Cochrane Review: Cooling for newborns with hypoxic ischaemic encephalopathy

Abstract

AbstractBackgroundNewborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia‐ischaemia in newborn infants may reduce neurological sequelae without adverse effects.ObjectivesTo determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long‐term neurodevelopmental disability and clinically important side effects.Search strategyThe standard search strategy of the Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 to June 2007), previous reviews including cross‐references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.Selection criteriaRandomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long‐term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome.Data collection and analysisThree review authors independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta‐analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals.Main resultsEight randomised controlled trials were included in this review, comprising 638 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age [typical RR 0.76 (95% CI 0.65, 0.89), typical RD ‐0.15 (95% CI ‐0.24, ‐0.07), NNT 7 (95% CI 4, 14)]. Cooling also resulted in statistically significant reductions in mortality [typical RR 0.74 (95% CI 0.58, 0.94), typical RD ‐0.09 (95% CI ‐0.16, ‐0.02), NNT 11 (95% CI 6, 50)] and in neurodevelopmental disability in survivors [typical RR 0.68 (95% CI 0.51, 0.92), typical RD ‐0.13 (95% CI ‐0.23, ‐0.03)]. Some adverse effects of hypothermia included an increase in the need for inotrope support of borderline significance and a significant increase in thrombocytopaenia.Authors' conclusionsThere is evidence from the eight randomised controlled trials included in this systematic review (n = 638) that therapeutic hypothermia is beneficial to term newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short‐term adverse effects. However, this review comprises an analysis based on less than half of all infants currently known to be randomised into eligible trials of cooling. Incorporation of data from ongoing and completed randomised trials (n = 829) will be important to clarify the effectiveness of cooling and to provide more information on the safety of therapeutic hypothermia, but could also alter these conclusions. Further trials to determine the appropriate method of providing therapeutic hypothermia, including comparison of whole body with selective head cooling with mild systemic hypothermia, are required.Plain language summaryCooling for newborns with hypoxic ischaemic encephalopathyThere is evidence that induced hypothermia (cooling) of newborn babies who may have suffered from a lack of oxygen at birth reduces death or disability, without increasing disability in survivors. This means that parents should expect that cooling will decrease their baby's chance of dying, and that if their baby survives, cooling will decrease his/her chance of major disability. A lack of oxygen before and during birth can destroy cells in a newborn baby's brain. The damage caused by the lack of oxygen continues for some time afterwards. One way to try and stop this damage is to induce hypothermia ‐ cooling the baby or just the baby's head for hours to days. This treatment may reduce the amount of damage to brain cells. This review found that there is evidence from trials to show that induced hypothermia helps to improve survival and development at 18 months for term newborn babies at risk of brain damage. The results of ongoing trials may or may not confirm these favourable results. More research is also needed on the different methods of cooling.