Cerebral palsy and brain cooling

Abstract

This month in The Journal there are 3 articles that discuss cerebral palsy (CP) and the use of hypothermia to decrease brain injury in newborns. Garfinkel et al used a Canadian CP registry to estimate that about 5% of CP could be prevented with the effective use of therapeutic hypothermia of asphyxiated term infants delivered in Canada. This low effectiveness results from the multiple factors pointed out in the editorial by Berg. Most cases of CP are not the result of the acute sentinel asphyxial events associated with deliveries, and many of the infants do not qualify for hypothermia treatment. Furthermore, the therapy is not highly effective. This discouraging overall effect of therapeutic hypothermia is compounded in low and middle-income countries (LMIC) as pointed out by the Commentary by Tagin et al. Hypoxic ischemic encephalopathy is responsible for an estimated 25% of all neonatal deaths worldwide, and asphyxia is responsible for a large number of fresh stillborns in LMIC countries. Although therapeutic hypothermia is an effective therapy in high resource environments, it has not been demonstrated to be effective in LMIC in a few trials. Although the therapy is relatively simple to deliver in any modern neonatal intensive care unit, there are multiple obstacles to its effective use in LMIC. Identification of the infant that qualifies for hypothermia treatment by the criteria used in high resource environments requires trained personnel and infrastructure, and, thus, is not easily accomplished. More lives could be saved by upgrading obstetric services to decrease stillborns and providing effective resuscitation, than by developing the infrastructure necessary for the rapid identification and treatment of the asphyxiated infant with hypothermia. Therapies to improve outcomes that are effective in one environment may not work in another. Even though therapeutic hypothermia is a major advance as the first treatment that can decrease brain injury in asphyxiated term infants, its overall impact on the incidence of CP and birth asphyxia will be small within the context of worldwide infant mortality. Article page 25▶ Article page 58▶ Editorial page 8▶ Cerebral Palsy after Neonatal Encephalopathy: How Much Is Preventable?The Journal of PediatricsVol. 167Issue 1PreviewTo determine the expected proportion of term cerebral palsy (CP) after neonatal encephalopathy (NE) that could theoretically be prevented by hypothermia and elucidate the perinatal factors associated with CP after NE in those who do not meet currently used clinical criteria required to qualify for hypothermia (“cooling criteria”). Full-Text PDF Neuroprotection for Perinatal Hypoxic Ischemic Encephalopathy in Low- and Middle-Income CountriesThe Journal of PediatricsVol. 167Issue 1PreviewPerinatal hypoxic ischemic encephalopathy (HIE) is associated with approximately one-quarter of global neonatal deaths.1 In 2010, there were an estimated 1.15 million cases of neonatal encephalopathy, of which 96% of were from low- and middle-income (LMI) countries.2 In the developed world, therapeutic hypothermia is now widely accepted as the standard of care for treating newborns with moderate to severe HIE.3 Therapeutic hypothermia has been found to reduce the risk of death or major neurodevelopmental disability at age 18 months (risk ratio [RR], 0.76; 95% CI, 0.69-0.84) and to increase survival with normal neurologic function (RR, 1.63; 95% CI, 1.36-1.95). Full-Text PDF Prevention of Cerebral Palsy: Which Infants Will Benefit from Therapeutic Hypothermia?The Journal of PediatricsVol. 167Issue 1PreviewCan cerebral palsy (CP) be prevented? The answer depends on the etiology of CP. Although the causes of CP are largely related to early brain injury, both the nature of that injury and the later manifestations can differ based on the gestational and postnatal ages at which the injury occurs, as well as its source. Full-Text PDF