = .016), but the area under the curve analysis (AUC) was low (AUC = 0.56). The predictive accuracy improved when the 10-minute Apgar score was combined with other risk variables available during resuscitation by using a classification and regression tree analysis (AUC = 0.66). CONCLUSIONS A 10-minute Apgar score of 0 alone does not predict the risk of death or moderate or severe disability well. The current study provides evidence in support of the 2020 American Heart Association/International Liaison Committee on Resuscitation recommendation for continuing resuscitative efforts for infants who need cardiopulmonary resuscitation at 10 minutes after birth.
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Affiliation(s)
- Vivek V Shukla
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carla M Bann
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Maran Ramani
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Susan R Hintz
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Rosemary D Higgins
- College of Health and Human Services, George Mason University, Fairfax, Virginia
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abbot R Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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17
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Flibotte J, Laptook AR, Shankaran S, McDonald SA, Baserga MC, Bell EF, Cotten CM, Das A, DeMauro SB, DuPont TL, Eichenwald EC, Heyne R, Jensen EA, Van Meurs KP, Dysart K. Blanket temperature during therapeutic hypothermia and outcomes in hypoxic ischemic encephalopathy. J Perinatol 2022; 42:348-353. [PMID: 34999716 PMCID: PMC9121861 DOI: 10.1038/s41372-021-01302-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Determine whether blanket temperatures during therapeutic hypothermia (TH) are associated with 18-22 month outcomes for infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 181 infants with HIE who received TH in two randomized trials within the Neonatal Research Network. We defined summative blanket temperature constructs and evaluated for association with a primary composite outcome of death or moderate/ severe disability at 18-22 months. RESULTS Each 0.5 °C above 33.5 °C in the mean of the highest quartile blanket temperature was associated with a 52% increase in the adjusted odds of death/ disability (aOR 1.52, 95% CI 1.09-2.11). Having >8 consecutive blanket temperatures above 33.5 °C rendered an aOR of death/disability of 5.04 in the first 24 h (95% CI 1.54-16.6) and 6.92 in the first 48 h (95% CI 2.20-21.8) of TH. CONCLUSIONS Higher blanket temperature during TH may be an early, clinically useful biomarker of HIE outcome.
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Affiliation(s)
- John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Scott A McDonald
- Biostatistics and Epidemiology, RTI International, Research Triangle Park, NC, USA
| | - Mariana C Baserga
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Abhik Das
- Biostatistics and Epidemiology, RTI International, Rockville, MD, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tara L DuPont
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin Dysart
- Division of Neonatal and Perinatal Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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18
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Thayyil S, Shankaran S. From Therapeutic Hypothermia to Targeted Temperature Management in Low-Resource Settings. Indian Pediatr 2022; 59:9-10. [PMID: 35060482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Sudhin Thayyil
- Imperial College London, London, UK. Correspondence to: Dr. Sudhin Thayyil, Professor of Perinatal Neuroscience, Imperial College London.
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19
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Shankaran S, Laptook A, Thayyil S. Hypothermia for neonatal encephalopathy: how do we move forward? Arch Dis Child Fetal Neonatal Ed 2022; 107:4-5. [PMID: 34656992 DOI: 10.1136/archdischild-2021-322565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Seetha Shankaran
- Pediatrics Neonatology, Wayne State University, Detroit, Michigan, USA
| | - Abbot Laptook
- Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
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20
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Thayyil S, Bassett P, Shankaran S. Questions about the HELIX trial – Authors' reply. The Lancet Global Health 2021; 9:e1654-e1655. [DOI: 10.1016/s2214-109x(21)00499-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 12/19/2022] Open
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21
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Chalak LF, Pappas A, Tan S, Das A, Sánchez PJ, Laptook AR, Van Meurs KP, Shankaran S, Bell EF, Davis AS, Heyne RJ, Pedroza C, Poindexter BB, Schibler K, Tyson JE, Ball MB, Bara R, Grisby C, Sokol GM, D’Angio CT, Hamrick SEG, Dysart KC, Cotten CM, Truog WE, Watterberg KL, Timan CJ, Garg M, Carlo WA, Higgins RD. 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. JAMA Neurol 2021; 78:1484-1493. [PMID: 34882200 PMCID: PMC8524352 DOI: 10.1001/jamaneurol.2021.3723] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | | | - Alexis S. Davis
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kurt Schibler
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston
| | - M. Bethany Ball
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Cathy Grisby
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Shannon E. G. Hamrick
- Emory University Hospital Midtown, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin C. Dysart
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Christopher J. Timan
- Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus
| | - Meena Garg
- Department of Pediatrics, University of California, Los Angeles
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Morales MM, Montaldo P, Ivain P, Pant S, Kumar V, Krishnan V, Shankaran S, Thayyil S. Association of Total Sarnat Score with brain injury and neurodevelopmental outcomes after neonatal encephalopathy. Arch Dis Child Fetal Neonatal Ed 2021; 106:669-672. [PMID: 33952626 PMCID: PMC8543215 DOI: 10.1136/archdischild-2020-321164] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/19/2021] [Accepted: 04/03/2021] [Indexed: 11/03/2022]
Abstract
We examined the association of Total Sarnat Score (TSS) with brain injury on neonatal magnetic resonance (MR) and adverse neurodevelopmental outcome (NDO) (death or moderate or severe disability) at 2 years of age in 145 infants undergoing therapeutic hypothermia for neonatal encephalopathy. TSS was associated with basal ganglia/thalamic injury on conventional MR (p=0.03) and thalamic N-acetyl aspartate on MR spectroscopy (R2=0.16, p=0.004) at 2 weeks of age, and Bayley Composite Cognitive (R2=0.18, p=0.01), Motor (R2=0.15, p=0.02) and Language (R2=0.11, p=0.01) Scores at 2 years of age after adjustment for seizures at the time of neurological assessment. The accuracy of TSS (area under the curve (AUC)=0.71) for predicting adverse NDO was similar to the modified Sarnat staging (AUC=0.72). TSS of >12 within 6 hours of birth indicated high risk of adverse NDO, while TSS of <4 indicated intact survival and was reassuring of a good outcome among cooled infants.
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Affiliation(s)
- Maria Moreno Morales
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK,Department of Neonatal Intensive Care, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
| | - Vijay Kumar
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
| | - Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
| | - Seetha Shankaran
- Department of Pediatrics, Division of Neonatal and Perinatal Medicine, Wayne State University Childrens Hospital of Michigan, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Brain Sciences Department, Imperial College of Science Technology and Medicine, London, UK
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23
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Blakely ML, Tyson JE, Lally KP, Hintz SR, Eggleston B, Stevenson DK, Besner GE, Das A, Ohls RK, Truog WE, Nelin LD, Poindexter BB, Pedroza C, Walsh MC, Stoll BJ, Geller R, Kennedy KA, Dimmitt RA, Carlo WA, Cotten CM, Laptook AR, Van Meurs KP, Calkins KL, Sokol GM, Sanchez PJ, Wyckoff MH, Patel RM, Frantz ID, Shankaran S, D’Angio CT, Yoder BA, Bell EF, Watterberg KL, Martin CA, Harmon CM, Rice H, Kurkchubasche AG, Sylvester K, Dunn JCY, Markel TA, Diesen DL, Bhatia AM, Flake A, Chwals WJ, Brown R, Bass KD, St. Peter SD, Shanti CM, Pegoli W, Skarda D, Shilyansky J, Lemon DG, Mosquera RA, Peralta-Carcelen M, Goldstein RF, Vohr BR, Purdy IB, Hines AC, Maitre NL, Heyne RJ, DeMauro SB, McGowan EC, Yolton K, Kilbride HW, Natarajan G, Yost K, Winter S, Colaizy TT, Laughon MM, Lakshminrusimha S, Higgins RD. Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial. Ann Surg 2021; 274:e370-e380. [PMID: 34506326 PMCID: PMC8439547 DOI: 10.1097/sla.0000000000005099] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.
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MESH Headings
- Drainage
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/psychology
- Enterocolitis, Necrotizing/surgery
- Feasibility Studies
- Female
- Humans
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/psychology
- Infant, Premature, Diseases/surgery
- Intestinal Perforation/mortality
- Intestinal Perforation/psychology
- Intestinal Perforation/surgery
- Laparotomy
- Male
- Neurodevelopmental Disorders/diagnosis
- Neurodevelopmental Disorders/epidemiology
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Martin L. Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Kevin P. Lally
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Barry Eggleston
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - David K. Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Gail E. Besner
- Department of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Rockville, MD
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque, NM
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - William E. Truog
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO
| | - Leif D. Nelin
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Brenda B. Poindexter
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Rachel Geller
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Reed A. Dimmitt
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Kara L. Calkins
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Pablo J. Sanchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ravi M. Patel
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Ivan D. Frantz
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Bradley A. Yoder
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Colin A. Martin
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Carroll M. Harmon
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Henry Rice
- Division of Pediatric General Surgery, Duke University, Durham, NC
| | - Arlet G. Kurkchubasche
- Department of Pediatric Surgery, Hasbro Children’s Hospital, Brown University, Providence, RI
| | - Karl Sylvester
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - James C. Y. Dunn
- Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
- Department of Pediatric Surgery, University of California, Los Angeles, CA
| | - Troy A. Markel
- Department of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Diana L. Diesen
- Department of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amina M. Bhatia
- Department of Pediatric Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Alan Flake
- Department of Pediatric Surgery, University of Pennsylvania, Philadelphia, PA
| | - Walter J. Chwals
- Department of Pediatric Surgery, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Rebeccah Brown
- Department of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kathryn D. Bass
- Division of Pediatric Surgery, University of Buffalo, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Shawn D. St. Peter
- Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO
| | | | - Walter Pegoli
- Department of Pediatric Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - David Skarda
- Department of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | | | - David G. Lemon
- Department of Pediatric Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Ricardo A. Mosquera
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Betty R. Vohr
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
| | - Isabell B. Purdy
- Department of Pediatrics, University of California, Los Angeles, CA
| | - Abbey C. Hines
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Nathalie L. Maitre
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Elisabeth C. McGowan
- Department of Pediatrics, Women’s & Infants Hospital, Brown University, Providence, RI
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Kimberly Yolton
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Kelley Yost
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sarah Winter
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Matthew M. Laughon
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
- College of Health and Human Services, George Mason University, Fairfax, VA
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24
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Salas AA, Carlo WA, Do BT, Bell EF, Das A, Van Meurs KP, Poindexter BB, Shankaran S, Younge N, Watterberg KL, Higgins RD. Growth Rates of Infants Randomized to Continuous Positive Airway Pressure or Intubation After Extremely Preterm Birth. J Pediatr 2021; 237:148-153.e3. [PMID: 34157349 PMCID: PMC8478787 DOI: 10.1016/j.jpeds.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/03/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effects of early treatment with continuous positive airway pressure (CPAP) on nutritional intake and in-hospital growth rates of extremely preterm (EPT) infants. STUDY DESIGN EPT infants (240/7-276/7 weeks of gestation) enrolled in the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT) were included. EPT infants who died before 36 weeks of postmenstrual age (PMA) were excluded. The growth rates from birth to 36 weeks of PMA and follow-up outcomes at 18-22 months corrected age of EPT infants randomized at birth to either early CPAP (intervention group) or early intubation for surfactant administration (control group) were analyzed. RESULTS Growth data were analyzed for 810 of 1316 infants enrolled in SUPPORT (414 in the intervention group, 396 in the control group). The median gestational age was 26 weeks, and the mean birth weight was 839 g. Baseline characteristics, total nutritional intake, and in-hospital comorbidities were not significantly different between the 2 groups. In a regression model, growth rates between birth and 36 weeks of PMA, as well as growth rates during multiple intervals from birth to day 7, days 7-14, days 14-21, days 21-28, day 28 to 32 weeks PMA, and 32-36 weeks PMA did not differ between treatment groups. Independent of treatment group, higher growth rates from day 21 to day 28 were associated with a lower risk of having a Bayley-III cognitive score <85 at 18-22 months corrected age (P = .002). CONCLUSIONS EPT infants randomized to early CPAP did not have higher in-hospital growth rates than infants randomized to early intubation.
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Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Barbara T. Do
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Krisa P. Van Meurs
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Brenda B. Poindexter
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | | | - Noelle Younge
- Department of Pediatrics, Duke University, Durham, NC
| | | | - Rosemary D. Higgins
- National Institute of Child Health and Human Development, Bethesda, MD and Department of Global and Community Health, George Mason University, Fairfax, VA
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25
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Marlow N, Shankaran S, Rogers EE, Maitre NL, Smyser CD. Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101274. [PMID: 34330680 DOI: 10.1016/j.siny.2021.101274] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.
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Affiliation(s)
| | | | | | - Nathalie L Maitre
- Nationwide Children's Hospital, Columbus, OH, USA; Vanderbilt University, Nashville, TN, USA
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26
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Krishnan V, Kumar V, Variane GFT, Carlo WA, Bhutta ZA, Sizonenko S, Hansen A, Shankaran S, Thayyil S. Need for more evidence in the prevention and management of perinatal asphyxia and neonatal encephalopathy in low and middle-income countries: A call for action. Semin Fetal Neonatal Med 2021; 26:101271. [PMID: 34330679 PMCID: PMC8650826 DOI: 10.1016/j.siny.2021.101271] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although low- and middle-income countries (LMICs) shoulder 90 % of the neonatal encephalopathy (NE) burden, there is very little evidence base for prevention or management of this condition in these settings. A variety of antenatal factors including socio-economic deprivation, undernutrition and sub optimal antenatal and intrapartum care increase the risk of NE, although little is known about the underlying mechanisms. Implementing interventions based on the evidence from high-income countries to LMICs, may cause more harm than benefit as shown by the increased mortality and lack of neuroprotection with cooling therapy in the hypothermia for moderate or severe NE in low and middle-income countries (HELIX) trial. Pooled data from pilot trials suggest that erythropoietin monotherapy reduces death and disability in LMICs, but this needs further evaluation in clinical trials. Careful attention to supportive care, including avoiding hyperoxia, hypocarbia, hypoglycemia, and hyperthermia, are likely to improve outcomes until specific neuroprotective or neurorestorative therapies available.
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Affiliation(s)
- Vaisakh Krishnan
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
| | - Vijay Kumar
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
| | | | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, USA.
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan.
| | | | - Anne Hansen
- Division of Newborn Medicine, Boston Children's Hospital, Boston, USA.
| | | | - Sudhin Thayyil
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK.
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27
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Thayyil S, Pant S, Montaldo P, Shukla D, Oliveira V, Ivain P, Bassett P, Swamy R, Mendoza J, Moreno-Morales M, Lally PJ, Benakappa N, Bandiya P, Shivarudhrappa I, Somanna J, Kantharajanna UB, Rajvanshi A, Krishnappa S, Joby PK, Jayaraman K, Chandramohan R, Kamalarathnam CN, Sebastian M, Tamilselvam IA, Rajendran UD, Soundrarajan R, Kumar V, Sudarsanan H, Vadakepat P, Gopalan K, Sundaram M, Seeralar A, Vinayagam P, Sajjid M, Baburaj M, Murugan KD, Sathyanathan BP, Kumaran ES, Mondkar J, Manerkar S, Joshi AR, Dewang K, Bhisikar SM, Kalamdani P, Bichkar V, Patra S, Jiwnani K, Shahidullah M, Moni SC, Jahan I, Mannan MA, Dey SK, Nahar MN, Islam MN, Shabuj KH, Rodrigo R, Sumanasena S, Abayabandara-Herath T, Chathurangika GK, Wanigasinghe J, Sujatha R, Saraswathy S, Rahul A, Radha SJ, Sarojam MK, Krishnan V, Nair MK, Devadas S, Chandriah S, Venkateswaran H, Burgod C, Chandrasekaran M, Atreja G, Muraleedharan P, Herberg JA, Kling Chong WK, Sebire NJ, Pressler R, Ramji S, Shankaran S. Hypothermia for moderate or severe neonatal encephalopathy in low-income and middle-income countries (HELIX): a randomised controlled trial in India, Sri Lanka, and Bangladesh. Lancet Glob Health 2021; 9:e1273-e1285. [PMID: 34358491 PMCID: PMC8371331 DOI: 10.1016/s2214-109x(21)00264-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Although therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia. METHODS We did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18-22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385. FINDINGS We screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87-1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention. INTERPRETATION Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available. FUNDING National Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation. TRANSLATIONS For the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Deepika Shukla
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vania Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Ravi Swamy
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Naveen Benakappa
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Prathik Bandiya
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Indramma Shivarudhrappa
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Jagadish Somanna
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | | | - Ankur Rajvanshi
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sowmya Krishnappa
- Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | | | | | | | | | - Monica Sebastian
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Usha D Rajendran
- Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Vignesh Kumar
- Institute of Child Health, Madras Medical College, Chennai, India
| | | | - Padmesh Vadakepat
- Institute of Child Health, Madras Medical College, Chennai, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Kavitha Gopalan
- Institute of Child Health, Madras Medical College, Chennai, India
| | - Mangalabharathi Sundaram
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Arasar Seeralar
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Prakash Vinayagam
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Mohamed Sajjid
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Mythili Baburaj
- Perinatal Epidemiology Unit, Bengaluru, Karnataka, India; Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | - Kanchana D Murugan
- Institute of Obstetrics and Gynaecology and Government Hospital for Women and Children, Madras Medical College, Chennai, India
| | | | | | - Jayashree Mondkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Swati Manerkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Anagha R Joshi
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Kapil Dewang
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | | | - Pavan Kalamdani
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Vrushali Bichkar
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Saikat Patra
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Kapil Jiwnani
- Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | | | - Sadeka C Moni
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Ismat Jahan
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Sanjoy K Dey
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mst N Nahar
- National Institute of Neurosciences, Dhaka, Bangladesh
| | | | - Kamrul H Shabuj
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | | | | | | | | | - Radhika Sujatha
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sobhakumar Saraswathy
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Aswathy Rahul
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Saritha J Radha
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Manoj K Sarojam
- Sree Avittom Thirunal Hospital and Government Medical College, Thiruvananthapuram, Kerala, India
| | - Vaisakh Krishnan
- Institute of Maternal and Child Health, Government Medical College, Kozhikode, Kerala, India
| | - Mohandas K Nair
- Institute of Maternal and Child Health, Government Medical College, Kozhikode, Kerala, India
| | - Sahana Devadas
- Vanivilas Hospital, Bangalore Medical College and Research Institute, Karnataka, India
| | - Savitha Chandriah
- Vanivilas Hospital, Bangalore Medical College and Research Institute, Karnataka, India
| | | | - Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Gaurav Atreja
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Jethro A Herberg
- Section of Paediatric Infectious Disease, Imperial College London, London, UK
| | - W K Kling Chong
- Centre for Perinatal Neuroscience, Imperial College London, London, UK; Department of Neuroradiology, Great Ormond Street Hospital, London, UK
| | - Neil J Sebire
- Perinatal Pathology, National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital for Children, University College London, London, UK
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, UK
| | | | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
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Krishnan V, Kumar V, Shankaran S, Thayyil S. Rise and Fall of Therapeutic Hypothermia in Low-Resource Settings: Lessons from the HELIX Trial. Indian J Pediatr 2021:10.1007/s12098-021-03861-y. [PMID: 34297336 DOI: 10.1007/s12098-021-03861-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/14/2021] [Indexed: 12/13/2022]
Abstract
In the past decade, therapeutic hypothermia using a variety of low-cost devices has been widely implemented in India and other low-and middle-income countries (LMIC) without adequate evidence of either safety or efficacy. The recently reported data from the world's largest cooling trial (HELIX - hypothermia for encephalopathy in low- and middle-income countries) in LMIC provides definitive evidence of harm of cooling therapy with increase in mortality (number to harm 9) and lack of neuroprotection. Although the HELIX participating centers were highly selected tertiary neonatal intensive care units in South Asia with facilities for invasive ventilation, cardiovascular support, and 3 Tesla magnetic resonance imaging (MRI), and the trial used state-of-the-art automated servo-controlled cooling devices, a therapy that is harmful under such optimal conditions cannot be safe in low-resource settings that cannot even afford servo-controlled cooling devices.The HELIX trial has set a new benchmark for conducting high quality randomized controlled trials in terms of research governance, consent, ethics, follow-up rates, and involvement of parents. The standard care for neonatal encephalopathy in LMIC should remain normothermia, with close attention to prevention of hyperthermia. There is no role for therapeutic hypothermia in LMIC as the efficacy of hypothermia is dependent on the population, and not merely on the level of neonatal intensive care facilities. Future research should explore timings and origins of brain injury and prevention of brain injury in LMIC, with a strong emphasis on academic research capacity building and patient and public engagement.
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Affiliation(s)
- Vaisakh Krishnan
- Institute of Maternal and Child Health, Calicut Medical College, Kozhikode, Kerala, India
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK
| | - Vijay Kumar
- Neonatal Intensive Care Unit, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK
| | - Seetha Shankaran
- Neonatal Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Sudhin Thayyil
- Centre of Perinatal Neuroscience, Department of Brain Sciences, Imperial College, London, W12 0HS, UK.
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Pant S, Elias MA, Woolfall K, Morales MM, Lincy B, Jahan I, Sumanasena SP, Ramji S, Shankaran S, Thayyil S. Parental and professional perceptions of informed consent and participation in a time-critical neonatal trial: a mixed-methods study in India, Sri Lanka and Bangladesh. BMJ Glob Health 2021; 6:bmjgh-2021-005757. [PMID: 34020995 PMCID: PMC8144040 DOI: 10.1136/bmjgh-2021-005757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/21/2021] [Accepted: 04/24/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction Time-critical neonatal trials in low-and-middle-income countries (LMICs) raise several ethical issues. Using a qualitative-dominant mixed-methods design, we explored informed consent process in Hypothermia for encephalopathy in low and middle-income countries (HELIX) trial conducted in India, Sri Lanka and Bangladesh. Methods Term infants with neonatal encephalopathy, aged less than 6 hours, were randomly allocated to cooling therapy or usual care, following informed parental consent. The consenting process was audio-video (A-V) recorded in all cases. We analysed A-V records of the consent process using a 5-point Likert scale on three parameters—empathy, information and autonomy. In addition, we used exploratory observation method to capture relevant aspects of consent process and discussions between parents and professionals. Finally, we conducted in-depth interviews with a subgroup of 20 parents and 15 healthcare professionals. A thematic analysis was performed on the observations of A-V records and on the interview transcripts. Results A total of 294 A-V records of the HELIX trial were analysed. Median (IQR) score for empathy, information and autonomy was 5 (0), 5 (1) and 5 (1), respectively. However, thematic analysis suggested that the consenting was a ceremonial process; and parental decision to participate was based on unreserved trust in the treating doctors, therapeutic misconception and access to an expensive treatment free of cost. Most parents did not understand the concept of a clinical trial nor the nature of the intervention. Professionals showed a strong bias towards cooling therapy and reported time constraints and explaining to multiple family members as key challenges. Conclusion Despite rigorous research governance and consent process, parental decisions were heavily influenced by situational incapacity and a trust in doctors to make the right decision on their behalf. Further research is required to identify culturally and context-appropriate strategies for informed trial participation.
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Affiliation(s)
- Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | | | - Kerry Woolfall
- Institute of Population Health, University of Liverpool, Liverpool, Merseyside, UK
| | | | | | - Ismat Jahan
- Department of Neonatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Dhaka District, Bangladesh
| | | | - Siddarth Ramji
- Pediatrics, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Seetha Shankaran
- Neonatal- Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
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30
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Ambalavanan N, Shankaran S, Laptook AR, Carper BA, Das A, Carlo WA, Cotten CM, Duncan AF, Higgins RD. Early Determination of Prognosis in Neonatal Moderate or Severe Hypoxic-Ischemic Encephalopathy. Pediatrics 2021; 147:peds.2020-048678. [PMID: 33986149 PMCID: PMC8168606 DOI: 10.1542/peds.2020-048678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early determination of prognosis is important in neonates with hypoxic-ischemic encephalopathy (HIE). Our objective was to test scoring systems developed earlier (original scoring system) and develop new prognostic models. METHODS Secondary analysis of data from the multicenter randomized controlled trial of longer, deeper, or usual care cooling in neonatal HIE (NCT01192776) that enrolled 364 neonates diagnosed with moderate or severe HIE. The primary outcome was death or moderate or severe disability at 18 to 22 months, and secondary outcome was death during initial hospitalization. Testing of early neurologic clinical examination (<6 hours of age) and the original scoring system for prognostic ability was done, followed by development of new scoring systems and classification and regression tree (CART) models by using early clinical variables (<6 hours of age). RESULTS For death or disability, the original scoring system correctly classified 75% (95% confidence interval: 69%-81%), whereas the new scoring system correctly classified 78% (73%-82%), and the CART model correctly classified 76% (72%-81%). Early neurologic clinical examination also had a correct classification rate of 76% (71%-80%). Depth and duration of cooling did not affect prediction. Only a few components of the early neurologic examination were associated with poor outcome. For death, the original scoring system correctly classified 72% (66%-77%), the new scoring system 68% (63%-72%), the new CART model 87% (83%-90%), and early neurologic evaluation 81% (77%-85%). CONCLUSIONS The 3 models (scoring system, CART, and early neurologic evaluation) were comparable in predicting death or disability. For in-hospital death, CART models were superior to scoring systems and early neurologic examination.
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Affiliation(s)
- Namasivayam Ambalavanan
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;
| | - Seetha Shankaran
- Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island
| | - Benjamin A. Carper
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Research Triangle Park, North Carolina
| | - Abhik Das
- Biostatistics and Epidemiology Division, Research Triangle Institute International, Rockville, Maryland
| | - Waldemar A. Carlo
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - C. Michael Cotten
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
| | - Andrea F. Duncan
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and,College of Health and Human Services, George Mason University, Fairfax, Virginia
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31
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Chawla S, Laptook AR, Smith EA, Tan S, Natarajan G, Wyckoff MH, Ambalavanan N, Bell EF, Van Meurs KP, Stevenson DK, Werner EF, Greenberg RG, Das A, Shankaran S. In-hospital mortality and morbidity among extremely preterm infants in relation to maternal body mass index. J Perinatol 2021; 41:1014-1024. [PMID: 33024258 PMCID: PMC8021608 DOI: 10.1038/s41372-020-00847-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/24/2020] [Accepted: 09/24/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective of this paper is to compare in-hospital survival and survival without major morbidities in extremely preterm infants in relation to maternal body mass index (BMI). METHODS This retrospective cohort study included extremely preterm infants (gestational age 220/7-286/7 weeks). This study was conducted at National Institute of Child Health and Human Development Neonatal Research Network sites. Primary outcome was survival without any major morbidity. RESULTS Maternal BMI data were available for 2415 infants. Survival without any major morbidity was not different between groups: 30.8% in the underweight/normal, 28.1% in the overweight, and 28.5% in the obese (P = 0.65). However, survival was lower in the obese group (76.5%) compared with overweight group (83.2%) (P = 0.02). Each unit increase in maternal BMI was associated with decreased odds of infant survival (P < 0.01). CONCLUSIONS Survival without any major morbidity was not associated with maternal obesity. An increase in maternal prepregnancy BMI was associated with decreased odds of infant survival.
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Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Myra H Wyckoff
- Department of Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | | | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David K Stevenson
- Department of Pediatrics/Neonatology, Stanford University, Palo Alto, CA, USA
| | - Erika F Werner
- Department of Obstetrics and Gynecology, Women and Infants Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
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32
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Dworetz AR, Natarajan G, Langer JC, Kinlaw K, James JR, Bidegain M, Das A, Poindexter BB, Bell EF, Cotten CM, Kirpalani H, Shankaran S, Stoll BJ. Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates. Arch Dis Child Fetal Neonatal Ed 2021; 106:238-243. [PMID: 33082153 PMCID: PMC8055718 DOI: 10.1136/archdischild-2020-318855] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates. DESIGN Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST. RESULTS Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74). CONCLUSIONS Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.
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Affiliation(s)
- April R Dworetz
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John C Langer
- Biostatistics and Epidemiology Division, RTI International, Rockville, MD
| | - Kathy Kinlaw
- Department of Pediatrics and the Center for Ethics, Emory University, Atlanta, GA
| | - Jennifer R James
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | | | - Abhik Das
- Biostatistics and Epidemiology Division, RTI International, Rockville, MD
| | - Brenda B Poindexter
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Haresh Kirpalani
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | | | - Barbara J Stoll
- McGovern Medical School, University of Texas Health Sciences Center, Houston, TX
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33
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Laptook AR, Shankaran S, Barnes P, Rollins N, Do BT, Parikh NA, Hamrick S, Hintz SR, Tyson JE, Bell EF, Ambalavanan N, Goldberg RN, Pappas A, Huitema C, Pedroza C, Chaudhary AS, Hensman AM, Das A, Wyckoff M, Khan A, Walsh MC, Watterberg KL, Faix R, Truog W, Guillet R, Sokol GM, Poindexter BB, Higgins RD. Limitations of Conventional Magnetic Resonance Imaging as a Predictor of Death or Disability Following Neonatal Hypoxic-Ischemic Encephalopathy in the Late Hypothermia Trial. J Pediatr 2021; 230:106-111.e6. [PMID: 33189747 PMCID: PMC7914162 DOI: 10.1016/j.jpeds.2020.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate if magnetic resonance imaging (MRI) is an accurate predictor for death or moderate-severe disability at 18-22 months of age among infants with neonatal encephalopathy in a trial of cooling initiated at 6-24 hours. STUDY DESIGN Subgroup analysis of infants ≥36 weeks of gestation with moderate-severe neonatal encephalopathy randomized at 6-24 postnatal hours to hypothermia or usual care in a multicenter trial of late hypothermia. MRI scans were performed per each center's practice and interpreted by 2 central readers using the Eunice Kennedy Shriver National Institute of Child Health and Human Development injury score (6 levels, normal to hemispheric devastation). Neurodevelopmental outcomes were assessed at 18-22 months of age. RESULTS Of 168 enrollees, 128 had an interpretable MRI and were seen in follow-up (n = 119) or died (n = 9). MRI findings were predominantly acute injury and did not differ by cooling treatment. At 18-22 months, death or severe disability occurred in 20.3%. No infant had moderate disability. Agreement between central readers was moderate (weighted kappa 0.56, 95% CI 0.45-0.67). The adjusted odds of death or severe disability increased 3.7-fold (95% CI 1.8-7.9) for each increment of injury score. The area under the curve for severe MRI patterns to predict death or severe disability was 0.77 and the positive and negative predictive values were 36% and 100%, respectively. CONCLUSIONS MRI injury scores were associated with neurodevelopmental outcome at 18-22 months among infants in the Late Hypothermia Trial. However, the results suggest caution when using qualitative interpretations of MRI images to provide prognostic information to families following perinatal hypoxia-ischemia. TRIAL REGISTRATION Clinicaltrials.gov: NCT00614744.
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Affiliation(s)
- Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown
University, Providence, RI
| | | | - Patrick Barnes
- Department of Radiology and Pediatrics, Stanford University
School of Medicine, Palo Alto, CA
| | - Nancy Rollins
- Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, TX
| | - Barbara T. Do
- Biostatistics and Epidemiology Division, RTI International,
Research Triangle Park, NC
| | - Nehal A. Parikh
- Perinatal Institute, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH
| | - Shannon Hamrick
- Emory University School of Medicine, Department of
Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and
Developmental Medicine, Stanford University School of Medicine and Lucile Packard
Children’s Hospital, Palo Alto, CA
| | - Jon E. Tyson
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City,
IA
| | | | | | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit,
MI
| | - Carolyn Huitema
- Social, Statistical and Environmental Sciences Unit, RTI
International, Rockville, MD
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | | | - Angelita M. Hensman
- Department of Pediatrics, Women and Infants Hospital, Brown
University, Providence, RI
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI
International, Rockville, MD
| | - Myra Wyckoff
- Department of Pediatrics, University of Texas
Southwestern Medical Center, Dallas, TX
| | - Amir Khan
- Department of Pediatrics, McGovern Medical School at The
University of Texas Health Science Center at Houston, Houston, TX
| | - Michelle C. Walsh
- Department of Pediatrics, Rainbow Babies &
Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | | | - Roger Faix
- Department of Pediatrics, Division of Neonatology,
University of Utah School of Medicine, Salt Lake City, UT
| | - William Truog
- Department of Pediatrics, Children’s Mercy
Hospital and University of Missouri Kansas City School of Medicine, Kansas City,
MO
| | - Ronnie Guillet
- University of Rochester School of Medicine and Dentistry,
Rochester, NY
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of
Medicine, Indianapolis, IN,Cincinnati Children’s Hospital Medical Center,
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati,
OH
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health
and Human Development, Pregnancy and Perinatology Branch,George Mason University, Fairfax, VA
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34
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Agarwal P, Shankaran S, Laptook AR, Chowdhury D, Lakshminrusimha S, Bonifacio SL, Natarajan G, Chawla S, Keszler M, Heyne RJ, Ambalavanan N, Walsh MC, Das A, Van Meurs KP. Outcomes of infants with hypoxic ischemic encephalopathy and persistent pulmonary hypertension of the newborn: results from three NICHD studies. J Perinatol 2021; 41:502-511. [PMID: 33402707 PMCID: PMC7954876 DOI: 10.1038/s41372-020-00905-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/18/2020] [Accepted: 12/01/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the association of persistent pulmonary hypertension of the newborn (PPHN) with death or disability among infants with moderate or severe hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia. METHODS We compared infants with and without PPHN enrolled in the hypothermia arm from three randomized controlled trials (RCTs): Induced Hypothermia trial, "usual care" arm of Optimizing Cooling trial, and Late Hypothermia trial. Primary outcome was death or disability at 18-22 months adjusted for severity of HIE, center, and RCT. RESULTS Among 280 infants, 67 (24%) were diagnosed with PPHN. Among infants with and without PPHN, death or disability was 47% vs. 29% (adjusted OR: 1.65, 0.86-3.14) and death was 26% vs. 12% (adjusted OR: 2.04, 0.92-4.53), respectively. CONCLUSIONS PPHN in infants with moderate or severe HIE was not associated with a statistically significant increase in primary outcome. These results should be interpreted with caution given the limited sample size.
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Affiliation(s)
- Prashant Agarwal
- Department of Pediatrics, Wayne State University, Detroit, MI, USA.
| | | | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Dhuly Chowdhury
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of Buffalo Women’s and Children’s Hospital of Buffalo, Buffalo, NY,University of California at Davis, Sacramento, CA
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | | | - Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, MI
| | - Martin Keszler
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
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35
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Montaldo P, Cunnington A, Oliveira V, Swamy R, Bandya P, Pant S, Lally PJ, Ivain P, Mendoza J, Atreja G, Padmesh V, Baburaj M, Sebastian M, Yasashwi I, Kamalarathnam C, Chandramohan R, Mangalabharathi S, Kumaraswami K, Kumar S, Benakappa N, Manerkar S, Mondhkar J, Prakash V, Sajjid M, Seeralar A, Jahan I, Moni SC, Shahidullah M, Sujatha R, Chandrasekaran M, Ramji S, Shankaran S, Kaforou M, Herberg J, Thayyil S. Transcriptomic profile of adverse neurodevelopmental outcomes after neonatal encephalopathy. Sci Rep 2020; 10:13100. [PMID: 32753750 PMCID: PMC7403382 DOI: 10.1038/s41598-020-70131-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/16/2020] [Indexed: 12/20/2022] Open
Abstract
A rapid and early diagnostic test to identify the encephalopathic babies at risk of adverse outcome may accelerate the development of neuroprotectants. We examined if a whole blood transcriptomic signature measured soon after birth, predicts adverse neurodevelopmental outcome eighteen months after neonatal encephalopathy. We performed next generation sequencing on whole blood ribonucleic acid obtained within six hours of birth from the first 47 encephalopathic babies recruited to the Hypothermia for Encephalopathy in Low and middle-income countries (HELIX) trial. Two infants with blood culture positive sepsis were excluded, and the data from remaining 45 were analysed. A total of 855 genes were significantly differentially expressed between the good and adverse outcome groups, of which RGS1 and SMC4 were the most significant. Biological pathway analysis adjusted for gender, trial randomisation allocation (cooling therapy versus usual care) and estimated blood leukocyte proportions revealed over-representation of genes from pathways related to melatonin and polo-like kinase in babies with adverse outcome. These preliminary data suggest that transcriptomic profiling may be a promising tool for rapid risk stratification in neonatal encephalopathy. It may provide insights into biological mechanisms and identify novel therapeutic targets for neuroprotection.
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Affiliation(s)
- Paolo Montaldo
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK. .,Neonatal Unit, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy.
| | - Aubrey Cunnington
- Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, UK
| | - Vania Oliveira
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Ravi Swamy
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Prathik Bandya
- Neonatal Medicine, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Stuti Pant
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Peter J Lally
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Phoebe Ivain
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Josephine Mendoza
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Gaurav Atreja
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vadakepat Padmesh
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Mythili Baburaj
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Monica Sebastian
- Neonatal Medicine, Institute of Child Health, Madras Medical College, Tamil Nadu, Chennai, India
| | - Indiramma Yasashwi
- Neonatal Medicine, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Chinnathambi Kamalarathnam
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Rema Chandramohan
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Sundaram Mangalabharathi
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Kumutha Kumaraswami
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Shobha Kumar
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Naveen Benakappa
- Neonatal Medicine, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | | | | | - Vinayagam Prakash
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Mohammed Sajjid
- Neonatal Medicine, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Arasar Seeralar
- Neonatal Medicine, Institute of Child Health, Madras Medical College, Tamil Nadu, Chennai, India
| | - Ismat Jahan
- Neonatal Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Mohammod Shahidullah
- Neonatal Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Radhika Sujatha
- Neonatal Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Manigandan Chandrasekaran
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Siddarth Ramji
- Neonatal Medicine, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
| | - Myrsini Kaforou
- Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, UK
| | - Jethro Herberg
- Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, UK
| | - Sudhin Thayyil
- Department of Brain Sciences, Centre for Perinatal Neuroscience, Imperial College London, London, UK
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Bauer CR, Langer J, Lambert-Brown B, Shankaran S, Bada HS, Lester B, Lagasse LL, Whitaker T, Hammond J. Association of prenatal opiate exposure with youth outcomes assessed from infancy through adolescence. J Perinatol 2020; 40:1056-1065. [PMID: 32444681 DOI: 10.1038/s41372-020-0692-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/23/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study examined acute findings and long-term outcome trajectories between birth and adolescence in children with prenatal opiate exposure. STUDY DESIGN Ninety children (45 opiate-exposed, 45 non-exposed) completed assessments between 1 month and 15 years of age. Outcome variables (medical, anthropomorphic, developmental, and behavioral) were analyzed at individual time points and using longitudinal statistical modeling. RESULTS Opiate-exposed infants displayed transient neurologic findings, but no substantial signs or symptoms long term. There were no group differences in growth, cognitive functioning, or behavior at individual time periods; however, the trajectories of outcomes using longitudinal analyses adjusting for variables known to impact outcome demonstrated increased deficits among opiate-exposed children over time with regards to weight, head circumference, cognitive functioning, and behavior. CONCLUSIONS Findings support concerns that maternal opiate use during pregnancy may negatively impact a child's developmental trajectory, which in turn may impose concerns to society (e.g., increased need for social, medical, and/or educational services).
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Affiliation(s)
- Charles R Bauer
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.
| | - John Langer
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC, 27709, USA
| | - Brittany Lambert-Brown
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Henrietta S Bada
- Department of Pediatrics, University of Kentucky Hospital, Lexington, KY, 40506, USA
| | - Barry Lester
- Department of Pediatrics Brown Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, RI, 02903, USA
| | - Lynn L Lagasse
- Department of Pediatrics Brown Center for the Study of Children at Risk, Warren Alpert Medical School of Brown University, Women and Infants Hospital of Rhode Island, Providence, RI, 02903, USA
| | - Toni Whitaker
- Boling Center for Developmental Disabilities, University of Tennessee Health Science Center, Memphis, TN, 38105, USA
| | - Jane Hammond
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC, 27709, USA
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Travers CP, Carlo WA, McDonald SA, Das A, Ambalavanan N, Bell EF, Sánchez PJ, Stoll BJ, Wyckoff MH, Laptook AR, Van Meurs KP, Goldberg RN, D’Angio CT, Shankaran S, DeMauro SB, Walsh MC, Peralta-Carcelen M, Collins MV, Ball MB, Hale EC, Newman NS, Profit J, Gould JB, Lorch SA, Bann CM, Bidegain M, Higgins RD. Racial/Ethnic Disparities Among Extremely Preterm Infants in the United States From 2002 to 2016. JAMA Netw Open 2020; 3:e206757. [PMID: 32520359 PMCID: PMC7287569 DOI: 10.1001/jamanetworkopen.2020.6757] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Racial/ethnic disparities in quality of care among extremely preterm infants are associated with adverse outcomes. OBJECTIVE To assess whether racial/ethnic disparities in major outcomes and key care practices were changing over time among extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used prospectively collected data from 25 US academic medical centers. Participants included 20 092 infants of 22 to 27 weeks' gestation with a birth weight of 401 to 1500 g born at centers participating in the National Institute of Child Health and Human Development Neonatal Research Network from 2002 to 2016. Of these infants, 9316 born from 2006 to 2014 were eligible for follow-up at 18 to 26 months' postmenstrual age (excluding 5871 infants born before 2006, 2594 infants born after 2014, and 2311 ineligible infants including 64 with birth weight >1000 g and 2247 infants with gestational age >26 6/7 weeks), of whom 745 (8.0%) did not have known follow-up outcomes at 18 to 26 months. MAIN OUTCOMES AND MEASURES Rates of mortality, major morbidities, and care practice use over time were evaluated using models adjusted for baseline characteristics, center, and birth year. Data analyses were conducted from 2018 to 2019. RESULTS In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Hospital mortality decreased over time in all groups. The rate of improvement in hospital mortality over time did not differ among black and Hispanic infants compared with white infants (black infants went from 35% to 24%, Hispanic infants went from 32% to 27%, and white infants went from 30% to 22%; P = .59 for race × year interaction). The rates of late-onset sepsis among black infants (went from 37% to 24%) and Hispanic infants (went from 45% to 23%) were initially higher than for white infants (went from 36% to 25%) but decreased more rapidly and converged during the most recent years (P = .02 for race × year interaction). Changes in rates of other major morbidities did not differ by race/ethnicity. Death before follow-up decreased over time (from 2006 to 2014: black infants, 14%; Hispanic infants, 39%, white infants, 15%), but moderate-severe neurodevelopmental impairment increased over time in all racial/ethnic groups (increase from 2006 to 2014: black infants, 70%; Hispanic infants, 123%; white infants, 130%). Rates of antenatal corticosteroid exposure (black infants went from 72% to 90%, Hispanic infants went from 73% to 83%, and white infants went from 86% to 90%; P = .01 for race × year interaction) and of cesarean delivery (black infants went from 45% to 59%, Hispanic infants went from 49% to 59%, and white infants went from 62% to 63%; P = .03 for race × year interaction) were initially lower among black and Hispanic infants compared with white infants, but these differences decreased over time. CONCLUSIONS AND RELEVANCE Among extremely preterm infants, improvements in adjusted rates of mortality and most major morbidities did not differ by race/ethnicity, but rates of neurodevelopmental impairment increased in all groups. There were narrowing racial/ethnic disparities in important care practices, including the use of antenatal corticosteroids and cesarean delivery.
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Affiliation(s)
- Colm P. Travers
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Scott A. McDonald
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Rockville, Maryland
| | | | | | - Pablo J. Sánchez
- Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus
| | - Barbara J. Stoll
- Children’s Healthcare of Atlanta, Grady Memorial Hospital, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Abbot R. Laptook
- Women and Infants’ Hospital, Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | | | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Sara B. DeMauro
- The Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Michele C. Walsh
- Rainbow Babies and Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | | | - Monica V. Collins
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - M. Bethany Ball
- Division of Neonatal and Developmental Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Ellen C. Hale
- Children’s Healthcare of Atlanta, Grady Memorial Hospital, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy S. Newman
- Rainbow Babies and Children’s Hospital, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Jochen Profit
- Division of Neonatal and Developmental Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey B. Gould
- Division of Neonatal and Developmental Medicine, Lucile Packard Children’s Hospital, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Scott A. Lorch
- The Children’s Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Carla M. Bann
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of Global and Community Health, George Mason University, Fairfax, Virginia
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38
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Chawla S, Bates SV, Shankaran S. Is It Time for a Randomized Controlled Trial of Hypothermia for Mild Hypoxic-Ischemic Encephalopathy? J Pediatr 2020; 220:241-244. [PMID: 31952851 PMCID: PMC8462395 DOI: 10.1016/j.jpeds.2019.11.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/04/2019] [Accepted: 11/20/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Sanjay Chawla
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI
| | - Sara V. Bates
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI.
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Natarajan G, Sriidhar A, Nolen T, Gantz M, Das A, Bell E, Hintz S, Bliss J, Greenberg R, Shankaran S. Authors' Response. Pediatrics 2020; 145:peds.2020-0056B. [PMID: 32234798 DOI: 10.1542/peds.2020-0056b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | | | - Abhik Das
- Statistician, Research Triangle Institute
| | | | | | - Joesph Bliss
- Neonatologist, Women and Infants Hospital of Rhode Island
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40
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Kariholu U, Montaldo P, Markati T, Lally PJ, Pryce R, Teiserskas J, Liow N, Oliveira V, Soe A, Shankaran S, Thayyil S. Therapeutic hypothermia for mild neonatal encephalopathy: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2020; 105:225-228. [PMID: 30567775 DOI: 10.1136/archdischild-2018-315711] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/26/2018] [Accepted: 11/29/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine if therapeutic hypothermia reduces the composite outcome of death, moderate or severe disability at 18 months or more after mild neonatal encephalopathy (NE). DATA SOURCE MEDLINE, Cochrane database, Scopus and ISI Web of Knowledge databases, using 'hypoxic ischaemic encephalopathy', 'newborn' and 'hypothermia', and 'clinical trials' as medical subject headings and terms. Manual search of the reference lists of all eligible articles and major review articles and additional data from the corresponding authors of selected articles. STUDY SELECTION Randomised and quasirandomised controlled trials comparing therapeutic hypothermia with usual care. DATA EXTRACTION Safety and efficacy data extracted independently by two reviewers and analysed. RESULTS We included the data on 117 babies with mild NE inadvertently recruited to five cooling trials (two whole-body cooling and three selective head cooling) of moderate and severe NE, in the meta-analysis. Adverse outcomes occurred in 11/56 (19.6%) of the cooled babies and 12/61 (19.7%) of the usual care babies (risk ratio 1.11 (95% CIs 0.55 to 2.25)). CONCLUSIONS Current evidence is insufficient to recommend routine therapeutic hypothermia for babies with mild encephalopathy and significant benefits or harm cannot be excluded.
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Affiliation(s)
- Ujwal Kariholu
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Theodora Markati
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Russell Pryce
- Centre for Perinatal Neuroscience, Imperial College London, London, UK.,Neonatal Unit, Medway Hospital NHS Trust, Gillingham, UK
| | | | - Natasha Liow
- Neonatal Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Aung Soe
- Neonatal Unit, Medway Hospital NHS Trust, Gillingham, UK
| | - Seetha Shankaran
- Neonatal Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
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41
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Marik PE, Shankaran S, King L. The effect of copper-oxide-treated soft and hard surfaces on the incidence of healthcare-associated infections: a two-phase study. J Hosp Infect 2020; 105:265-271. [PMID: 32068014 DOI: 10.1016/j.jhin.2020.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Copper-oxide-impregnated linens and hard surfaces within the hospital environment have emerged as a novel technology to reduce environmental contamination and thereby potentially reduce the risk of healthcare-associated infections (HCAIs). METHODS This was a two-phase study. Phase 1 was a prospective, cluster-randomized, cross-over clinical trial in which one pod (eight beds) of our general ICU (GICU) utilized copper-oxide-impregnated linens whereas the other pod (eight beds) used standard hospital linens. Phase 2 was a two-year before-after study, following the relocation of three ICUs into a new ICU tower in which all the hard surfaces were treated with copper oxide (in addition to copper-impregnated linens). HCAIs were recorded using the National Healthcare Safety Network definitions. FINDINGS A total of 1282 patients were enrolled in phase 1. There was no difference in the rate of HCAI between the patients who received standard compared with copper oxide linen. In phase 2 there was a significant reduction in the number of infections due to Clostridioides difficile (2.4 per 1000 vs 0.7 per 1000 patient-days; incidence rate ratio: 3.3; 95% confidence interval: 1.4-8.7; P = 0.002) but no difference in the rate of central-line-associated bloodstream infections nor of catheter-associated urinary tract infections. CONCLUSION Copper-oxide-impregnated linens alone had no effect on the rate of HCAI. Our data suggest that copper-oxide-treated hard surfaces reduced the rate of infections due to C. difficile; however, important confounders cannot be excluded.
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Affiliation(s)
- P E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA.
| | - S Shankaran
- Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, VA, USA; Division of Infectious Diseases, Rush University Medical Center, Chicago, IL, USA
| | - L King
- Infection Prevention and Control Coordinator, Sentara Norfolk General Hospital, Norfolk, VA, USA
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42
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Montaldo P, Ivain P, Lally P, Bassett P, Pant S, Oliveira V, Mendoza J, Morales M, Swamy R, Shankaran S, Thayyil S. White matter injury after neonatal encephalopathy is associated with thalamic metabolite perturbations. EBioMedicine 2020; 52:102663. [PMID: 32062359 PMCID: PMC7016374 DOI: 10.1016/j.ebiom.2020.102663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although thalamic magnetic resonance (MR) spectroscopy (MRS) accurately predicts adverse outcomes after neonatal encephalopathy, its utility in infants without MR visible deep brain nuclei injury is not known. We examined thalamic MRS metabolite perturbations in encephalopathic infants with white matter (WM) injury with or without cortical injury and its associations with adverse outcomes. METHODS We performed a subgroup analysis of all infants recruited to the MARBLE study with isolated WM or mixed WM/cortical injury, but no visible injury to the basal ganglia/thalamus (BGT) or posterior limb of the internal capsule (PLIC). We used binary logistic regression to examine the association of MRS biomarkers with three outcomes (i) WM injury score (1 vs. 2/3); (ii) cortical injury scores (0/1 vs. 2/3); and (iii) adverse outcomes (defined as death, moderate/severe disability) at two years (yes/no). We also assessed the accuracy of MRS for predicting adverse outcome. FINDINGS Of the 107 infants included in the analysis, five had adverse outcome. Reduced thalamic N-acetylaspartate concentration [NAA] (odds ratio 0.4 (95% CI 0.18-0.93)) and elevated thalamic Lactate/NAA peak area ratio (odds ratio 3.37 (95% CI 1.45-7.82)) were significantly associated with higher WM injury scores, but not with cortical injury. Thalamic [NAA] (≤5.6 mmol/kg/wet weight) had the best accuracy for predicting adverse outcomes (sensitivity 1.00 (95% CI 0.16-1.00); specificity 0.95 (95% CI 0.84-0.99)). INTERPRETATION Thalamic NAA is reduced in encephalopathic infants without MR visible deep brain nuclei injury and may be a useful predictor of adverse outcomes. FUNDING The National Institute for Health Research (NIHR).
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK; Department of Neonatal Intensive Care, Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy.
| | - Phoebe Ivain
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Pete Lally
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Vania Oliveira
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Maria Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
| | | | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, UK
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Montaldo P, Vakharia A, Ivain P, Mendoza J, Oliveira V, Markati T, Shankaran S, Thayyil S. Pre-emptive opioid sedation during therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2020; 105:108-109. [PMID: 31072966 DOI: 10.1136/archdischild-2019-317050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Paolo Montaldo
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK.,Neonatal Intensive Care Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Anuj Vakharia
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Phoebe Ivain
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Josephine Mendoza
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Vania Oliveira
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Theodora Markati
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Department of Paediatrics, Centre for Perinatal Neuroscience, Imperial College London and Imperial Neonatal Service, London, UK
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44
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Montaldo P, Lally PJ, Oliveira V, Swamy R, Mendoza J, Atreja G, Kariholu U, Shivamurthappa V, Liow N, Teiserskas J, Pryce R, Soe A, Shankaran S, Thayyil S. Therapeutic hypothermia initiated within 6 hours of birth is associated with reduced brain injury on MR biomarkers in mild hypoxic-ischaemic encephalopathy: a non-randomised cohort study. Arch Dis Child Fetal Neonatal Ed 2019; 104:F515-F520. [PMID: 30425113 PMCID: PMC6788875 DOI: 10.1136/archdischild-2018-316040] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the effect of therapeutic hypothermia on MR biomarkers and neurodevelopmental outcomes in babies with mild hypoxic-ischaemic encephalopathy (HIE). DESIGN Non-randomised cohort study. SETTING Eight tertiary neonatal units in the UK and the USA. PATIENTS 47 babies with mild HIE on NICHD neurological examination performed within 6 hours after birth. INTERVENTIONS Whole-body cooling for 72 hours (n=32) or usual care (n=15; of these 5 were cooled for <12 hours). MAIN OUTCOME MEASURES MRI and MR spectroscopy (MRS) within 2 weeks after birth, and a neurodevelopmental outcome assessment at 2 years. RESULTS The baseline characteristics in both groups were similar except for lower 10 min Apgar scores (p=0.02) in the cooled babies. Despite this, the mean (SD) thalamic NAA/Cr (1.4 (0.1) vs 1.6 (0.2); p<0.001) and NAA/Cho (0.67 (0.08) vs 0.89 (0.11); p<0.001) ratios from MRS were significantly higher in the cooled group. Cooled babies had lower white matter injury scores than non-cooled babies (p=0.02). Four (27%) non-cooled babies with mild HIE developed seizures after 6 hours of age, while none of the cooled babies developed seizures (p=0.008). Neurodevelopmental outcomes at 2 years were available in 40 (85%) of the babies. Adverse outcomes were seen in 2 (14.3%) non-cooled babies, and none of the cooled babies (p=0.09). CONCLUSIONS Therapeutic hypothermia may have a neuroprotective effect in babies with mild HIE, as demonstrated by improved MRS biomarkers and reduced white matter injury on MRI. This may warrant further evaluation in adequately powered randomised controlled trials.
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Ravi Swamy
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
| | - Gaurav Atreja
- Neonatal Unit, Imperial Healthcare NHS Trust, London, UK
| | - Ujwal Kariholu
- Neonatal Unit, Imperial Healthcare NHS Trust, London, UK
| | | | - Natasha Liow
- Neonatal Unit, Imperial Healthcare NHS Trust, London, UK
| | | | - Russell Pryce
- Oliver Fisher Neonatal Unit, Medway NHS Hospital Foundation Trust, Gillingham, UK
| | - Aung Soe
- Oliver Fisher Neonatal Unit, Medway NHS Hospital Foundation Trust, Gillingham, UK
| | - Seetha Shankaran
- Perinatal-Neonatal Medicine, Wayne State University, Detroit, Michigan, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, UK
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Natarajan G, Shankaran S, Nolen TL, Sridhar A, Kennedy KA, Hintz SR, Phelps DL, DeMauro SB, Carlo WA, Gantz MG, Das A, Greenberg RG, Younge NE, Bliss JM, Seabrook R, Sánchez PJ, Wyckoff MH, Bell EF, Vohr BR, Higgins RD. Neurodevelopmental Outcomes of Preterm Infants With Retinopathy of Prematurity by Treatment. Pediatrics 2019; 144:e20183537. [PMID: 31337693 PMCID: PMC6855825 DOI: 10.1542/peds.2018-3537] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Among extremely preterm infants, we evaluated whether bevacizumab therapy compared with surgery for retinopathy of prematurity (ROP) is associated with adverse outcomes in early childhood. METHODS This study was a retrospective analysis of prospectively collected data on preterm (22-26 + 6/7 weeks' gestational age) infants admitted to the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers who received bevacizumab or surgery exclusively for ROP. The primary outcome was death or severe neurodevelopmental impairment (NDI) at 18 to 26 months' corrected age (Bayley Scales of Infant and Toddler Development, Third Edition cognitive or motor composite score <70, Gross Motor Functional Classification Scale level ≥2, bilateral blindness or hearing impairment). RESULTS The cohort (N = 405; 214 [53%] boys; median [interquartile range] gestational age: 24.6 [23.9-25.3] weeks) included 181 (45%) infants who received bevacizumab and 224 (55%) who underwent ROP surgery. Infants treated with bevacizumab had a lower median (interquartile range) birth weight (640 [541-709] vs 660 [572.5-750] g; P = .02) and longer durations of conventional ventilation (35 [21-58] vs 33 [18-49] days; P = .04) and supplemental oxygen (112 [94-120] vs 105 [84.5-120] days; P = .01). Death or severe NDI (adjusted odds ratio [aOR] 1.42; 95% confidence interval [CI] 0.94 to 2.14) and severe NDI (aOR 1.14; 95% CI 0.76 to 1.70) did not differ between groups. Odds of death (aOR 2.54 [95% CI 1.42 to 4.55]; P = .002), a cognitive score <85 (aOR 1.78 [95% CI 1.09 to 2.91]; P = .02), and a Gross Motor Functional Classification Scale level ≥2 (aOR 1.73 [95% CI 1.04 to 2.88]; P = .04) were significantly higher with bevacizumab therapy. CONCLUSIONS In this multicenter cohort of preterm infants, ROP treatment modality was not associated with differences in death or NDI, but the bevacizumab group had higher mortality and poor cognitive outcomes in early childhood. These data reveal the need for a rigorous appraisal of ROP therapy.
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Affiliation(s)
- Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, Michigan;
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Tracy L Nolen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Amaanti Sridhar
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Kathleen A Kennedy
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Dale L Phelps
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Sara B DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Noelle E Younge
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Joseph M Bliss
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Ruth Seabrook
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
| | - Pablo J Sánchez
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa; and
| | - Betty R Vohr
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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46
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Montaldo P, Swamy R, Bassett P, Lally PJ, Shankaran S, Thayyil S. Pitfalls in using neonatal brain NAA to predict infant development – Authors' reply. Lancet Neurol 2019; 18:423-424. [DOI: 10.1016/s1474-4422(19)30116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/06/2019] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
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47
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Rysavy MA, Bell EF, Iams JD, Carlo WA, Li L, Mercer BM, Hintz SR, Stoll BJ, Vohr BR, Shankaran S, Walsh MC, Brumbaugh JE, Colaizy TT, Das A, Higgins RD. Discordance in Antenatal Corticosteroid Use and Resuscitation Following Extremely Preterm Birth. J Pediatr 2019; 208:156-162.e5. [PMID: 30738658 PMCID: PMC6486854 DOI: 10.1016/j.jpeds.2018.12.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/08/2018] [Accepted: 12/31/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe discordance in antenatal corticosteroid use and resuscitation following extremely preterm birth and its relationship with infant survival and neurodevelopment. STUDY DESIGN A multicenter cohort study of 4858 infants 22-26 weeks of gestation born 2006-2011 at 24 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, with follow-up through 2013. Survival and neurodevelopmental outcomes were available at 18-22 months of corrected age for 4576 (94.2%) infants. We described antenatal interventions, resuscitation, and infant outcomes. We modeled the effect on infant outcomes of each hospital increasing antenatal corticosteroid exposure for resuscitated infants born at 22-24 weeks of gestation to rates observed at 25-26 weeks of gestation. RESULTS Discordant antenatal corticosteroid use and resuscitation, where one and not the other occurred, were more frequent for births at 22 and 23 but not 24 weeks (rate ratio [95% CI] at 22 weeks: 1.7 [1.3-2.2]; 23 weeks: 2.6 [2.2-3.2]; 24 weeks: 1.0 [0.8-1.2]) when compared with 25-26 weeks. Among infants resuscitated at 23 weeks, adjusting each hospital's rate of antenatal corticosteroid use to the average at 25-26 weeks (89.2%) was projected to increase infant survival by 7.1% (95% CI 5.4-8.8%) and survival without severe impairment by 6.4% (95% CI 4.7-8.1%). No significant change in outcomes was projected for infants resuscitated at 22 weeks, where few (n = 22) resuscitated infants received antenatal corticosteroids. CONCLUSIONS Infants born at 23 weeks were more frequently resuscitated without antenatal corticosteroids than other extremely preterm infants. When resuscitation is intended, consistent provision of antenatal corticosteroids may increase infant survival and survival without impairment. TRIAL REGISTRATION ClinicalTrials.govNCT00063063 (Generic Database) and NCT00009633 (Follow-Up Study).
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Affiliation(s)
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Lei Li
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH
| | - Susan R Hintz
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Barbara J Stoll
- Dean's Office, University of Texas Medical School at Houston, Houston, TX
| | - Betty R Vohr
- Department of Pediatrics, Women & Infants' Hospital, Brown University, Providence, RI
| | | | - Michele C Walsh
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH
| | - Jane E Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | | | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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48
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Laptook A, Tyson JE, Pedroza C, Shankaran S, Bell EF, Goldberg R, Ambalavanan N, Munoz B, Das A. Response to a different view concerning the NICHD neonatal research network late hypothermia trial. Acta Paediatr 2019; 108:772-773. [PMID: 30664824 DOI: 10.1111/apa.14725] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Abbot Laptook
- Women & Infants Hospital of Rhode Island; Warren Alpert Medical School of Brown University-Pediatrics; Providence RI USA
| | - Jon E. Tyson
- McGovern Medical School; University of Texas Health Science Center at Houston-Pediatrics; Houston TX USA
| | - Claudia Pedroza
- McGovern Medical School; University of Texas Health Science Center at Houston-Pediatrics; Houston TX USA
| | - Seetha Shankaran
- Department of Pediatrics; Wayne State University; Detroit MI USA
| | - Edward F. Bell
- Department of Pediatrics; University of Iowa; Iowa City IA USA
| | | | | | - Breda Munoz
- RTI International - Biostatistics and Epidemiology; Research Triangle Park NC USA
| | - Abhik Das
- RTI International - Biostatistics and Epidemiology; Rockville MD USA
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49
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Dagle JM, Ryckman KK, Spracklen CN, Momany AM, Cotten CM, Levy J, Page GP, Bell EF, Carlo WA, Shankaran S, Goldberg RN, Ehrenkranz RA, Tyson JE, Stoll BJ, Murray JC. Genetic variants associated with patent ductus arteriosus in extremely preterm infants. J Perinatol 2019; 39:401-408. [PMID: 30518802 PMCID: PMC6391165 DOI: 10.1038/s41372-018-0285-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Patent ductus arteriosus (PDA) is a commonly observed condition in preterm infants. Prior studies have suggested a role for genetics in determining spontaneous ductal closure. Using samples from a large neonatal cohort we tested the hypothesis that common genetic variations are associated with PDA in extremely preterm infants. STUDY DESIGN Preterm infants (n = 1013) enrolled at NICHD Neonatal Research Network sites were phenotyped for PDA. DNA was genotyped for 1634 single nucleotide polymorphisms (SNPs) from candidate genes. Analyses were adjusted for ancestral eigenvalues and significant epidemiologic variables. RESULTS SNPs in several genes were associated with the clinical diagnosis of PDA and with surgical ligation in extremely preterm neonates diagnosed with PDA (p < 0.01). None of the associations were significant after correction for multiple comparisons. CONCLUSION We identified several common genetic variants associated with PDA. These findings may inform further studies on genetic risk factors for PDA in preterm infants.
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Affiliation(s)
- John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA.
| | - Kelli K Ryckman
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Allison M Momany
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Levy
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, Durham, NC, USA
| | - Grier P Page
- Social, Statistical and Environmental Sciences Unit, RTI International, Atlanta, GA, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | | | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Jon E Tyson
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX, USA
| | - Barbara J Stoll
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jeffrey C Murray
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
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50
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Liow N, Montaldo P, Lally PJ, Teiserskas J, Bassett P, Oliveira V, Mendoza J, Slater R, Shankaran S, Thayyil S. Preemptive Morphine During Therapeutic Hypothermia After Neonatal Encephalopathy: A Secondary Analysis. Ther Hypothermia Temp Manag 2019; 10:45-52. [PMID: 30807267 DOI: 10.1089/ther.2018.0052] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Although therapeutic hypothermia (TH) improves outcomes after neonatal encephalopathy (NE), the safety and efficacy of preemptive opioid sedation during cooling therapy is unclear. We performed a secondary analysis of the data from a large multicountry prospective observational study (Magnetic Resonance Biomarkers in Neonatal Encephalopathy [MARBLE]) to examine the association of preemptive morphine infusion during TH on brain injury and neurodevelopmental outcomes after NE. All recruited infants had 3.0 Tesla magnetic resonance imaging and spectroscopy at 1 week, and neurodevelopmental outcome assessments at 22 months. Of 223 babies recruited to the MARBLE study, the data on sedation were available from 169 babies with moderate (n = 150) or severe NE (n = 19). Although the baseline characteristics and admission status were similar, the babies who received morphine infusion (n = 141) were more hypotensive (49% vs. 25%, p = 0.02) and had a significantly longer hospital stay (12 days vs. 9 days, p = 0.009) than those who did not (n = 28). Basal ganglia/thalamic injury (score ≥1) and cortical injury (score ≥1) was seen in 34/141 (24%) and 37/141 (26%), respectively, of the morphine group and 4/28 (14%) and 3/28 (11%) of the nonmorphine group (p > 0.05). On regression modeling adjusted for potential confounders, preemptive morphine was not associated with mean (standard deviation [SD]) thalamic N-acetylaspartate (NAA) concentration (6.9 ± 0.9 vs. 6.5 ± 1.5; p = 0.97), and median (interquartile range) lactate/NAA peak area ratios (0.16 [0.12-0.21] vs. 0.13 [0.11-0.18]; p = 0.20) at 1 week, and mean (SD) Bayley-III composite motor (92 ± 23 vs. 94 ± 10; p = 0.98), language (89 ± 22 vs. 93 ± 8; p = 0.53), and cognitive scores (95 ± 21 vs. 99 ± 13; p = 0.56) at 22 months. Adverse neurodevelopmental outcome (adjusted for severity of encephalopathy) was seen in 26 (18%) of the morphine group, and none of the nonmorphine group (p = 0.11). Preemptive morphine sedation during TH does not offer any neuroprotective benefits and may be associated with increased hospital stay. Optimal sedation during induced hypothermia requires further evaluation in clinical trials.
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Affiliation(s)
- Natasha Liow
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom.,Neonatal Unit, Università degli Studi della Campania, "Luigi Vanvitelli," Italy
| | - Peter J Lally
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Justinas Teiserskas
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | | | - Vânia Oliveira
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Josephine Mendoza
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
| | - Rebeccah Slater
- Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Seetha Shankaran
- Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College London, London, United Kingdom
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