Need for more evidence in the prevention and management of perinatal asphyxia and neonatal encephalopathy in low and middle-income countries: A call for action

Neonatal Neurocritical Care in Low-Resource Settings: Challenges and Innovations in Hypoxic-Ischemic Encephalopathy

Many neonatal neuroprotective strategies have been developed to reduce the impact of hypoxic-ischemic encephalopathy on mortality and long-term neurodevelopmental outcomes. The most effective strategy to date is therapeutic hypothermia, which has been shown to improve survival rates and neurologic outcomes. However, a recent International Liaison Committee on Resuscitation statement recommends using therapeutic hypothermia only in specialized neonatal neurocritical care facilities, which are not universally accessible. Low-resource settings are particularly disadvantaged due to a lack of trained professionals, financial constraints, equipment scarcity, and inadequate infrastructure. While adjunctive neuroprotective therapies and telehealth tools may help to bridge this gap, more evidence is needed to establish effectiveness of these therapies.

Application and Acceptance of Bedside MRI in the NICU Setting

PURPOSE

This study aims to assess the applicability of ultralow-field (ULF) magnetic resonance imaging (MRI) in the neonatal intensive care unit (NICU), its impact on both the neonate being scanned and neighboring patients, and its effects on medical procedures and early parent-child interaction.

BACKGROUND

Neonatal MRI is crucial for diagnosis and treatment in the NICU, but access is limited, both in high-income countries and low- and middle-income countries. Portable ULF MRI presents an opportunity to expand access, but its applicability and potential impacts on neonates and nearby patients have not been studied, including its effects on medical care and early parent-child interaction.

METHODS

We assessed applicability, safety and stress levels of neonates during ULF MRI at a NICU by measuring heart rate, oxygen saturation and blood pressure of the neonate scanned and neighboring patients and by measuring subjective stress levels assessed by attending physicians, nurses and parents. Using questionnaires, we assessed whether medical care and early parent-child interaction was affected.

RESULTS

No significant differences were found in the physiological measures of the scanned and neighboring neonates. Medical care and parent-child interaction were not affected by ULF MRI.

CONCLUSIONS

ULF MRI can be safely performed in the NICU without causing stress to neonates or affecting medical care or parent-child interaction. It can be performed at the bedside during natural sleep, requiring fewer resources compared to high-field MRI, making it a viable point-of-care option in both the NICU and low-resource settings. This could significantly increase MRI accessibility.

Pragmatic strategies for improving prevention, diagnosis, and treatment of epilepsy in low- and middle-income countries

Epilepsy poses a major public health challenge in low- and middle-income countries (LMICs), where prevention, diagnosis, and treatment must be tailored to local resources, infrastructure, and cultural contexts. Despite their diversity, LMICs commonly experience a pronounced urban-rural disparity in epilepsy care, with rural communities facing limited healthcare infrastructure, a shortage of specialists, and pervasive stigma. Prevention efforts should focus on modifiable risk factors. Neurocysticercosis, a leading preventable cause of epilepsy in endemic regions, can be addressed through improved sanitation, access to clean water, and timely treatment supported by low-cost diagnostics. Enhancing perinatal care, injury prevention, and stroke management is also essential to reduce epilepsy incidence. Stigma continues to hinder care. Targeted education campaigns aimed at schools, community leaders, and the general public are vital to improving awareness and reducing discrimination. Bridging diagnostic gaps requires accessible, cost-effective tools such as portable EEGs, smartphone-based seizure recordings, and mobile diagnostic applications. Integration of these technologies into community health systems, and their use by trained primary care providers and community health workers, enables earlier detection and ongoing monitoring, particularly in underserved areas. Treatment strategies should prioritize "easy-to-use," well-tolerated medications such as levetiracetam. Improving the affordability of antiseizure medications involves promoting generic alternatives, revising patent laws, regulating drug prices, setting price ceilings for essential medicines, and enabling bulk procurement. National health insurance schemes are crucial to ensure access for low-income populations. Expanding access through home-based care by community health workers, mobile outreach clinics, telemedicine, and collaboration with traditional healers can further improve treatment adherence and outcomes. Finally, training primary care physicians in epilepsy care is essential, as they are often the first point of contact for patients in rural and resource-limited settings.

Neonatal encephalopathy and hypoxic-ischemic encephalopathy: the state of the art

Neonatal Encephalopathy (NE) remains a major cause of death and long-term severe disabilities, including epilepsy and cerebral palsy in term and near-term infants. The single most common cause is hypoxic-ischemic encephalopathy (HIE). However, there are many other potential causes, including infection, intracranial hemorrhage, stroke, brain malformations, metabolic disorders, and genetic causes. The appropriate management depends on both the specific cause and the stage of evolution of injury. Key tools to expand our understanding of the timing and causes of NE include aEEG, or even better, video EEG monitoring, neuro-imaging including cranial ultrasound and MRI, placental investigations, metabolic, biomarker, and genetic studies. This information is critical to better understand the underlying causes of NE. Therapeutic hypothermia improves outcomes after HIE, but there is still considerable potential to do better. Careful clinical and pre-clinical studies are needed to develop novel therapeutics and to help provide the right treatment at the right time for this high-risk population. IMPACT: Neonatal encephalopathy is complex and multifactorial. This review seeks to expand understanding of the causes, timing, and evolution of encephalopathy in newborns. We highlight key unanswered questions about neonatal encephalopathy.

Case Report: Ultralow-field portable MRI improves the diagnosis of congenital hydrocephalus

Introduction

Congenital hydrocephalus is an increasing condition both in high as in low and middle income countries. Main causes include aqueductal stenosis, neonatal central nervous system infections, intracranial hemorrhage, malformations and tumors. Investigation of its etiology should include magnetic resonance imaging (MRI) to detect especially pathologies of the fossa cranii posterior. However, MRI is not available to every infant presenting with congenital hydrocephalus especially in those countries with the highest prevalence. New portable ultralow-field MRI (ULF) allows low resource and bedside imaging and thus widens the access to MRI for those infants. This study presents two cases of newborns with congenital hydrocephalus who underwent ULF scanning revealing a tumor of the fossa cranii posterior as cause of hydrocephalus. This study shows that ULF scanning allows to detect and characterize brain tumors as well as metastases.

Setting and patients

In this case report, we present two cases of newborns antenatally diagnosed with hydrocephalus with no further pathology detected in repeated cranial ultrasound and, in one case, fetal MRI. We performed ULF imaging using a portable 0.064T MRI during natural sleep and high-field 3T MRI to investigate the etiology of congenital hydrocephalus in these infants.

Main results

ULF imaging revealed a tumor of the fossa cranii posterior in both cases. MRI signalling detected in ULF imaging was specific for each tumor (ATRT, low grade glioma). In one case, ULF imaging also detected intracerebral metastasis.

Conclusions

We demonstrated that ULF imaging is able to detect tumors of the fossa cranii posterior that are not detected on ultrasound and shows their specific MR-signalling as well as detect metastasis. Additionally, compared to 3T MRI, ULF MRI was able to reveal significant findings while requiring fewer resources and being easier to perform. Therefore, we propose that children with congenital hydrocephalus not showing any abnormalities on cranial ultrasound should undergo ULF MRI. This imaging modality holds potential for monitoring neonatal tumors and detecting metastasis.

Survival Status and Predictors of Mortality Among Asphyxiated Neonates Admitted to Jimma University Medical Center, Southwest Ethiopia: A Retrospective Cohort Study

Background and Aims

Perinatal asphyxia is the second leading cause of neonatal mortality in sub-Saharan African countries, including Ethiopia. This study aimed to assess survival status and predictors of mortality among neonates admitted to Jimma University Medical Center with perinatal asphyxia.

Methods

A retrospective cohort study was conducted on 373 asphyxiated neonates admitted to Jimma University Medical Center from April 12, 2019, to May 5, 2022. Data were collected from May 18 to June 3, 2022, entered into Epidata version 3.1, and analyzed using R software version 4.2.1. On univariate Cox regression, variables with a p < 0.25 were selected for the final model. Multivariate Cox regression was used to identify significant predictors of mortality among asphyxiated neonates at a 0.05 level of significance and a corresponding 95% confidence interval of the adjusted hazard ratio.

Results

The median survival time of the participants was 20 (95% CI: 18-23) days. During 2888 days of total person-time at risk, a 29.09 (95% CI: 23.20-36.01) per 1000 person-days incidence rate of neonatal mortality was identified. The significant predictors of mortality were stage III Hypoxic ischemic encephalopathy (AHR: 3.46, 95% CI: 1.55-7.70), acute kidney injury (AHR: 2.82, 95% CI: 1.28-6.23), and stress ulcers (AHR: 2.24, 95% CI: 1.26-3.97).

Conclusion

The incidence of mortality was relatively high among the study participants. Stage III Hypoxic ischemic encephalopathy, acute kidney injury, and stress ulcers were significant predictors.

Neonatal Shock: Current Dilemmas and Future Research Avenues

Neonatal shock presents a complex clinical challenge and is one of the leading causes of mortality. Traditionally, neonatal shock is equated to hypotension, and therapeutics are often initiated based on low blood pressure (BP) values alone. This fails to address the underlying goal of optimizing the tissue perfusion resulting in both over- and under-treatment of neonatal shock. Also, what defines a normal BP in neonates is still a contentious topic. Further, the most appropriate way of measuring BP in neonates with shock is still debated. Shock secondary to transient circulatory instability and patent ductus arteriosus, conditions that are unique to preterm neonates, have not been researched adequately. Treatment of myocardial dysfunction secondary to perinatal asphyxia, a leading cause of neonatal mortality, is still a conundrum. Quite similarly, there are only a handful of controlled trials evaluating therapeutics in some of the other commonly encountered conditions, namely, septic shock and hypoperfusion secondary to pulmonary hypertension. Even the universally practiced intervention of volume expansion with crystalloid boluses in shock is not backed by high-certainty evidence in neonates. Though the diagnostic modalities of functional echocardiography and near-infrared spectroscopy have aided greatly in the management of neonatal shock in recent years, these have not been proven to be associated with improved critical clinical outcomes such as mortality and major brain injury. To conclude, neonatologists often rely on limited evidence, mostly anecdotal, when treating neonatal shock. This review critically examines the current evidence with respect to various aspects of neonatal shock with an objective to identify the lacunae in the literature that may fuel future research, eventually paving the way to efficacious, safe and evidence-based clinical practice.

EEG background activity, seizure burden and early childhood outcomes in neonatal encephalopathy in Uganda: a prospective feasibility cohort study

Background

Intrapartum-related neonatal encephalopathy (NE) is a leading cause of childhood mortality and morbidity. Continuous electroencephalography (EEG) is gold standard for neonatal brain monitoring; however, low-income country data is lacking. We examined EEG in a Ugandan cohort with NE to describe feasibility, background activity, seizure prevalence and burden, and associations with clinical presentation and outcome.

Methods

Neonates with NE were recruited from a single hospital referral centre in Kampala, Uganda (Oct 2019-Oct 2020) and underwent EEG monitoring. Feasibility was assessed as to whether EEG monitoring of diagnostic quality could be achieved from days 1-5. Evolution of clinical presentation was assessed by Sarnat classification and daily Thompson score was performed. EEG background severity was graded at 12, 24, 48 and 72 h after birth, and at time of Thompson score. Seizures were annotated remotely by experts and assessed for frequency, duration, burden, and status epilepticus. Early childhood outcome was assessed at follow up, and adverse outcome defined as death or neurodevelopmental impairment (NDI) at 18-24 months of age.

Findings

In this prospective feasibility cohort study, diagnostic quality EEGs were recorded for 50 of 51 recruited neonates (median duration 71.4 h, IQR 52.4-72.2), indicating feasibility. Of 39 participants followed to 18-24 months, 13 died and 7 had NDI. Daily Thompson score and EEG background grade were strongly correlated across all timepoints (days 1-5). Thompson score of ≥7 was most predictive of moderate-severe EEG background abnormality (AUC 0.83). Prognostic accuracy of moderate-severe EEG background grade to predict NDI was high (AUC 0.74). Electrographic seizures were seen in 52% (26); median seizure burden was high at 264 min (IQR 27.8-523.7, range 1.3-1374.1); half (13) had status epilepticus.

Interpretation

EEG monitoring was feasible as a research tool in this sub-Saharan Africa setting. EEG background activity correlated strongly with scored neurological assessment and predicted adverse early childhood outcome. Seizure prevalence and burden, including status epilepticus, were high in this uncooled cohort with important potential longer-term implications for survivors.

Funding

Bill & Melinda Gates Foundation grant number OPP1210890; Wellcome Trust Innovator award (209325/Z/17/Z).

On target dosing: erythropoietin exposure in neonates with hypoxic-ischemic encephalopathy in the HEAL trial

BACKGROUND

The High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial for neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia demonstrated no neurodevelopmental benefit but was associated with a higher rate of serious adverse events (SAEs). Understanding if targeted Epo plasma exposures were achieved in the HEAL trial and if SAEs were associated with higher exposures would help future therapeutic programs of Epo as a candidate neuroprotective treatment.

METHODS

Ancillary study of a subset of HEAL neonates who received Epo (1000 U/kg IV on days 1, 2, 3, 4, and 7) and had plasma drug concentrations measured. Within a Bayesian pharmacokinetic framework, the area under the curve during the first 48 h (AUC48h) and 7 days (AUC7d) of treatment was estimated. The % of neonates who achieved animal model neuroprotective targets of AUC48h >140,000 mU*h/ml and AUC7d >420,000 mU*h/ml was calculated. The relationship between AUC7d and SAEs after study drug was evaluated using logistic regression.

RESULTS

Among n = 89 neonates, variation in Epo exposure was low, and over 95% of neonates achieved the target AUC48h and AUC7d. No meaningful relationship was seen between AUC7d and risk of SAE.

CONCLUSIONS

The Epo dosing strategy in the HEAL trial consistently achieved target plasma exposures. Higher exposures were not associated with SAEs.

IMPACT

In the HEAL randomized, placebo-controlled trial of high-dose erythropoietin (Epo) for neonates with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia, the Epo dosing strategy achieved animal model neuroprotective plasma exposure targets in >95% of neonates. This understanding further strengthens the HEAL trial's primary conclusion that Epo provides no additional benefit in neonates with HIE also receiving therapeutic hypothermia. While Epo treatment was associated with a higher rate of serious adverse events (SAEs) compared to placebo in the primary HEAL trial, higher plasma exposures of Epo were not associated with the risk of SAEs.

Factors associated with mortality and neurodevelopmental impairment at 12 months in asphyxiated newborns: a retrospective cohort study in rural Tanzania from January 2019 to June 2022

BACKGROUND

Worldwide about 2.3 million newborns still die in the neonatal period and the majority occurs in low- and middle-income countries (LMICs). Intrapartum-related events account for 24% of neonatal mortality. Of these events, intrapartum birth asphyxia with subsequent neonatal encephalopathy is the main cause of child disabilities in LMICs. Data on neurodevelopmental outcome and early risk factors are still missing in LMICs. This study aimed at investigating the factors associated with mortality, risk of neurodevelopmental impairment and adherence to follow-up among asphyxiated newborns in rural Tanzania.

METHODS

This retrospective observational cohort study investigated mortality, neurodevelopmental risk and adherence to follow-up among asphyxiated newborns who were admitted to Tosamaganga Hospital (Tanzania) from January 2019 to June 2022. Neurodevelopmental impairment was assessed using standardized Hammersmith neurologic examination. Admission criteria were Apgar score < 7 at 5 min of life and birth weight > 1500 g. Babies with clinically visible congenital malformations were excluded. Comparisons between groups were performed using the Mann-Whitney test, the Chi-square test, and the Fisher test.

RESULTS

Mortality was 19.1% (57/298 newborns) and was associated with outborn (p < 0.0001), age at admission (p = 0.02), lower Apgar score at 5 min (p = 0.003), convulsions (p < 0.0001) and intravenous fluids (IV) (p = 0.003). Most patients (85.6%) were lost to follow-up after a median of 1 visit (IQR 0-2). Low adherence to follow-up was associated with female sex (p = 0.005). The risk of neurodevelopmental impairment at the last visit was associated with longer travel time between household and hospital (p = 0.03), female sex (p = 0.04), convulsions (p = 0.007), respiratory distress (p = 0.01), administration of IV fluids (p = 0.04), prolonged oxygen therapy (p = 0.004), prolonged hospital stay (p = 0.0007) and inappropriate growth during follow-up (p = 0.0002).

CONCLUSIONS

Our findings demonstrated that mortality among asphyxiated newborns in a rural hospital in Tanzania remains high. Additionally, distance from home to hospital and sex of the newborn correlated to higher risks of neurodevelopmental impairment. Educational interventions among the population about the importance of regular health assessment are needed to improve adherence to follow-up and for preventive purposes. Future studies should investigate the role of factors affecting the adherence to follow-up.

Echocardiographic evaluation of myocardial dysfunction in term neonates with perinatal asphyxia

Background & Objective

One third of the neonatal deaths worldwide are attributed to perinatal asphyxia. We aimed to determine the prevalence and determinants of cardiac dysfunction, through echocardiographic evaluation, in term neonates with perinatal asphyxia.

Methods

This cross-sectional study was conducted at a tertiary care setting over a period of six months from 1st January 2021 to 30th June 2021. Term neonates, weighing ≥ 2500 grams, born with Apgar score < 7 and admitted within 48-hours of life were consecutively enrolled. Using Levene classification neonates were grouped into moderate and severe perinatal asphyxia. All neonates underwent transthoracic echocardiographic evaluation after 24-hours of stabilization and within 72-hours of life. Descriptive statistics are calculated, and logistic regression analysis is done to determine the risk factors of myocardial dysfunction.

Results

Among 166 neonates, 53% (n=88) were males, mean gestational age was 38.1 ± 0.89 weeks. Moderate asphyxia was present in 121 (72.9%). Most common echocardiographic finding was pulmonary hypertension in 50% followed by patent ductus arteriosus (PDA) in 37.2% and mitral regurgitation in 6.6%. Myocardial dysfunction was detected in 28.9% of the neonates. Three independent determinants of myocardial dysfunction were severe asphyxia [adjusted odds ratio (aOR) 5.01, 95% CI 2.2-11.4; p-value <0.001], having patent ductus arteriosus (aOR 5.11, 95% CI 2.2-11.8; p-value < 0.001) and delivery through cesarean section (aOR 2.65, 95% CI 1.2-5.9; p-value 0.02).

Conclusions

Myocardial dysfunction among neonates with perinatal asphyxia is common and severity of asphyxia, mode of delivery and presence of patent ductus arteriosus are important determinants.

Neonatal Resuscitation and Delivery Room Care: A Changing Global Landscape

With 98% of neonatal deaths occurring in low- and middle-income countries (LMICs), leading health organizations continue to focus on global reduction of neonatal mortality. The presence of a skilled clinician at delivery has been shown to decrease mortality. However, there remain significant barriers to training and maintaining clinician skills and ensuring that facility-specific resources are consistently available to deliver the most essential, evidence-based newborn care. The dynamic nature of resource availability poses an additional challenge for essential newborn care educators in LMICs. With increasing access to advanced neonatal resuscitation interventions (ie, airway devices, code medications, umbilical line placement), the international health-care community is tasked to consider how to best implement these practices safely and effectively in lower-resourced settings. Current educational training programs do not provide specific instructions on how to scale these advanced neonatal resuscitation training components to match available materials, staff proficiency, and system infrastructure. Individual facilities are often faced with adapting content for their local context and capabilities. In this review, we discuss considerations surrounding curriculum adaptation to meet the needs of a rapidly changing landscape of resource availability in LMICs to ensure safety, equity, scalability, and sustainability.

The General Movement Optimality Score-Revised (GMOS-R) with Socioeconomically Stratified Percentile Ranks

Background: The general movement optimality score (GMOS) quantifies the details of general movements (GMs). We recently conducted psychometric analyses of the GMOS and developed a revised scoresheet. Consequently, the GMOS-Revised (GMOS-R) instrument necessitated validation using new percentile ranks. This study aimed to provide these percentile ranks for the GMOS-R and to investigate whether sex, preterm birth, or the infant's country of birth and residence affected the GMOS-R distribution. Methods: We applied the GMOS-R to an international sample of 1983 infants (32% female, 44% male, and 24% not disclosed), assessed in the extremely and very preterm period (10%), moderate (12%) and late (22%) preterm periods, at term (25%), and post-term age (31%). Data were grouped according to the World Bank's classification into lower- and upper-middle-income countries (LMICs and UMICs; 26%) or high-income countries (HICs; 74%), respectively. Results: We found that sex and preterm or term birth did not affect either GM classification or the GMOS-R, but the country of residence did. A lower median GMOS-R for infants with normal or poor-repertoire GMs from LMICs and UMICs compared with HICs suggests the use of specific percentile ranks for LMICs and UMICs vs. HICs. Conclusion: For clinical and scientific use, we provide a freely available GMOS-R scoring sheet, with percentile ranks reflecting socioeconomic stratification.

Leflunomide Treatment Does Not Protect Neural Cells following Oxygen-Glucose Deprivation (OGD) In Vitro

Neonatal hypoxia-ischemia (HI) affects 2-3 per 1000 live births in developed countries and up to 26 per 1000 live births in developing countries. It is estimated that of the 750,000 infants experiencing a hypoxic-ischemic event during birth per year, more than 400,000 will be severely affected. As treatment options are limited, rapidly identifying new therapeutic avenues is critical, and repurposing drugs already in clinical use offers a fast-track route to clinic. One emerging avenue for therapeutic intervention in neonatal HI is to target mitochondrial dysfunction, which occurs early in the development of brain injury. Mitochondrial dynamics are particularly affected, with mitochondrial fragmentation occurring at the expense of the pro-fusion protein Optic Atrophy (OPA)1. OPA1, together with mitofusins (MFN)1/2, are required for membrane fusion, and therefore, protecting their function may also safeguard mitochondrial dynamics. Leflunomide, an FDA-approved immunosuppressant, was recently identified as an activator of MFN2 with partial effects on OPA1 expression. We, therefore, treated C17.2 cells with Leflunomide before or after oxygen-glucose deprivation, an in vitro mimic of HI, to determine its efficacy as a neuroprotection and inhibitor of mitochondrial dysfunction. Leflunomide increased baseline OPA1 but not MFN2 expression in C17.2 cells. However, Leflunomide was unable to promote cell survival following OGD. Equally, there was no obvious effect on mitochondrial morphology or bioenergetics. These data align with studies suggesting that the tissue and mitochondrial protein profile of the target cell/tissue are critical for taking advantage of the therapeutic actions of Leflunomide.

Acute symptomatic seizures in newborns: a narrative review

Acute symptomatic seizures are the main sign of neurological dysfunction in newborns. This is linked to the unique characteristics of the neonatal brain, making it hyperexcitable compared to older ages, and to the common occurrence of some forms of acquired brain injury, namely hypoxic-ischemic encephalopathy. In this narrative review we will provide an overview of neonatal seizures definition, their main underlying etiologies, diagnostic work-up and differential diagnoses, and will discuss about therapeutic options and prognostic outlook. The latest publications from the ILAE Task Force on Neonatal Seizures will be presented and discussed. Of note, they highlight the current lack of robust evidence in this field of clinical neurology. We will also report on specificities pertaining to low-and-middle income countries in terms of incidence, main etiologies and diagnosis. The possibilities offered by telemedicine and automated seizures detection will also be summarized in order to provide a framework for future directions in seizures diagnosis and management with a global perspective. Many challenges and opportunities for improving identification, monitoring and treatment of acute symptomatic seizures in newborns exist. All current caveats potentially represent different lines of research with the aim to provide better care and reach a deeper understanding of this important topic of neonatal neurology.

Biochemical profiles and organ dysfunction in neonates with hypoxic-ischemic encephalopathy post-hoc analysis of the THIN trial

BACKGROUND

Therapeutic hypothermia for infants with moderate to severe hypoxic-ischemic encephalopathy is well established as standard of care in high-income countries. Trials from low- and middle-income countries have shown contradictory results, and variations in the level of intensive care provided may partly explain these differences. We wished to evaluate biochemical profiles and clinical markers of organ dysfunction in cooled and non-cooled infants with moderate/severe hypoxic-ischemic encephalopathy.

METHODS

This secondary analysis of the THIN (Therapeutic Hypothermia in India) study, a single center randomized controlled trial, included 50 infants with moderate to severe hypoxic-ischemic encephalopathy randomized to therapeutic hypothermia (n = 25) or standard care with normothermia (n = 25) between September 2013 and October 2015. Data were collected prospectively and compared by randomization groups. Main outcomes were metabolic acidosis, coagulopathies, renal function, and supportive treatments during the intervention.

RESULTS

Cooled infants had lower pH than non-cooled infants at 6-12 h (median (IQR) 7.28 (7.20-7.32) vs 7.36 (7.31-7.40), respectively, p = 0.003) and 12-24 h (median (IQR) 7.30 (7.24-7.35) vs 7.41 (7.37-7.43), respectively, p < 0.001). Thrombocytopenia (< 100 000) was, though not statistically significant, twice as common in cooled compared to non-cooled infants (4/25 (16%) and 2/25 (8%), respectively, p = 0.67). No significant difference was found in the use of vasopressors (14/25 (56%) and 17/25 (68%), p = 0.38), intravenous bicarbonate (5/25 (20%) and 3/25 (12%), p = 0.70) or treatment with fresh frozen plasma (10/25 (40%) and 8/25 (32%), p = 0.56)) in cooled and non-cooled infants, respectively. Urine output < 1 ml/kg/h was less common in cooled infants compared to non-cooled infants at 0-24 h (7/25 (28%) vs. 16/23 (70%) respectively, p = 0.004).

CONCLUSIONS

This post hoc analysis of the THIN study support that cooling of infants with hypoxic-ischemic encephalopathy in a level III neonatal intensive care unit in India was safe. Cooled infants had slightly lower pH, but better renal function during the first day compared to non-cooled infants. More research is needed to identify the necessary level of intensive care during cooling to guide further implementation of this neuroprotective treatment in low-resource settings.

TRIAL REGISTRATION

Data from this article was collected during the THIN-study (Therapeutic Hypothermia in India; ref. CTRI/2013/05/003693 Clinical Trials Registry - India).

Outborn newborns drive birth asphyxia mortality rates-An 8 year analysis at a rural level two nursery in Uganda

Birth asphyxia is a leading cause of global neonatal mortality. Most cases occur in low- and middle- income countries and contribute to half of neonatal deaths in Uganda. Improved understanding of the risk factors associated with mortality among these patients is needed. We performed a retrospective cohort study of a clinical database and report maternal demographics, clinical characteristics and outcomes from neonates with birth asphyxia at a Ugandan level two unit from 2014 through 2021. "Inborn" patients were born at the hospital studied and "outborn" were born at another facility or home and then admitted to the hospital studied. Doctors assigned the patient's primary diagnosis at death or discharge. We performed a Poisson model regression of factors associated with mortality among patients with asphyxia. The study included 1,565 patients with birth asphyxia and the proportion who were outborn rose from 26% to 71% over eight years. Mortality in asphyxiated patients increased over the same period from 9% to 27%. Factors independently associated with increased death included outborn birth location (ARR 2.1, p<0.001), admission in the year 2020 (ARR 2.4, p<0.05) and admission respiratory rate below 30bpm (RR 3.9, p<0.001), oxygen saturation <90% (ARR 2.0, p<0.001) and blood sugar >8.3 mmol/L (RR 1.7, p<0.05). Conversely, a respiratory rate >60bpm was protective against death (ARR 0.6, p<0.05). Increased birth asphyxia mortality at this referral unit was associated with increasing admission of outborn patients. Patients born at another facility and transferred face unique challenges. Increased capacity building at lower-level birth facilities could include improved staffing, training and equipment for labor monitoring and newborn resuscitation as well as training on the timely identification of newborns with birth asphyxia and resources for transfer. These changes may reduce incidence of birth asphyxia, improve outcomes among birth asphyxia patients and help meet global targets for newborn mortality.

Marked variability in institutional deliveries and neonatal outcomes during the COVID-19 lockdown in Nigeria

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic and the interventions to mitigate its spread impacted access to healthcare, including hospital births and newborn care. This study evaluated the impact of COVID-19 lockdown measures on newborn service utilization in Nigeria.

METHODS

The records of women who delivered in hospitals and babies admitted to neonatal wards were retrospectively reviewed before (March 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic lockdown in selected facilities in Nigeria.

RESULTS

There was a nationwide reduction in institutional deliveries during the COVID-19 lockdown period in Nigeria, with 14 444 before and 11 723 during the lockdown-a decrease of 18.8%. The number of preterm admissions decreased during the lockdown period (30.6% during lockdown vs 32.6% pre-lockdown), but the percentage of outborn preterm admissions remained unchanged. Newborn admissions varied between zones with no consistent pattern. Although neonatal jaundice and prematurity remained the most common reasons for admission, severe perinatal asphyxia increased by nearly 50%. Neonatal mortality was significantly higher during the COVID-19 lockdown compared with pre-lockdown (110.6/1000 [11.1%] vs 91.4/1000 [9.1%], respectively; p=0.01). The odds of a newborn dying were about four times higher if delivered outside the facility during the lockdown (p<0.001).

CONCLUSIONS

The COVID-19 lockdown had markedly deleterious effects on healthcare seeking for deliveries and neonatal care that varied between zones with no consistent pattern.

Outcomes of Neonates with Hypoxic-Ischemic Encephalopathy Treated with Magnesium Sulfate: A Systematic Review with Meta-analysis

OBJECTIVE

To assess magnesium sulfate (MgSO4) as a neuroprotective agent in hypoxic-ischemic encephalopathy.

STUDY DESIGN

For this systematic review, PubMed, EMBASE, the Cochrane Library, EMCARE, and MedNar were searched in November 2022 for randomized controlled trials (RCTs). Meta-analysis was conducted using Stata 16.0 and RevMan 5.3.

RESULTS

Twenty RCTs with a total sample size of 1485 were included, of which 16 were from settings where therapeutic hypothermia (TH) was not offered. Regarding MgSO4 in settings where TH was not offered, only 1 study evaluated composite outcome of death or disability at ≥18 months and reported such poor outcome in 8 of 14 control infants and 4 of 8 in the MgSO4 group. MgSO4 was not associated with mortality (RR, 0.86; 95% CI, 0.72-1.03; 13 RCTs) or hypotension (RR, 1.02; 95% CI, 0.88-1.18; 5 RCTs). Thirteen studies reported that MgSO4 improved in-hospital outcomes, such as reduced seizure burden and improved neurological status at discharge. MgSO4 reduced the risk of poor suck feeds (RR, 0.52; 95% CI, 0.40-0.68; 6RCTs) and abnormal electroencephalogram (RR, 0.64; 95% CI, 0.45-0.93; 5 RCTs). Certainty of evidence was moderate for mortality and low or very low for other outcomes. For studies with MgSO4 as an adjunct to TH, none reported on death or neurodevelopmental disability at ≥18 months. MgSO4 was not associated with mortality (RR, 0.65; 95% CI, 0.34-1.27; 3 RCTs) or hypotension (RR, 1.0; 95% CI, 0.71-1.40; 3 RCTs).

CONCLUSIONS

Evidence around long-term outcomes of MgSO4 when used with or without TH was scant. MgSO4 therapy may improve in-hospital neurological outcomes without affecting mortality in settings where TH is not offered. Well-designed RCTs for neuroprotection are needed, especially in low-resource settings.

TRIAL REGISTRATION

"Open Science Forum" (https://doi.org/10.17605/OSF.IO/FRM4D).

Protective effect of resveratrol on mitochondrial biogenesis during hyperoxia-induced brain injury in neonatal pups

BACKGROUND

Neonatal hyperoxic brain injury is caused by exposure to hyperphysiological oxygen content during the period of incomplete development of the oxidative stress defence system, resulting in a large number of reactive oxygen species (ROS) and causing damage to brain tissue. Mitochondrial biogenesis refers to the synthesis of new mitochondria from existing mitochondria, mostly through the PGC-1α/Nrfs/TFAM signalling pathway. Resveratrol (Res), a silencing information regulator 2-related enzyme 1 (Sirt1) agonist, has been shown to upregulate the level of Sirt1 and the expression of peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α). We speculate that Res has a protective effect on hyperoxia-induced brain injury through mitochondrial biogenesis.

METHODS

Sprague-Dawley (SD) pups were randomly divided into the nonhyperoxia (NN) group, the nonhyperoxia with dimethyl sulfoxide (ND) group, the nonhyperoxia with Res (NR) group, the hyperoxia (HN) group, the hyperoxia with dimethyl sulfoxide (HD) group, and the hyperoxia with Res (HR) group within 12 h after birth. The HN, HD, and HR groups were placed in a high-oxygen environment (80‒85%), and the other three groups were placed in the standard atmosphere. The NR and HR groups were given 60 mg/kg Res every day, the ND and HD groups were given the same dose of dimethyl sulfoxide (DMSO) every day, and the NN and HN groups were given the same dose of normal saline every day. On postnatal day (PN) 1, PN7, and PN14, brain samples were acquired for HE staining to assess pathology, TUNEL to detect apoptosis, and real-time quantitative polymerase chain reaction and immunoblotting to detect the expression levels of Sirt1, PGC-1α, nuclear respiratory factor 1 (Nrf1), nuclear respiratory factor 2 (Nrf2) and mitochondrial transcription factor A (TFAM) in brain tissue.

RESULTS

Hyperoxia induced brain tissue injury; increased brain tissue apoptosis; inhibited Sirt1, PGC-1α, Nrf1, Nrf2, TFAM mRNA expression in mitochondria; diminished the ND1 copy number and ND4/ND1 ratio; and decreased Sirt1, PGC-1α, Nrf1, Nrf2, and TFAM protein levels in the brain. In contrast, Res reduced brain injury and attenuated brain tissue apoptosis in neonatal pups and increased the levels of the corresponding indices.

CONCLUSION

Res has a protective effect on hyperoxia-induced brain injury in neonatal SD pups by upregulating Sirt1 and stimulating the PGC-1α/Nrfs/TFAM signalling pathway for mitochondrial biogenesis.

PM2.5-related neonatal encephalopathy due to birth asphyxia and trauma: a global burden study from 1990 to 2019

Long-term exposure to fine particulate matter (PM_2.5) may increase the risk of neonatal encephalopathy due to birth asphyxia and trauma. However, little is known about the trends of PM_2.5-related neonatal encephalopathy burden under different levels of social and economic development. We studied the burden of PM_2.5-related neonatal encephalopathy due to birth asphyxia and trauma measured by the age-standardized mortality rate (ASMR) and the age-standardized disability-adjusted life years rate (ASDR), and its trends with the socio-demographic index (SDI) in 192 countries and regions from 1990 to 2019. This is a retrospective study using the Global Burden of Disease Study 2019 (GBD2019) database. The age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life years rate (ASDR) are used to measure the burden of PM_2.5-related neonatal encephalopathy in different countries and regions. The mortality rate (per 100 thousand) is used to evaluate the differences of PM_2.5-related neonatal encephalopathy burden in sex and age. The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) are used to reflect the trends of PM_2.5-related neonatal encephalopathy burden over years (1990-2019) and are calculated using a Joinpoint model. The relationship of the socio-demographic index with the ASMR and ASDR is calculated using Gaussian process regression. In summary, the global burden of PM_2.5-related neonatal encephalopathy increased since 1990, especially in boys, early neonates, and regions with low-middle SDI. Globally, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy burden in 2019 were 0.59 (95% CI: 0.40, 0.83) per 100,000 people and 52.59 (95% CI: 35.33, 73.67) per 100,000 people, respectively. From 1990 to 2019, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy increased by 44.39% and 44.19%, respectively. The global average annual percentage changes of ASMR and ASDR were 1.3 (95% CI: 1.0, 1.6). The relationship between the socio-demographic index and the burden of PM_2.5-related neonatal encephalopathy presented negative correlation when the socio-demographic index was more than 0.60. Middle, high-middle, and high SDI regions had decreasing trends of PM_2.5-related neonatal encephalopathy, of which the AAPCs for both ASMR and ASDR ranged from - 0.3 to - 3.1. Besides improving the progress in national policy and the coverage rate of maternal and neonatal health care and facility-based delivery, air pollution control may also be a better way for countries with large and increasing amounts of exposure to PM_2.5 pollution to reduce neonatal encephalopathy. And our results also suggest that low and low-middle SDI countries should appropriately pay more attention to early newborns and boys.

Heart rate variability analysis for the prediction of EEG grade in infants with hypoxic ischaemic encephalopathy within the first 12 h of birth

Background and aims

Heart rate variability (HRV) has previously been assessed as a biomarker for brain injury and prognosis in neonates. The aim of this cohort study was to use HRV to predict the electroencephalography (EEG) grade in neonatal hypoxic-ischaemic encephalopathy (HIE) within the first 12 h.

Methods

We included 120 infants with HIE recruited as part of two European multi-centre studies, with electrocardiography (ECG) and EEG monitoring performed before 12 h of age. HRV features and EEG background were assessed using the earliest 1 h epoch of ECG-EEG monitoring. HRV was expressed in time, frequency and complexity features. EEG background was graded from 0-normal, 1-mild, 2-moderate, 3-major abnormalities to 4-inactive. Clinical parameters known within 6 h of birth were collected (intrapartum complications, foetal distress, gestational age, mode of delivery, gender, birth weight, Apgar at 1 and 5, assisted ventilation at 10 min). Using logistic regression analysis, prediction models for EEG severity were developed for HRV features and clinical parameters, separately and combined. Multivariable model analysis included 101 infants without missing data.

Results

Of 120 infants included, 54 (45%) had normal-mild and 66 (55%) had moderate-severe EEG grade. The performance of HRV model was AUROC 0.837 (95% CI: 0.759-0.914) and clinical model was AUROC 0.836 (95% CI: 0.759-0.914). The HRV and clinical model combined had an AUROC of 0.895 (95% CI: 0.832-0.958). Therapeutic hypothermia and anti-seizure medication did not affect the model performance.

Conclusions

Early HRV and clinical information accurately predicted EEG grade in HIE within the first 12 h of birth. This might be beneficial when EEG monitoring is not available in the early postnatal period and for referral centres who may want some objective information on HIE severity.

Incidence and outcomes of intrapartum-related neonatal encephalopathy in low-income and middle-income countries: a systematic review and meta-analysis

AIM

To examine the incidence of intrapartum-related neonatal encephalopathy, and neonatal mortality and neurodevelopmental outcomes associated with it in low-income and middle-income countries.

METHODS

Reports were included when neonatal encephalopathy diagnosed clinically within 24 hours of birth in term or near-term infants born after intrapartum hypoxia-ischaemia defined as any of the following: (1) pH≤7.1 or base excess ≤-12 or lactate ≥6, (2) Apgar score ≤5 at 5 or 10 min, (3) continuing resuscitation at 5 or 10 min or (4) no cry from baby at 5 or 10 min. Peer-reviewed articles were searched from Ovid MEDLINE, Cochrane, Web of Science and WHO Global Index Medicus with date limits 1 November 2009 to 17 November 2021. Risk of bias was assessed using modified Newcastle Ottawa Scale. Inverse variance of heterogenicity was used for meta-analyses.

RESULTS

There were 53 reports from 51 studies presenting data on 4181 children with intrapartum-related neonatal encephalopathy included in the review. Only five studies had data on incidence, which ranged from 1.5 to 20.3 per 1000 live births. Neonatal mortality was examined in 45 studies and in total 636 of the 3307 (19.2%) infants died. Combined outcome of death or moderate to severe neurodevelopmental disability was reported in 19 studies and occurred in 712 out of 1595 children (44.6%) with follow-up 1 to 3.5 years.

CONCLUSION

Though there has been progress in some regions, incidence, case mortality and morbidity in intrapartum-related neonatal encephalopathy has been static in the last 10 years.

PROSPERO REGISTRATION NUMBER

CRD42020177928.

The causes of preterm neonatal deaths in India and Pakistan (PURPOSe): a prospective cohort study

BACKGROUND

Preterm birth remains the major cause of neonatal death worldwide. South Asia contributes disproportionately to deaths among preterm births worldwide, yet few population-based studies have assessed the underlying causes of deaths. Novel evaluations, including histological and bacteriological assessments of placental and fetal tissues, facilitate more precise determination of the underlying causes of preterm deaths. We sought to assess underlying and contributing causes of preterm neonatal deaths in India and Pakistan.

METHODS

The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe) was a prospective cohort study done in three hospitals in Davangere, India, and two hospitals in Karachi, Pakistan. All pregnant females older than 14 years were screened at the time of presentation for delivery, and those with an expected or known preterm birth, defined as less than 37 weeks of gestation, were enrolled. Liveborn neonates with a weight of 1000 g or more who died by 28 days after birth were included in analyses. Placentas were collected and histologically evaluated. In addition, among all neonatal deaths, with consent, minimally invasive tissue sampling was performed for histological analyses. PCR testing was performed to assess microbial pathogens in the placental, blood, and fetal tissues collected. An independent panel reviewed available data, including clinical description of the case and all clinical maternal, fetal, and placental findings, and results of PCR bacteriological investigation and minimally invasive tissue sampling histology, from all eligible preterm neonates to determine the primary and contributing maternal, placental, and neonatal causes of death.

FINDINGS

Between July 1, 2018, and March 26, 2020, of the 3470 preterm neonates enrolled, 804 (23%) died by 28 days after birth, and, of those, 615 were eligible and had their cases reviewed by the panel. Primary maternal causes of neonatal death were hypertensive disease (204 [33%] of 615 cases), followed by maternal complication of pregnancy (76 [12%]) and preterm labour (76 [11%]), whereas the primary placental causes were maternal and fetal vascular malperfusion (172 [28%] of 615) and chorioamnionitis, funisitis, or both (149 [26%]). The primary neonatal cause of death was intrauterine hypoxia (212 [34%] of 615) followed by congenital infections (126 [20%]), neonatal infections (122 [20%]), and respiratory distress syndrome (126 [20%]).

INTERPRETATION

In south Asia, intrauterine hypoxia and congenital infections were the major causes of neonatal death among preterm babies. Maternal hypertensive disorders and placental disorders, especially maternal and fetal vascular malperfusion and placental abruption, substantially contributed to these deaths.

FUNDING

Bill & Melinda Gates Foundation.

Mitochondrial dynamics in the neonatal brain - a potential target following injury?

The impact of birth asphyxia and its sequelae, hypoxic–ischaemic (HI) brain injury, is long-lasting and significant, both for the infant and for their family. Treatment options are limited to therapeutic hypothermia, which is not universally successful and is unavailable in low resource settings. The energy deficits that accompany neuronal death following interruption of blood flow to the brain implicate mitochondrial dysfunction. Such HI insults trigger mitochondrial outer membrane permeabilisation leading to release of pro-apoptotic proteins into the cytosol and cell death. More recently, key players in mitochondrial fission and fusion have been identified as targets following HI brain injury. This review aims to provide an introduction to the molecular players and pathways driving mitochondrial dynamics, the regulation of these pathways and how they are altered following HI insult. Finally, we review progress on repurposing or repositioning drugs already approved for other indications, which may target mitochondrial dynamics and provide promising avenues for intervention following brain injury. Such repurposing may provide a mechanism to fast-track, low-cost treatment options to the clinic.

Neonatal Seizures-Perspective in Low-and Middle-Income Countries

Neonatal seizures are the commonest neurological emergency and are associated with poor neurodevelopmental outcome. While they are generally difficult to diagnose and treat, they pose a significant clinical challenge for physicians in low- and middle-income countries (LMIC). They are mostly provoked seizures caused by an acute brain insult such as hypoxic-ischemic encephalopathy (HIE), ischemic stroke, intracranial hemorrhage, infections of the central nervous system, or acute metabolic disturbances. Early onset epilepsy syndromes are less common. Clinical diagnosis of seizures in the neonatal period are frequently inaccurate, as clinical manifestations are difficult to distinguish from nonseizure behavior. Additionally, a high proportion of seizures are electrographic-only without any clinical manifestations, making diagnosis with EEG or aEEG a necessity. Only focal clonic and focal tonic seizures can be diagnosed clinically with adequate diagnostic certainty. Prompt diagnosis and timely treatment are important, with evidence suggesting that early treatment improves the response to antiseizure medication. The vast majority of published studies are from high-income countries, making extrapolation to LMIC impossible, thus highlighting the urgent need for a better understanding of the etiologies, comorbidities, and drug trials evaluating safety and efficacy in LMIC. In this review paper, the authors present the latest data on etiology, diagnosis, classification, and guidelines for the management of neonates with the emphasis on low-resource settings.

Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia

Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated.