Neonatal neurological examination during the first 6h after birth

A New Horizon for Understanding the Comparative Effectiveness for Cooling Prospectively Infants with Mild Encephalopathy

The authors summarize the methodology for a new pragmatic comparative effectiveness research investigation, Cooling Prospectively Infants with Mild Encephalopathy (COOLPRIME), which uses sites' existing mild hypoxic-ischemic encephalopathy (HIE) treatment preference (hypothermia or normothermia) to assess hypothermia effectiveness and safety. COOLPRIME's primary aim is to determine the safety and effectiveness of hypothermia compared to normothermia in mild HIE. Engagement of Families and Community Affected by Hypoxic-Ischemic Encephalopathy strongly favored Effectiveness over Efficacy Trials leading to COOL PRIME design.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants

BACKGROUND

To determine the diagnostic accuracy of Hammersmith Neonatal Neurological Examination (HNNE) at 30-32 weeks postmenstrual age (PMA, 'Early') and term equivalent age (TEA) in infants born <31 weeks PMA to predict cognitive outcomes at 12 months corrected age (CA).

METHODS

Prospective cohort study of 119 infants (73 males; median 28.4 weeks gestational age at birth) who underwent Early and TEA HNNE. At 12 months CA, 104 participants completed Bayley Scales of Infant and Toddler Development, 3rd Edition, (Bayley-III). Optimum cut-off points for each HNNE subscale were determined to establish diagnostic accuracy for predicting adverse cognitive outcomes on the Bayley-III Cognitive Composite Scale (≤85).

RESULTS

The best diagnostic accuracy for HNNE total score at 30-32 weeks PMA predicting cognitive impairment occurred at cut-off ≤16.7 (sensitivity (Se) = 71%, specificity (Sp) = 51%). The Abnormal Signs subscale demonstrated the best balance of sensitivity/specificity combination (Se = 71%, Sp = 71%; cut-off ≤1.5). For HNNE at TEA, the total score at cut-off ≤24.5 had Se = 71% and Sp = 47% for predicting cognitive impairment. The Tone Patterns subscale demonstrated the strongest diagnostic accuracy at TEA (Se = 71%, Sp = 63%; cut-off ≤3).

CONCLUSIONS

Early and TEA HNNE demonstrated moderate diagnostic accuracy for cognitive outcomes at 12-months CA in infants born <31 weeks gestational age.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; Trial Registration Number: ACTRN12613000280707; web address of trial: http://www.ANZCTR.org.au/ACTRN12613000280707.aspx .

IMPACT

Early Hammersmith Neonatal Neurological Examination (HNNE) assessment at 30-32 weeks postmenstrual age has moderate diagnostic accuracy for cognitive outcomes at 12 months corrected age in infants born <31 weeks gestation. Early HNNE at 30-32 weeks has stronger predictive validity than HNNE at term equivalent age. Early HNNE may provide an early marker for risk-stratification to optimise the planning of post-discharge support and follow-up services for infants born preterm.

A Neurologist's Guide to Neonatal Neurodevelopmental Assessments and Preterm Brain Injury

Despite advances in medical care and improved survival of extremely preterm infants, rates of neurodevelopmental impairment remain high. Outcomes are significantly improved with early intervention, but infants must be appropriately identified to facilitate services. Neuroimaging provides important information regarding neurodevelopmental outcomes but prognosticating and communicating risk remains challenging. Standardized neonatal neurodevelopmental assessments provide supplemental information to aid in the identification of high-risk infants and counseling for their families.

New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care

Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.

Gestational Age-Specific Distribution of the Hammersmith Neonatal Neurological Examination Scores Among Low-Risk Neonates in Ghana

OBJECTIVE

To describe gestational age-specific distribution of scores for the Hammersmith Neonatal Neurological Examination (HNNE) up to 48 h after birth in a low-risk, term-born, single-center sample in Ghana.

STUDY DESIGN

This is a nested substudy of a larger prospective study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment) comprising 140 low-risk, term-born neonates at Korle Bu Teaching Hospital in Accra, Ghana, between November 2018 and February 2019. The sample was stratified into three gestational age groups: early-term (37 + 0-38 + 6, weeks + days; n = 61), full-term (39 + 0-40 + 6, weeks + days; n = 52), and late/post-term (41 + 0-42 + 6, weeks + days; n = 27). Neonates were administered the 34-item HNNE by trained physicians. As per the original British scoring system, raw scores for the Ghanaian sample were plotted and scores > 10th centile were assigned a score of 1, 5th-10th centile 0.5, and < 5th centile 0.

RESULTS

The range of raw scores for 16/34 HNNE items varied with gestational age. Specifically, 100% (7/7), 50% (5/10), 33% (1/3), 33% (1/3), 20% (1/5), and 14% (1/7) of items within the orientation and behavior, tone, abnormal signs/patterns, movements, tone patterns, and reflexes subdomain, respectively showed a different distribution of scores above the 10th centile across the three gestational age groups.

CONCLUSION

Differences in gestational age-specific results within our sample in comparison to the original British sample could be, albeit unlikely, due to misclassification of gestational age, unmeasured maternal or fetal morbidity, or perhaps more likely, variation in testing or test conditions, or some combination of these. Genetic variation in neurological development is also a possibility. Further research is warranted to determine the reasons for differences. Our findings highlight the need to determine the accuracy and reliability of standardized neurologic assessments in predicting neurodevelopmental risk for infants in low- and middle-income countries.

Perspectives from the Society for Pediatric Research. Neonatal encephalopathy clinical trials: developing the future

The next phase of clinical trials in neonatal encephalopathy (NE) focuses on hypothermia adjuvant therapies targeting alternative recovery mechanisms during the process of hypoxic brain injury. Identifying infants eligible for neuroprotective therapies begins with the clinical detection of brain injury and classification of severity. Combining a variety of biomarkers (serum, clinical exam, EEG, movement patterns) with innovative clinical trial design and analyses will help target infants with the most appropriate and timely treatments. The timing of magnetic resonance imaging (MRI) and MR spectroscopy after NE both assists in identifying the acute perinatal nature of the injury (days 3-7) and evaluates the full extent and evolution of the injury (days 10-21). Early, intermediate outcome of neuroprotective interventions may be best defined by the 21-day neuroimaging, with recognition that the full neurodevelopmental trajectory is not yet defined. An initial evaluation of each new therapy at this time point may allow higher-throughput selection of promising therapies for more extensive investigation. Functional recovery can be assessed using a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action. As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow safe, efficient, and targeted therapeutics. IMPACT: As precision medicine revolutionizes healthcare, it should also include the redesign of NE clinical trials to allow faster development of safe, effective, and targeted therapeutics. This article provides a multidisciplinary perspective on the future of clinical trials in NE; novel trial design; study management and oversight; biostatistical methods; and a combination of serum, imaging, and neurodevelopmental biomarkers can advance the field and improve outcomes for infants affected by NE. Innovative clinical trial designs, new intermediate trial end points, and a trajectory of neurodevelopmental evaluations targeted to a prespecified and mechanistically derived hypothesis of drug action can help address common challenges in NE clinical trials and allow for faster selection and validation of promising therapies for more extensive investigation.

Neonatal neurological examination in a resource-limited setting: What defines normal?

OBJECTIVE

To describe the results of the Hammersmith Neonatal Neurological Examination (HNNE) in a low-risk, term-born, contemporary sample in Ghana. Of particular interest was to compare these findings with the original British study that validated the HNNE, and published data from other low- and middle-income countries.

STUDY DESIGN

In a nested substudy of a larger prospective study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment), 140 low-risk, term-born neonates (39.3 ± 1.4 weeks gestation) at Korle Bu Teaching Hospital in Accra, Ghana were administered the 34-item HNNE from birth to 48 h of age by trained physicians. Neonates' performance was compared with previously published normative data from the United Kingdom (1998), and published data from Thailand, Myanmar, Vietnam, and Uganda.

RESULTS

Ghanaian neonates demonstrated lower scores on 29/34 HNNE items relative to normative data from the United Kingdom (P < .05), with only 5% of Ghanaian neonates in our sample classified as neurologically optimal. There were significant differences in the proportion of neonates scoring optimally per HNNE item between our Ghanaian sample, compared with published data from other settings (Thai [13/16 items], Burmese [14/16 items], Vietnamese [7/9 items], and Ugandan [22/34 items] neonates). Raw scores were markedly different between Ghanaian and British neonates, with Ghanaian neonates demonstrating lower median and wider range of scores. These differences were less prominent between Ghanaian and Ugandan neonates.

CONCLUSION

Our findings raise questions as to whether or not the thresholds for optimality for the HNNE based on data from the United Kingdom are applicable to Ghanaian newborns. Our study could not fully resolve whether the differences in scores were due to genetic differences in developmental pathways, the implementation of the assessment, or the characteristics of our sample. Low proportions of neonates scoring optimally from other low- and middle-income countries suggest the need for further research to determine the clinical utility of the HNNE in resource-limited settings, including the predictive value for neurodevelopment later in infancy.

Inter-rater reliability of the modified Sarnat examination in preterm infants at 32-36 weeks' gestation

OBJECTIVE

To test the inter-rater reliability of the modified Sarnat neurologic examination in preterm neonates and to correlate abnormalities with the presence of perinatal acidosis.

METHODS

Prospective study of 32-36 weeks' gestational age infants admitted to the neonatal intensive care unit. Each infant had two Sarnat examinations performed at <6 h, one by a gold standard (GS) study investigator, and the second either by (a) another GS examiner or (b) an attending physician (28 examiners), all blinded to clinical variables. Agreement was calculated using kappa (k) statistics.

RESULTS

One hundred and two (9, fetal acidosis) infants underwent a modified Sarnat examination. Among GS examiners, agreement was excellent (k > 0.8) except for Moro, while among all examiners agreement was very good (k > 0.7) except for both Moro and tone. Subgroup analysis at 32-34 weeks' showed fair/poor Moro compared to excellent agreement at ≥35 weeks. Increasing abnormalities correlated with acidosis (r = -0.6, P < 0.01).

CONCLUSIONS

Strong inter-rater reliability for the modified Sarnat was observed except for tone and Moro in preterm infants. Experience of the examiners resulted in improved reliability in tone, while for the Moro agreement improved only beyond 35 weeks. Findings suggest the need of adjustment of the examination form specific for preterm infants.