Severe HIE Research Articles

Seizures in Asphyxiated Term Newborns Based on Admission Thompson Score at the Women and Newborn Hospital, University Teaching Hospitals in Lusaka, Zambia.

Purpose: The main purpose of the study was to investigate seizures in asphyxiated term neonates based on the admission Thompson score at the University of Zambia, Women and New-born Neonatal Intensive Care Unit. Methodology: A cross-sectional descriptive study design was used to conduct the study between (May 2022 to April 2023) in the Neonatal Intensive Care Unit (NICU) at the University Teaching Hospital for Women and Newborns in Lusaka Zambia. Stratified sampling was used to collect 217 files of neonates born at the tertiary facility as well as those referred from other centres with Apgar scores of ≤ 7 at one and five minutes of life. A structured questionnaire was used to collect data from medical records, the Thompson score (TS) was assessed on admission and details of neonatal seizures were analyzed using chi-square, fisher’s exact test and multivariable logistic regression. Findings: On admission, TS assessment was conducted on all 217 neonates of which 169 (77.9 %) neonates were classified with mild HIE,45 (20.9 %) moderate and 3(1.4 %) with severe HIE. Most neonates (77.4%) presented with seizures on admission. Results of the chi-square and fisher's exact tests showed that Thompson's score on admission was significantly associated with seizure occurrence (p=0.001). On multivariable binary logistic regression neonates with moderate HIE had over 10 times more odds of seizure occurrence compared to neonates with a mild HIE score (aOR=10.6, CI=2.32, 48.1, p=0.002). A unique contribution to theory, practice, and policy: The study concluded that seizures were present in all categories of HIE, the majority of who were classified with moderate HIE based on the Thompson score. Therefore, improving the quality of intrapartum care at the Women and Newborn Hospital can significantly reduce the occurrence of asphyxia and its complication.

Perinatal risk factors for asphyxia and the occurrence of hypoxic-ischemic encephalopathy in newborns

Intranatal asphyxia and hypoxic-ischemic encephalopathy of newborns are caused by risk factors from both the mother and the fetus, which makes the pathophysiology of this condition extremely difficult. Data from the federal statistical observation form No. 32 for the Moscow region show minor changes in the number of chronic diseases, a burdened obstetric and gynecological history, as well as pathology during pregnancy and childbirth in pregnant women over 3 years Perinatal risk factors were significantly more common in newborns with severe intranatal asphyxia and HIE compared with a moderate degree who underwent a therapeutic hypothremia procedure. Complications during the birth process, surgical methods of rapid fetal extraction (vacuum extractor) were the causal factors of asphyxia. To a minor extent, the asphyxia of the newborn is affected by the untimely discharge of amniotic fluid.

Acute kidney injury in neonates with hypoxic ischemic encephalopathy based on serum creatinine decline compared to KDIGO criteria.

Neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia (HIE + TH) are at risk for acute kidney injury (AKI). The standardized Kidney Disease Improving Global Outcomes (KDIGO) criteria identifies AKI based on a rise in serum creatinine (SCr) or reduced urine output. This definition is challenging to apply in neonates given the physiologic decline in SCr during the first week of life. Gupta et al. proposed alternative neonatal criteria centered on rate of SCr decline. This study aimed to compare the rate of AKI based on KDIGO and Gupta in neonates with HIE and to examine associations with mortality and morbidity. A retrospective review was performed of neonates with moderate to severe HIE + TH from 2008 to 2020 at a single center. AKI was assessed in the first 7days after birth by KDIGO and Gupta criteria. Mortality, brain MRI severity of injury, length of stay, and duration of respiratory support were compared between AKI groups. Among 225 neonates, 64 (28%) met KDIGO, 69 (31%) neonates met Gupta but not KDIGO, and 92 (41%) did not meet either definition. Both KDIGO-AKI and GuptaOnly-AKI groups had an increased risk of the composite mortality and/or moderate/severe brain MRI injury along with longer length of stay and prolonged duration of respiratory support compared to those without AKI. AKI in neonates with HIE + TH was common and varied by definition. The Gupta definition based on rate of SCr decline identified additional neonates not captured by KDIGO criteria who are at increased risk for adverse outcomes. Incorporating the rate of SCr decline into the neonatal AKI definition may increase identification of clinically relevant kidney injury in neonates with HIE + TH.

Erythropoietin in Neonates with Perinatal Asphyxia Undergoing Therapeutic Hypothermia—A Prospective Cohort Study

Aims To assess the safety and feasibility of erythropoietin (EPO) in asphyxiated neonates undergoing therapeutic hypothermia (TH). Subjects and methods This study enrolled 60 neonates with HIE undergoing TH. 30 neonates were divided into EPO with TH group, where neonates received EPO (dose), at a dose rate of 1000 IU/kg/48 hours, for four doses and the remaining 30 neonates undergoing TH were into control group. Magnetic resonance imaging brain was undertaken between 10 and 14 days of life in surviving neonates. The Bayley Scales of Infant (BSI) Development IV was performed at regular intervals up to the age of 12 months. Results Amplitude-integrated electroencephalogram (aEEG) showed burst suppression (19% vs. 11%), low voltage (10% vs. 4%), and flat trace (7% vs. 3%) in control group in comparison with EPO concurrent with TH group which was statistically significant. Brain magnetic-resonance imaging (MRI) done at 12 days (±2 days) showed significant brain injury patterns such as severe brain injury (4% vs. 9% P = .05) and regional specific HIE (7% vs. 13%, P = .03) in control group of only TH neonates. At 12 months, neurodevelopment outcomes in EPO with TH group neonates showed a favorable outcome. Conclusion rhEPO concurrent with TH in HIE neonates resulted in significantly less severe brain injuries in MRI brain in HIE neonates. aEEG changes were less statistically significant in EPO with TH group with favorable neurodevelopmental outcomes at 12 months of age.

An observational, multicenter, registry-based cohort study of Turkish Neonatal Society in neonates with Hypoxic ischemic encephalopathy

Background Hypoxic ischemic encephalopathy (HIE) is a significant cause of mortality and short- and long-term morbidities. Therapeutic hypothermia (TH) has been shown to be the standard care for HIE of infants ≥36 weeks gestational age (GA), as it has been demonstrated to reduce the rates of mortality, and adverse neurodevelopmental outcomes. This study aims to determine the incidence of HIE in our country, to assess the TH management in infants with HIE, and present short-term outcomes of these infants. Methods The Turkish Hypoxic Ischemic Encephalopathy Online Registry database was established for this multicenter, prospective, observational, nationally-based cohort study to evaluate the data of infants born at ≥34 weeks GA who displayed evidence of neonatal encephalopathy (NE) between March, 2020 and April 2022. Results The incidence of HIE among infants born at ≥36 weeks GA (n = 965) was 2.13 per 1000 live births (517:242440), and accounting for 1.55% (965:62062) of all neonatal intensive care unit admissions. The rates of mild, moderate and severe HİE were 25.5% (n = 246), 58.9% (n = 568), and 15.6% (n = 151), respectively. Infants with severe HIE had higher rates of abnormal magnetic resonance imaging (MRI) findings, and mortality (p<0.001). No significant difference in mortality and abnormal MRI results was found according to the time of TH initiation (<3 h, 3–6 h and >6 h) (p>0.05). TH was administered to 85 (34.5%) infants with mild HIE, and of those born of 34–35 weeks of GA, 67.4% (n = 31) received TH. A total of 58 (6%) deaths were reported with a higher mortality rate in infants born at 34–35 weeks of GA (OR 3.941, 95% Cl 1.446–10.7422, p = 0.007). Conclusion The incidence of HIE remained similar over time with a reduction in mortality rate. The timing of TH initiation, whether <3 or 3–6 h, did not result in lower occurrences of brain lesions on MRI or mortality. An increasing number of infants with mild HIE and late preterm infants with HIE are receiving TH; however, the indications for TH require further clarification. Longer follow-up studies are necessary for this vulnerable population.

Volumetric changes in brain MRI of infants with hypoxic-ischemic encephalopathy and abnormal neurodevelopment who underwent therapeutic hypothermia

BackgroundHypoxic-ischemic encephalopathy (HIE) is a severe neonatal complication that can result in 40–60 % of long-term morbidity. Magnetic Resonance Imaging (MRI) is a noninvasive method which is usually performed before discharge to visually assess acquired cerebral lesions associated with HIE and severity of lesions possibly providing a guide for detecting adverse outcomes. This study aims to evaluate the impact of HIE on brain volume changes observed in MRI scans performed at a mean 10 days of life, which can serve as a prognostic indicator for abnormal neurodevelopmental (ND) outcomes at 18–24 months among HIE infants. MethodsWe retrospectively identified a cohort of HIE patients between June 2013 and March 2017. The inclusion criteria for therapeutic hypothermia (TH) were a gestational age ≥35 weeks, a birth weight ≥1800 g, and the presence of ≥ moderate HIE. Brain MRI was performed at a mean 10 days of life and brain volumes (total brain volume, cerebral volume, cerebellar volume, brain stem volume, and ventricle volume) were measured for quantitative assessment. At 18–24 months, the infants returned for follow-up evaluations, during which their cognitive, language, and motor skills were assessed using the Bayley Scales of Infant and Toddler Development III. ResultsThe study recruited a total of 240 infants between 2013 and 2017 for volumetric brain MRI evaluation. Among these, 83 were normal control infants, 107 were TH-treated HIE infants and 37 were HIE infants who did not receive TH due to contraindications. Clinical evaluation was further proceeded. We compared the brain volumes between the normal control infants (n = 83) with normal ND but TH-treated HIE infants (n = 76), abnormal ND TH-treated HIE infants (n = 31), and the severe HIE MRI group with no TH (n = 37). The abnormal ND TH-treated HIE infants demonstrated a significant decrease in brainstem volume and an increase in ventricle size (p < 0.001) (Table 4). Lastly, the severe brain MRI group who did not receive TH showed significantly smaller brain stem (p = 0.006), cerebellar (p = 0.006) and cerebrum volumes (p = 0.027), accompanied by larger ventricular size (p = 0.013) compared to the normal control group (Table 5). ConclusionIn addition to assessing the location of brain injuries in MRI scans, the reduction in brain stem volume coupled with an increase in ventricular volume in HIE infants may serve as a biomarker indicating severe HIE and adverse long-term ND outcomes among HIE infants who either received therapeutic hypothermia (TH) treatment or not.

Neurodevelopmental outcome of babies with moderate to severe birth asphyxia with hypoxic ischemic encephalopathy treated with and without therapeutic hypothermia followed up till 6-24 month of age at tertiary care hospital of Southern Rajasthan

hypoxic ischemic encephalopathy. There are very few studies comparing the neurodevelopmental outcomes in neonates with moderate to severe HIE who received and not received TH. Objective was assessment of neurodevelopmental outcome between TH and non-TH group till last follow-up. Methods: Hospital Based Prospective study. All term neonates with Moderate to severe birth asphyxia with HIE who received TH and not received TH, admitted in NICU of BalChikitsalay, RNTMC, Udaipur, consenting for the study were followed up at age 3-6 month, 6-12 month, 12-18 month and 18-24 month from September 2018 to February 2021 and neurodevelopment outcome was assessed. Results: 70 neonates with birth asphyxia HIE II / III were included in the study, 35 in TH group and 35 in non-TH group. Out of 70 babies enrolled 46 (65.7%) were having normal development and 24 (34.3%) were having development delay. Out of 46 who were having development delay 6 (17.4%) were of TH group and 18 (51.4%) were of non-TH group. Most of the babies of TH group i.e., 30 (85.7%) were neurodevelopmentally normal and 5 (14.3%) were having some neurodevelopmental abnormality. In non-TH group 15 (42.8%) were normal and 20 (57.2%) were having some neurodevelopmental abnormality. Conclusions: Results of the study showed significantly better outcome in infant who received therapeutic hypothermia than those who did not.

Prediction of outcome of hypoxic-ischemic encephalopathy in newborns undergoing therapeutic hypothermia using heart rate variability.

To assess the use of continuous heart rate variability (HRV) as a predictor of brain injury severity in newborns with moderate to severe HIE that undergo therapeutic hypothermia. Two cohorts of newborns (n1 = 55, n2 = 41) with moderate to severe hypoxic-ischemic encephalopathy previously treated with therapeutic hypothermia. HRV was characterized by root mean square in the short time scales (RMSS) during therapeutic hypothermia and through completion of rewarming. A logistic regression and Naïve Bayes models were developed to predict the MRI outcome of the infants using RMSS. The encephalopathy grade and gender were used as control variables. For both cohorts, the predicted outcomes were compared with the observed outcomes. Our algorithms were able to predict the outcomes with an area under the receiver operating characteristic curve of about 0.8. HRV assessed by RMSS can predict severity of brain injury in newborns with HIE.

Citicoline in hypoxic ischemic encephalopathy in neonates: a randomized controlled trial

BackgroundHypoxic-ischemic encephalopathy (HIE) is one of the major complications that can lead to death or disability in neonates. We assessed the effect of citicoline as a neuroprotector in neonates with moderate and severe HIE.MethodsThis clinical trial was carried on 80 neonates with moderate to severe HIE who were not candidates for therapeutic cooling. They were subdivided randomly into two groups; citicoline treatment group which included 40 neonates who received citicoline 10 mg / kg /12 h IV for 4 weeks plus other supportive measures and the control group which included 40 neonates who were managed with placebo and the same supportive measures. All patients were evaluated for duration of mechanical ventilation (MV), need for inotropes, seizures (type, frequency, and duration), and duration of NICU. Cranial ultrasounds and brain magnetic resonance image (MRI) were performed for all included neonates after 4 weeks of treatment. Follow- ups of all neonates for the neurodevelopmental outcomes were done at 3, 6, 9, and 12 months.ResultsThere was a significant reduction in the number of neonates having seizures after discharge in the citicoline-treated group (2 neonates) compared to the control group (11 neonates). Cranial ultrasound and MRI findings at 4 weeks were significantly better in the treatment group compared to the control group. Moreover, neurodevelopmental outcome showed significant improvement at 9 and 12 months in the citicoline treated neonates compared to the control group. There was statistically significant reduction in the duration of seizures, NICU stay, inotrope use, and MV in the treatment group compared to the control group. Citicoline was well tolerated with no remarkable side effects.ConclusionCiticoline could be a promising neuroprotector drug in neonates with HIE.Trial registrationThe study was registered at ClinicalTrials.gov (NCT03949049). Registered at 14 May 2019, https://clinicaltrials.gov/ct2/show/NCT03949049

Use of EEG in neonatal hypoxic-ischemic encephalopathy: A French survey of current practice and perspective for improving health care

ObjectivesControlled therapeutic hypothermia (CTH) is a standard of care in the management of neonatal hypoxic-ischemic encephalopathy HIE in newborns after 36 weeks of gestational age (WGA) in France. The electroencephalogram (EEG) plays a major role in HIE diagnosis and follow-up. We conducted a French national survey on the current use of EEG in newborn undergoing CTH. MethodsBetween July and October 2021, an email survey was sent to the heads of the Neonatal intensive care units (NICUs) in metropolitan and overseas French departments and territories. ResultsOut of 67, 56 (83%) of NICUs responded. All of them performed CTH in children born after 36 WGA with clinical and biological criteria of moderate to severe HIE. 82% of the NICUs used conventional EEG (cEEG) before 6 h of life (H6), prior to CTH being performed, to inform decisions about its use. However, half of the 56 NICUs had limited access after regular working hours. 51 of the 56 centers (91%) used cEEG, either short-lasting or continuous monitoring during cooling, while 5 centers conducted only amplitude EEG (aEEG). Only 4 of 56 centers (7%) used cEEG systematically both prior to CTH and for continuous monitoring under CTH. DiscussionThe use of cEEG in the management of neonatal HIE was widespread in NICUs, but with significant disparities when considering 24-hour access. The introduction of a centralized neurophysiological on-call system grouping several NICUs would be of major interest for most centers which do not have the facility of EEG outside working hours.

The Short Term Outcome of Therapeutic Hypothermia Compared with Standard Treatment among Asphyxiated Newborns Presenting after 6 hours of Life

Objectives: To compare the short term outcome of therapeutic hypothermia in asphyxiated newborn with standard treatment presenting after 6 hours of life. Methodology: It was Randomized controlled trial conducted in the department of Pediatric Medicine, Bahawal Victoria Hospital, Bahawalpur from December 2018 to June 2019 after taking ethical approval from institutional ethical review committee and informed written consent from parents of patients. Confidentiality of the data was maintained and it was assured that no harm to study participants is done. A total of 108 term neonates with moderate to severe HIE presenting &gt;6 hours of life were included. Preterm infants, major congenital anomaly and overt bleeding were excluded. Then selected patients were placed randomly into Group A (hypothermia group) &amp; Group B (conservative group), by using lottery method. Outcome variable like mortality within 1st week was noted. There was no conflict of interest in the study and funding was done by the authors. Results: The mean age of patients in group A was 17.69 ± 6.68 hours and in group B was 17.60 ± 6.65 hours. Out of 108 patients, 62 (57.41%) were males and 46 (42.59%) were females with male to female ration of 1.3:1. There was mortality within one week (short term outcome) in 07 (12.96%) patients in Group A (hypothermia group) while in Group B (conservative group), it was seen in 16 (29.63%) patients. Conclusion: This study concluded that there is benefit of therapeutic hypothermia in asphyxiated newborns after 6 hours of life and short term outcome is better after therapeutic hypothermia in asphyxiated newborns. Keywords: Asphyxia, Encephalopathy, Mortality, Cooling.

OBSERVATIONAL STUDY ON ROLE OF NEUROSONOGRAM IN INTRACRANIAL PATHOLOGIES IN NEONATES AT A TERTIARY CARE CENTER.

ABSTRACT BACKGROUND AND OBJECTIVES: Neonates face a lot of challenges especially based on their gestational age, maternal factors, birth weight at the time of delivery, immediate cry following birth. H ypoxic ischemic encephalopathy and Germinal matrix haemorrhage constitutes major portion of those challenges. To identify varied conditions, we can take help of imaging in form of neurosonogram. METHODS : Neurosonogram was carried out on all n tool including followeonates both as screening and diagnostic up scans. A total of 100 preterm babies with positive findings were included in the study. An analysis was performed over different pathologies including grading of specific condition in requir ed areas. RESULTS: Our study comprising of 100 neonates with brain pathologies showed following results. In our study of 100 neonates, most of the disease burden is by vascular causes (56%), then followed by infective (19%), congenit al (14%), trauma (8%), metabolic (2%) and miscellaneous (2%). 52% of PVL showed associated risk factors. CONCLUSION: In our study 100 preterm babies with suspected brain injuries were studied with ultrasound through anterior fontanelle and mastoid sutures. Neurosonogram can detect various intracranial pathologies on par with CT scan . Transcranial doppler can reflect the cerebral blood volume and perfusion status through RESISTIVE INDEX and abnormal values according to literature are &gt;0.8 and &lt;0.4 and can be noticed in severe HIE and conditions which increases intracranial pressure . Any measure that decreases the vasospasm which decreases RI can eventually prevent the neonate having progression of ischemia and further new infarct. 1

Placental pathology as a marker of brain injury in infants with hypoxic ischemic encephalopathy

BackgroundHypoxic Ischemic Encephalopathy (HIE) can lead to devastating consequences for the affected infant. Although therapeutic cooling benefits infants with moderate and severe HIE, differentiating mild from moderate-severe HIE may be challenging. The placenta reflects the fetal intrauterine environment and may reveal underlying processes that affect brain injury. AimTo describe placental histopathology using the Amsterdam Placental Workshop Group Criteria in different grades of HIE. Study designRetrospective cohort. SubjectsInfants admitted to a tertiary care neonatal intensive care unit with a diagnosis of HIE between 2011 and 2016. Outcome measureMaternal and neonatal clinical variables and placental histopathology using the Amsterdam Placental Workshop Group Criteria were compared between mild and moderate-severe HIE. Mann-Whitney or t-test or ꭓ2 were performed for bivariate associations as appropriate. To explain the relationship between placental pathology and severity of HIE odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using logistic regression models. ResultsOf the 73 infants in the study, 23 had mild and 50 moderate-sever HIE. There was no difference in maternal and neonatal characteristics except for sentinel events which were higher in the moderate- severe group. On placental histopathology, acute inflammation, including fetal inflammatory reaction (FIR) were significantly higher in the moderate-severe group. After adjusting for confounders, FIR remained significantly associated with moderate-severe HIE, ORs 6.29, 95 % CI 1.5–25. ConclusionOur study demonstrates FIR in the placenta is associated with severity of HIE.

Neonatal Hypoxic-Ischemic Encephalopathy: Perspectives of Neuroprotective and Neuroregenerative Treatments.

Hypoxic-ischemic encephalopathy (HIE) is a serious condition that could have deleterious neurological outcomes, such as cerebral palsy, neuromotor disability, developmental disability, epilepsy, and sensitive or cognitive problems, and increase the risk of death in severe cases. Once HIE occurs, molecular cascades are triggered favoring the oxidative stress, excitotoxicity, and inflammation damage that promote cell death via apoptosis or necrosis. Currently, the therapeutic hypothermia is the standard of care in HIE; however, it has a small window of action and only can be used in children of more than 36 gestational weeks; for this reason, it is very important to develop new therapies to prevent the progression of the hypoxic-ischemic injury or to develop neuroregenerative therapies in severe HIE cases. The objective of this revision is to describe the emerging treatments for HIE, either preventing cell death for oxidative stress, excitotoxicity, or exacerbated inflammation, as well as describing a new therapeutic approach for neuroregeneration, such as mesenchymal stem cells, brain-derived neurotrophic factor, and gonadotropin realizing hormone agonists.

58 Relationship Between Early Laboratory Measures and Neurological Injury in Neonates Undergoing Therapeutic Hypothermia

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Hypoxic-ischemic encephalopathy (HIE) is a major contributor to morbidity and mortality. Therapeutic hypothermia (TH) is the standard of care for neonates with moderate to severe HIE. Brain magnetic resonance imaging (MRI) is the imaging modality of choice for confirmation of HIE, assessment of injury severity, and prognostication. Reliable, inexpensive and widely available laboratory measures for early identification of risk for neurological injury can play a critical role in the optimal management of neonatal HIE, especially in the resource-limited setting. Our study examined whether derangements in early routine laboratory measures (acid-base, haematological, metabolic) were worse in neonates with MRI findings of neurological injury. Objectives Primary objective: To evaluate the role of early laboratory measures in predicting neurological injury as detected by MRI at 72 hours. Secondary objective: To evaluate the role of early laboratory measures in predicting survival to NICU discharge in patients with HIE. Design/Methods This single-centre, retrospective cohort study included neonates ≥ 35 weeks gestation with moderate to severe HIE, who had undergone therapeutic hypothermia. Based on findings of brain MRI completed within 72 hours of life, our cohort was divided into 2 groups: neonates with, and without, evidence of neurological injury consistent with HIE. Baseline characteristics, as well as laboratory measures, were compared between groups, and a receiver operating characteristic (ROC) curve analysis was conducted to determine the cut-off for prediction of neurological injury based on the highest sensitivity and specificity values. Results 104 neonates were analyzed. Baseline characteristics (Table 1) were similar between both groups, except for cord venous pH and base excess (BE), which were significantly lower in the abnormal MRI group (p = 0.02). In bivariate analysis, pH (at 1 h of age, p = 0.027), BE (at 1 h, p = 0.001, and 6 h of age, p = 0.004), ionized calcium (at 6 h of age, p = 0.02), and platelets (at 1 h of age, p = 0.004) were significantly different in neonates with abnormal MRI. In ROC curve analysis, BE at 1 h of life was the best predictor of abnormal MRI (AUC = 0.71, p = 0.002), with a cut-off value of ≤ -14.95, sensitivity of 67% and specificity of 66% (Figure 1). Conclusion Among neonates with HIE undergoing TH, early laboratory measures such as acid-base status, ionized calcium, and platelet count were worse in neonates with abnormal MRI, in comparison to neonates with normal MRI. Base excess at 1 h of life is a good predictor of abnormal MRI. Future prospective studies to validate these findings are needed

Outcomes for Newborns with Mild Hypoxic-Ischemic Encephalopathy: A Retrospective Study

Background: HIE remains a significant cause of mortality and long-term disability in late preterm and term newborns. At birth, the only available distinction between mild, moderate, and severe HIE is based on the clinical ground. Nevertheless, mild HIE can be presented with subtle or subjective clinical features which may mislead the treating physician and delay his decision to intervene. Methods: This is a retrospective descriptive study examined all inborn newborns ≥ 35 weeks gestational age born at a single, tertiary level Neonatal Intensive Care Unit (NICU) in women’s hospital. The study revised newborns who were admitted to NICU during the period from November 2014 till November 2020 under the diagnoses of mild HIE. The decision to start therapeutic hypothermia in cases of mHIE was off-label and it was taken according to the clinical judgment of the treating team. Results: Out of the 265 newborns admitted with a history suggestive of HIE or neurological deficits, only 116 newborns matched the diagnosis of mHIE according to the above-mentioned exclusions. 19 newborns out of the 116 mHIE cases received therapeutic hypothermia. Antepartum and or intrapartum complications were recorded in 48 mothers including an infant of insulin-dependent diabetic mother 12, pre-eclampsia 3, cord prolapse 2, shoulder dystocia 2, antepartum hemorrhage 8, chorioamnionitis 6, poor CTG tracing 13, and ruptured uterus 2. Mean gestation was 38±2 weeks, mean birth weight was 3.0±0.5 kg, Cesarean section was 57 % in the un-cooled group vs 75% in the cooled group. Mean Apgar score at 10th minute was 7.9±1.8 vs 5.3±2.2 in the un-cooled vs cooled group, the p-value is 0.002. Arterial cord pH was 7.15±0.3 vs 6.92±0.26. The base deficit in the first-hour blood gas was -7.83±5 vs -12± 5.6 (P=0.005). The Total number of cooled newborns was 19 (16%). Respiratory support was required in 76% of un-cooled newborns vs 95 % of cooled newborns. Most of the newborns have achieved full sucking power within 10 days (99%). Cooled newborns had to stay longer in the NICU because of the added number of cooling where the length of stay was 11±4.7 days vs 6.9±4.7 days in un-cooled newborns. The MRI brain was done on 25 newborns, 12 MRIs were reported as abnormal (48 %) and consistent with hypoxic-ischemic changes, 5/97 in the un-cooled cases and 7 in the cooled cases. Neurodevelopmental assessments at 12 months and 18 months of age were abnormal in 14/116 newborns (12%). Conclusion: The current assumptions about the benignity of mild form of HIE may not be accurate. More attention to this category of HIE, clear diagnostic criteria, longer clinical observation, and vigilant neurological assessment are all required.

Neurological assessment and immediate outcome of newborns treated with therapeutic hypothermia at tertiary care hospital of southern Rajasthan-a randomized control trial

Background: Therapeutic hypothermia (TH) is standard-of-care for infants with moderate and severe HIE in developed countries; TH has been shown to decrease the risk of brain injury in asphyxiated newborns. Observations were like: 1) Asses morbidity and mortality in neonates with moderate and severe birth asphyxia treated with TH and 2) Asses neurological outcome in neonates.Methods: A RCT was done in NICU of Balchikitsalaya, RNTMC, Udaipur. Phase changing material, FS 21, FS 29 used to provide TH for 72 hours, started within 6 hours of birth and neurological outcome was assessed.Results: Total 60 neonates were enrolled 30 cases given TH and 30 control not given TH. Neurological assessment on basis of Thompson scoring, done on admission, 24, 48, 72 and 96 hours for both groups. At 48 hours, mean score in controls 14.5±1.67 and cases 11.47±2.34 (p&lt;0.05). At discharge, mean score for controls was 11.31±3.67 and for cases was 5.24±2.72 (p&lt;0.005). Mortality was 4 (13.3%) in cases and 11 (36.7%) in control group. Among 45 survivors, 25 (55.5%) required anticonvulsant at discharge; 15 from controls, 10 from cases group.Conclusions: There was significant decrease in mortality in birth asphyxia babies given TH as compared to babies not given TH. Also, significant improvement in Thompson score among the cooled neonates at and after 48 hours of age suggestive of better immediate neurological outcome in these babies. Anticonvulsant’s requirement was also significantly less in therapeutic hypothermia group.

Newer Therapies In Management of Neonatal Birth Asphyxia

Asphyxia is an insult to the fetus or newborn due to lack of oxygen or lack of perfusion to various organs.1 National Neonatology Forum of India has defined asphyxia as gasping or ineffective breathing or lack of breathing at 1 min of life.2Birth asphyxia is one of the most important causes of neonatal brain injury whose incidence ranges from 3.7 to 9/1000 deliveries in the west.3 With the advent of therapeutic hypothermia (TH), improved outcomes are being reported in moderate HIE. TH, however, has not demonstrated improvement in outcomes related to severe HIE. . This has led clinicians and researchers to continue evaluating complementary and/or alternative therapies for infants with HIE. In this review, we will discuss current and emerging therapies in the management of HIE, other than hypothermia. With issues of access to health care and the burden of birth asphyxia shifting to developing and least developed nations, there is a need for alternative and supplementary neuroprotective agents. Low cost and easy availability along with ease of use would assist in ensuring that these therapies have global applicability. So global efforts must be taken to increase such studies as birth asphyxia is causing more morbidity &amp; mortality globally.

Feasibility of minimal enteral nutrition in neonates with perinatal asphyxia during therapeutic hypothermia: A randomized controlled trial.

Background: Therapeutic Hypothermia (TH) is a standard of care for neonates with birth asphyxia with moderate to severe hypoxic-ischemic encephalopathy. Despite lack of evidence, it is common practice to withhold feeds during TH due to risk of NEC. As there are no prior Indian studies and in view of limited evidence, this study was aimed to assess the feasibility of minimal enteral nutrition in our cohort of asphyxiated neonates during TH. Methods: This study was conducted in the Level III a NICU of Shri BM Patil Medical College Hospital and Research Centre, Vijayapura. Design: Open-label, parallel grouped, randomized controlled trial. 100 asphyxiated neonates undergoing therapeutic hypothermia were enrolled. Eligible newborns were randomized to receive either minimal enteral feeding or no feeding (50 newborns in each group) during therapeutic hypothermia. Results: Both groups were comparable in maternal and neonatal characteristics. Among 100 cooled neonates, 50 cooled neonates were randomized to MEN group and 50 cooled neonates to Control group. No statistically significant differences were observed among complications associated with therapeutic hypothermia between MEN group and Control group. Indicators of Sepsis and NEC such as Leucopenia/Neutropenia/Thrombocytopenia were observed in both groups which was not statistically significant (p>0.05). MEN neonates had a reduced length of hospital stay (mean 9 ± 2 days vs. 14 ± 3 days, p<0.05), and time to reach full oral feeds (7 ± 2 days vs. 12 ± 3 days, p<0.05). Conclusion: Minimal enteral feeding for neonates with moderate or severe HIE receiving therapeutic hypothermia is safe and feasible and associated with decreased time to reach full enteral feeding and reduced NICU stay and is not associated with significant complications like NEC.

Ecthyma Gangrenosum in 5-Month-Old Long-Term Ventilated Infant: A Case Report

Rationale: Ecthyma gangrenosum (EG) is an aggressive cutaneous disease caused by local or systemic infection with Pseudomonas aeruginosa. EG is characterized by cutaneous manifestations ranging from nodule and papule to necrotic ulceration with surrounding erythema, especially with black eschar or central crust. EG presents with characteristic skin lesions which is important to establish diagnosis of sepsis caused by P aeruginosa, a serious condition that can be treated efficiently if diagnosed early. Patient concerns: A 5-month-old male infant, case of Severe HIE, Ventilatory dependent with Tracheostomy, NGT feeding, Epilepsy and dystonia admitted to Cambridge Medical and rehabilitation Center (CMRC)–AUH -UAE. Developed characteristic skin lesions of EG and developed sepsis. Diagnoses: Ecthyma gangrenosum and sepsis caused by Pseudomonas aeruginosa. Interventions: Meropenem was used in combination with Vancomycin at first and then continued only with Meropenem. Outcomes: Cure. Lessons: Early recognition of EG plays an important role in providing appropriate empiric antibiotic treatment at early stage and improves the prognosis. Close clinical follow up on skin lesion evolution is an alternative to possible invasive management.