Abstract
BackgroundAn early clinical score predicting an abnormal amplitude-integrated electroencephalogram (aEEG) or moderate-severe hypoxic ischemic encephalopathy (HIE) may allow rapid triage of infants for therapeutic hypothermia. We aimed to determine if early clinical examination could predict either an abnormal aEEG at age 6 hours or moderate-severe HIE presenting within 72 hours of birth.MethodsSixty infants ≥ 36 weeks gestational age were prospectively enrolled following suspected intrapartum hypoxia and signs of encephalopathy. Infants who were moribund, had congenital conditions that could contribute to the encephalopathy or had severe cardio-respiratory instability were excluded. Predictive values of the Thompson HIE score, modified Sarnat encephalopathy grade (MSEG) and specific individual signs at age 3–5 hours were calculated.ResultsAll of the 60 infants recruited had at least one abnormal primitive reflex. Visible seizures and hypotonia at 3–5 hours were strongly associated with an abnormal 6-hour aEEG (specificity 88% and 92%, respectively), but both had a low sensitivity (47% and 33%, respectively). Overall, 52% of the infants without hypotonia at 3–5 hours had an abnormal 6-hour aEEG. Twelve of the 29 infants (41%) without decreased level of consciousness at 3–5 hours had an abnormal 6-hour aEEG (sensitivity 67%; specificity 71%). A Thompson score ≥ 7 and moderate-severe MSEG at 3–5 hours, both predicted an abnormal 6-hour aEEG (sensitivity 100 vs. 97% and specificity 67 vs. 71% respectively). Both assessments predicted moderate-severe encephalopathy within 72 hours after birth (sensitivity 90%, vs. 88%, specificity 92% vs. 100%). The 6-hour aEEG predicted moderate-severe encephalopathy within 72 hours (sensitivity 75%, specificity 100%) but with lower sensitivity (p = 0.0156) than the Thompson score (sensitivity 90%, specificity 92%). However, all infants with a normal 3- and 6-hour aEEG with moderate-severe encephalopathy within 72 hours who were not cooled had a normal 24-hour aEEG.ConclusionsThe encephalopathy assessment described by the Thompson score at age 3–5 hours is a sensitive predictor of either an abnormal 6-hour aEEG or moderate-severe encephalopathy presenting within 72 hours after birth. An early Thompson score may be useful to assist with triage and selection of infants for therapeutic hypothermia.
Highlights
An early clinical score predicting an abnormal amplitude-integrated electroencephalogram or moderate-severe hypoxic ischemic encephalopathy (HIE) may allow rapid triage of infants for therapeutic hypothermia
The specific clinical signs we analyzed were those used as entry criteria in the cooling trials with abnormal amplitude-integrated electroencephalogram (aEEG) as an additional criterion [15,16,17]. These clinical signs included decreased level of consciousness, visible seizures, hypotonia, and abnormal reflexes; iii.) The ability of the Thompson score threshold to predict moderate-severe encephalopathy presenting within 72 hours after birth
We determined the ability of early clinical and aEEG assessment to predict moderate-severe encephalopathy presenting within 72 hours after birth
Summary
An early clinical score predicting an abnormal amplitude-integrated electroencephalogram (aEEG) or moderate-severe hypoxic ischemic encephalopathy (HIE) may allow rapid triage of infants for therapeutic hypothermia. Shalak et al defined a modification of Sarnat’s [7] encephalopathy grading (the modified Sarnat encephalopathy grade) [13] They showed that the presence of at least one clinical sign of moderate-severe encephalopathy occurring in at least three of six separate components during the first 12 hours after birth, had a similar sensitivity but lower specificity for prediction of an abnormal outcome at discharge than a severely abnormal fronto-parietal aEEG. Shalak found that a combination of both mild and moderate encephalopathic clinical signs identified infants with an abnormal outcome at discharge with a sensitivity of 100% This is in keeping with our knowledge of the evolving nature of HIE [7,14] and it suggests that infants can subsequently develop moderate-severe encephalopathy following initial signs of mild encephalopathy
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