Past, present and future of hypothermic neuroprotection for neonatal encephalopathy in Japan: time to say good-by to the old remedies

Promoting sound development of preterm infants in the name of developmental neuroscience: Beyond advanced life support and neuroprotection

Despite the increased survival opportunities for extremely preterm infants, their long-term cognitive outcomes remain poor, with increased incidence of cognitive impairments in childhood and reduced opportunities to attend higher education in young adulthood compared to their term-born peers. Given that a considerable fraction of preterm infants develop cognitive impairments even without apparent sentinel events at birth and cerebral lesions on MRI assessed at term equivalent age, future strategies to improve the outcome may need to address cerebral dysfunction, which cannot be explained by the classical understanding of the injury cascade triggered by hypoxia-ischaemia around birth. Developmental care has been proposed to minimize neurodevelopmental impairments related to preterm birth. However, considerable modes of cares, environmental settings and procedures provided by the developmental care of current style appear to offer little benefit to the sound development of infants. Although it is obvious that advanced life support and neuroprotective treatments fall far short in compensating for the burden of preterm birth, researchers need to make further effort to fill the knowledge gap in the cerebral function of foetuses and newborn infants before establishing evidence-based developmental care. Clinicians need to develop an ability to translate the findings from basic and translational studies incorporating their potential biases and limitations. Care for newborn infants needs to be reassessed, including but not limited to developmental care, in the context that any sensory input and motor reaction of preterm infants may ultimately affect their cognitive functioning.

The baby cooling project of Japan to implement evidence-based neonatal cooling

Therapeutic hypothermia was first recommended as a standard of care by international guidelines in 2010. However, at that time, the number of centers capable of providing standard cooling was limited even in Japan. The aim of this project was to implement a nationwide network of evidence-based cooling within 3 years. A taskforce was formed in June 2010 to undergo the primary nationwide practice survey, design of action plans, and the appraisal of interventions by involving all registered level-II/III neonatal intensive care units in Japan. Based on findings from the primary survey, aggressive action plans were introduced that focused on the formulation of clinical recommendations, facilitation of educational events, and opening of an online case registry. Findings from the follow-up survey (January 2013) were compared with the results from the primary survey (June 2010). Four workshops and three consensus meetings were held to formulate clinical recommendations, which were followed by the publication of practical textbooks, large-scale education seminars, and implementation of a case registry. A follow-up survey covering 253 units (response rate: 89.1%) showed that cooling centers increased from 89 to 135. Twelve prefectures had no cooling centers in 2010, whereas all 47 prefectures had at least one in 2013. In cooling centers, adherence to the standard cooling protocols and the use of servo-controlled cooling devices improved from 20.7% to 94.7% and from 79.8% to 98.5%, respectively. A rapid improvement in the national provision of evidence-based cooling was achieved. International consensus guidelines coupled with domestic interventions might be effective in changing empirical approaches to evidence-based practice.