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Pawale D, Fursule A, Tan J, Wagh D, Patole S, Rao S. Prevalence of hearing impairment in neonatal encephalopathy due to hypoxia-ischemia: a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03261-w. [PMID: 38769399 DOI: 10.1038/s41390-024-03261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/17/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND This systematic review was undertaken to estimate the overall prevalence of hearing impairment in survivors of neonatal HIE. METHODS PubMed, EMBASE, CINAHL, EMCARE and Cochrane databases, mednar (gray literature) were searched till January 2023. Randomized controlled trials and observational studies were included. The main outcome was estimation of overall prevalence of hearing impairment in survivors of HIE. RESULTS A total of 71studies (5821 infants assessed for hearing impairment) were included of which 56 were from high income countries (HIC) and 15 from low- or middle-income countries (LMIC). Overall prevalence rate of hearing impairment in cooled infants was 5% (95% CI: 3-6%, n = 4868) and 3% (95% CI: 1-6%, n = 953) in non-cooled HIE infants. The prevalence rate in cooled HIE infants in LMICs was 7% (95% CI: 2-15%) and in HICs was 4% (95% CI: 3-5%). The prevalence rate in non-cooled HIE infants in LMICs was 8% (95% CI: 2-17%) and HICs was 2% (95% CI: 0-4%). CONCLUSIONS These results would be useful for counseling parents, and in acting as benchmark when comparing institutional data, and while monitoring future RCTs testing new interventions in HIE. There is a need for more data from LMICs and standardization of reporting hearing impairment. IMPACT The overall prevalence rate of hearing impairment in cooled infants with HIE was 5% (95% CI: 3-6%) and 3% (95% CI: 1-6%) in the non-cooled infants. The prevalence rate in cooled HIE infants in LMICs was 7% (95% CI: 2-15%) and in HICs was 4% (95% CI: 3-5%). The prevalence rate in non-cooled HIE infants in LMICs was 8% (95% CI: 2-17%) and HICs was 2% (95% CI: 0-4%). These results would be useful for counseling parents, and in acting as benchmark when comparing institutional data, and while monitoring future RCTs testing new interventions in HIE.
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Affiliation(s)
- Dinesh Pawale
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
| | - Anurag Fursule
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
| | - Jason Tan
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Deepika Wagh
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Sanjay Patole
- School of Medicine, University of Western Australia, Crawley, WA, Australia
- Department of Neonatology, King Edwards Memorial Hospital, Perth, WA, Australia
| | - Shripada Rao
- Department of Neonatology, Perth Children's Hospital, Perth, WA, Australia.
- School of Medicine, University of Western Australia, Crawley, WA, Australia.
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Lv H, Wang Q, Liu F, Jin L, Ren P, Li L. A biochemical feedback signal for hypothermia treatment for neonatal hypoxic-ischemic encephalopathy: focusing on central nervous system proteins in biofluids. Front Pediatr 2024; 12:1288853. [PMID: 38766393 PMCID: PMC11100326 DOI: 10.3389/fped.2024.1288853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
Hypothermia has been widely used to treat moderate to severe neonatal hypoxic-ischemic encephalopathy (HIE), yet evaluating the effects of hypothermia relies on clinical neurology, neuroimaging, amplitude-integrated electroencephalography, and follow-up data on patient outcomes. Biomarkers of brain injury have been considered for estimating the effects of hypothermia. Proteins specific to the central nervous system (CNS) are components of nervous tissue, and once the CNS is damaged, these proteins are released into biofluids (cerebrospinal fluid, blood, urine, tears, saliva), and they can be used as markers of brain damage. Clinical reports have shown that CNS-specific marker proteins (CNSPs) were early expressed in biofluids after brain damage and formed unique biochemical profiles. As a result, these markers may serve as an indicator for screening brain injury in infants, monitoring disease progression, identifying damage region of brain, and assessing the efficacy of neuroprotective measures. In clinical work, we have found that there are few reports on using CNSPs as biological signals in hypothermia for neonatal HIE. The aim of this article is to review the classification, origin, biochemical composition, and physiological function of CNSPs with changes in their expression levels after hypothermia for neonatal HIE. Hopefully, this review will improve the awareness of CNSPs among pediatricians, and encourage future studies exploring the mechanisms behind the effects of hypothermia on these CNSPs, in order to reduce the adverse outcome of neonatal HIE.
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Affiliation(s)
- Hongyan Lv
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
- Department of Neonatal Pathology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
| | - Qiuli Wang
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
| | - Fang Liu
- Department of Pediatrics, The 980 Hospital of the PLA Joint Logistics Support Force, Shijiazhuang, China
| | - Linhong Jin
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
| | - Pengshun Ren
- Department of Neonatology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
| | - Lianxiang Li
- Department of Neonatal Pathology, Handan Maternal and Child Health Care Hospital, Handan, Hebei, China
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Fei Q, Wang D, Yuan T. Comparison of Different Adjuvant Therapies for Hypothermia in Neonates with Hypoxic-Ischemic Encephalopathy: A Systematic Review and Network Meta-Analysis. Indian J Pediatr 2024; 91:235-241. [PMID: 37199820 DOI: 10.1007/s12098-023-04563-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/10/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES Neonatal hypoxic-ischemic encephalopathy is a major cause of perinatal death and neurodevelopmental impairment (NDI). Hypothermia (HT) is the standard of care; however, additional neuroprotective agents are required to improve prognosis. The authors searched for all drugs in combination with HT and compared their effects using a network meta-analysis. METHODS The authors searched PubMed, Embase, and Cochrane Library until September 24, 2022 for articles assessing mortality, NDI, seizures, and abnormal brain imaging findings in neonates with hypoxic-ischemic encephalopathy. Direct pairwise comparisons and a network meta-analysis was performed under random effects. RESULTS Thirteen randomized clinical trials enroled 902 newborns treated with six combination therapies: erythropoietin magnesium sulfate, melatonin (MT), topiramate, xenon, and darbepoetin alfa. The results of all comparisons were not statistically significant, except for NDI, HT vs. MT+HT: odds ratio = 6.67, 95% confidence interval = 1.14-38.83; however, the overall evidence quality was low for the small sample size. CONCLUSIONS Currently, no combination therapy can reduce mortality, seizures, or abnormal brain imaging findings in neonatal hypoxic-ischemic encephalopathy. According to low quality evidence, HT combined with MT may reduce NDI.
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Affiliation(s)
- Qiang Fei
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Binsheng Rd, No.3333, Hangzhou, 310003, China
| | - Dandan Wang
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Binsheng Rd, No.3333, Hangzhou, 310003, China
| | - Tianming Yuan
- Department of Neonatology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Binsheng Rd, No.3333, Hangzhou, 310003, China.
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Marques KL, Rodrigues V, Balduci CTN, Montes GC, Barradas PC, Cunha-Rodrigues MC. Emerging therapeutic strategies in hypoxic-ischemic encephalopathy: a focus on cognitive outcomes. Front Pharmacol 2024; 15:1347529. [PMID: 38469401 PMCID: PMC10925695 DOI: 10.3389/fphar.2024.1347529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/30/2024] [Indexed: 03/13/2024] Open
Abstract
Perinatal hypoxia-ischemia represents a significant risk to CNS development, leading to high mortality rates, diverse damages, and persistent neurological deficits. Despite advances in neonatal medicine in recent decades, the incidence of HIE remains substantial. Motor deficits can manifest early, while cognitive impairments may be diagnosed later, emphasizing the need for extended follow-up. This review aims to explore potential candidates for therapeutic interventions for hypoxic-ischemic encephalopathy (HIE), with a focus on cognitive deficits. We searched randomized clinical trials (RCT) that tested drug treatments for HIE and evaluated cognitive outcomes. The results included studies on erythropoietin, melatonin, magnesium sulfate, topiramate, and a combination of vitamin C and ibuprofen. Although there are several indications of the efficacy of these drugs among animal models, considering neuroprotective properties, the RCTs failed to provide complete effectiveness in the context of cognitive impairments derived from HIE. More robust RCTs are still needed to advance our knowledge and to establish standardized treatments for HIE.
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Affiliation(s)
- Kethely L. Marques
- Laboratory of Neurobiology, Pharmacology and Psychobiology Department, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Victor Rodrigues
- Faculty of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cassiana T. N. Balduci
- Laboratory of Neurobiology, Pharmacology and Psychobiology Department, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rare Diseases Sales Force, Daiichi Sankyo Brazil, São Paulo, Brazil
| | - Guilherme C. Montes
- Laboratory of Neurobiology, Pharmacology and Psychobiology Department, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Penha C. Barradas
- Laboratory of Neurobiology, Pharmacology and Psychobiology Department, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marta C. Cunha-Rodrigues
- Laboratory of Neurobiology, Pharmacology and Psychobiology Department, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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刘 一, 夏 世. [Research research on the use of melatonin in combination with therapeutic hypothermia for the treatment of neonatal hypoxic-ischemic encephalopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:864-869. [PMID: 37668036 PMCID: PMC10484075 DOI: 10.7499/j.issn.1008-8830.2302099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/21/2023] [Indexed: 09/06/2023]
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) remains one of the leading causes of death and long-term neurodevelopmental disorders in full-term neonates, and there is currently no curative treatment. Therapeutic hypothermia is now a standard therapy for HIE in the neonatal intensive care unit, but its safety and efficacy in remote areas remains unclear. Melatonin is an indole endocrine hormone mainly produced by the pineal gland and it has the ability to easily penetrate the blood-brain barrier. Through receptor and non-receptor mechanisms, melatonin exerts anti-oxidative and anti-inflammatory effects and participates in the regulation of organelle function and the inhibition of cell death. Melatonin is considered one of the most promising drugs for the treatment of HIE based on its reliable safety profile and clinical/preclinical results. This article reviews the recent research on the use of melatonin in combination with therapeutic hypothermia for the treatment of neonatal HIE.
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Roberts NS, Handy MJ, Ito Y, Hashimoto K, Jensen FE, Talos DM. Anti-seizure efficacy of perampanel in two established rodent models of early-life epilepsy. Epilepsy Behav 2023; 143:109194. [PMID: 37119576 DOI: 10.1016/j.yebeh.2023.109194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/10/2023] [Accepted: 03/23/2023] [Indexed: 05/01/2023]
Abstract
Early-life seizures can be refractory to conventional antiseizure medications (ASMs) and can also result in chronic epilepsy and long-term behavioral and cognitive deficits. Treatments targeting age-specific mechanisms contributing to epilepsy would be of clinical benefit. One such target is the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) subtype of excitatory glutamate receptor, which is upregulated in the developing brain. Perampanel is a non-competitive, selective AMPAR antagonist that is FDA-approved for focal onset seizures (FOS) or primary generalized tonic-clonic seizures (PGTC) in children and adults. However, the efficacy of perampanel treatment in epilepsy patients younger than 4 years has been less documented. We thus tested the efficacy of perampanel in two early-life seizure models: (1) a rat model of hypoxia-induced neonatal seizures and (2) a mouse model of Dravet syndrome with hyperthermia-induced seizures. Pretreatment with perampanel conferred dose-dependent protection against early-life seizures in both experimental models. These findings suggest that AMPAR-mediated hyperexcitability could be involved in the pathophysiology of early-life seizures, which may be amenable to treatment with perampanel.
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Affiliation(s)
- Nicholas S Roberts
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcus J Handy
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshimasa Ito
- Formerly: Neurology Business Group, Eisai Co., Ltd., Tsukuba, Ibaraki, Japan
| | - Keisuke Hashimoto
- Deep Human Biology Learning, Eisai Co., Ltd., Tsukuba, Ibaraki, Japan
| | - Frances E Jensen
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Delia M Talos
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ovcjak A, Pontello R, Miller SP, Sun HS, Feng ZP. Hypothermia combined with neuroprotective adjuvants shortens the duration of hospitalization in infants with hypoxic ischemic encephalopathy: Meta-analysis. Front Pharmacol 2023; 13:1037131. [PMID: 36686686 PMCID: PMC9853207 DOI: 10.3389/fphar.2022.1037131] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: Therapeutic hypothermia (TH) is the current standard of care for neonatal hypoxic-ischemic encephalopathy (HIE), yet morbidity and mortality remain significant. Adjuvant neuroprotective agents have been suggested to augment hypothermic-mediated neuroprotection. This analysis aims to identify the classes of drugs that have been used in combination with hypothermia in the treatment of neonatal HIE and determine whether combination therapy is more efficacious than TH alone. Methods: A systematic search of PubMed, Embase and Medline from conception through December 2022 was conducted. Randomized- and quasi-randomized controlled trials, observational studies and retrospective studies evaluating HIE infants treated with combination therapy versus TH alone were selected. Primary reviewers extracted information on mortality, neurodevelopmental impairment and length of hospitalization for meta-analyses. Effect sizes were pooled using a random-effects model and measured as odds ratio (OR) or mean difference (MD) where applicable, and 95% confidence intervals (CI) were calculated. Risk of bias was assessed using the tool from the Cochrane Handbook for Systematic Reviews of Interventions. Results: The search strategy collected 519 studies, 16 of which met analysis inclusion criteria. HIE infants totaled 1,288 infants from included studies, 646 infants received some form of combination therapy, while 642 received TH alone. GABA receptor agonists, NMDA receptor antagonists, neurogenic and angiogenic agents, stem cells, glucocorticoids and antioxidants were identified as candidate adjuvants to TH that have been evaluated in clinical settings compared to TH alone. Length of hospitalization was significantly reduced in infants treated with combination therapy (MD -4.81, 95% CI [-8.42. to -1.19], p = .009) compared to those treated with TH alone. Risk of mortality and neurodevelopmental impairment did not differ between combination therapy and TH alone groups. Conclusion: Compared to the current standard of care, administration of neuroprotective adjuvants with TH reduced the duration of hospitalization but did not impact the risk of mortality or neurodevelopmental impairment in HIE infants. Meta-analysis was limited by a moderate risk of bias among included studies and small sample sizes. This analysis highlights the need for preclinical trials to conduct drug development studies in hypothermic settings to identify relevant molecular targets that may offer additive or synergistic neuroprotection to TH, and the need for larger powered clinical trials to determine the dose and timing of administration at which maximal clinical benefits are observed for adjuvant neuroprotectants.
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Affiliation(s)
- Andrea Ovcjak
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Riley Pontello
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Steve P. Miller
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hong-Shuo Sun
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Department of Pharmacology and Toxicology, Faculty of Medicine, The University of Toronto, Toronto, ON, Canada,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Zhong-Ping Feng
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,*Correspondence: Zhong-Ping Feng,
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Xie Y, Yang Y, Yuan T. Brain Damage in the Preterm Infant: Clinical Aspects and Recent Progress in the Prevention and Treatment. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2023; 22:27-40. [PMID: 35209835 DOI: 10.2174/1871527321666220223092905] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 12/16/2022]
Abstract
Although the prevalence of brain injury and related neurodevelopmental disabilities resulting from preterm birth are major public health concerns, there are no definite neuroprotective strategies to prevent or reduce brain injury. The pattern of brain injury seen in preterm infants has evolved into more subtle lesions that are still essential to diagnose regarding neurodevelopmental outcomes. There is no specific effective method for the treatment of premature infant brain injury, and the focus of clinical treatment is still on prevention. Prevention of this injury requires insight into the pathogenesis, but many gaps exist in our understanding of how neonatal treatment procedures and medications impact cerebral hemodynamics and preterm brain injury. Many studies provide evidence about the prevention of premature infant brain injury, which is related to some drugs (such as erythropoietin, melatonin, mesenchymal stem cells, etc.). However, there are still some controversies about the quality of research and the effectiveness of therapy. This review aims to recapitulate the results of preclinical studies and provide an update on the latest developments around etiological pathways, prevention, and treatment.
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Affiliation(s)
- Yixuan Xie
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Yue Yang
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
| | - Tianming Yuan
- Department of Neonatology, Children\'s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, P.R. China
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Pedroza-García KA, Calderón-Vallejo D, Quintanar JL. Neonatal Hypoxic-Ischemic Encephalopathy: Perspectives of Neuroprotective and Neuroregenerative Treatments. Neuropediatrics 2022; 53:402-417. [PMID: 36030792 DOI: 10.1055/s-0042-1755235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Karina A Pedroza-García
- Departamento de Fisiología y Farmacología, Laboratorio de Neurofisiología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, México
| | - Denisse Calderón-Vallejo
- Departamento de Fisiología y Farmacología, Laboratorio de Neurofisiología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, México.,Departamento de Morfología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, México
| | - J Luis Quintanar
- Departamento de Fisiología y Farmacología, Laboratorio de Neurofisiología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, México
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Bäcke P, Bruschettini M, Sibrecht G, Thernström Blomqvist Y, Olsson E. Pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Cochrane Database Syst Rev 2022; 11:CD015023. [PMID: 36354070 PMCID: PMC9647594 DOI: 10.1002/14651858.cd015023.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Newborn infants affected by hypoxic-ischemic encephalopathy (HIE) undergo therapeutic hypothermia. As this treatment seems to be associated with pain, and intensive and invasive care is needed, pharmacological interventions are often used. Moreover, painful procedures in the newborn period can affect pain responses later in life, impair brain development, and possibly have a long-term negative impact on neurodevelopment and quality of life. OBJECTIVES To determine the effects of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. SEARCH METHODS We searched CENTRAL, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the trial register ISRCTN in August 2021. We also checked the reference lists of relevant articles to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCT), quasi-RCTs and cluster-randomized trials comparing drugs used for the management of pain or sedation, or both, during therapeutic hypothermia: any opioids (e.g. morphine, fentanyl), alpha-2 agonists (e.g. clonidine, dexmedetomidine), N-Methyl-D-aspartate (NMDA) receptor antagonist (e.g. ketamine), other analgesics (e.g. paracetamol), and sedatives (e.g. benzodiazepines such as midazolam) versus another drug, placebo, no intervention, or non-pharmacological interventions. Primary outcomes were analgesia and sedation, and all-cause mortality to discharge. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified by the search strategy for inclusion. We planned to use the GRADE approach to assess the certainty of evidence. We planned to assess the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomization, blinding, loss to follow-up, and handling of outcome data). We planned to evaluate treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. MAIN RESULTS: We did not find any completed studies for inclusion. Amongst the four excluded studies, topiramate and atropine were used in two and one trial, respectively; one study used dexmedetomidine and was initially reported in 2019 to be a randomized trial. However, it was an observational study (correction in 2021). We identified one ongoing study comparing dexmedetomidine to morphine. AUTHORS' CONCLUSIONS We found no studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of pharmacological interventions for pain and sedation management in newborn infants undergoing therapeutic hypothermia.
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Affiliation(s)
- Pyrola Bäcke
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Greta Sibrecht
- Newborns' Infectious Diseases Department, Poznan University of Medical Sciences, Poznan, Poland
| | - Ylva Thernström Blomqvist
- Neonatal Intensive Care Unit, University Hospital, Uppsala, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Emma Olsson
- Department of Pediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
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Guidotti I, Lugli L, Ori L, Roversi MF, Casa Muttini ED, Bedetti L, Pugliese M, Cavalleri F, Stefanelli F, Ferrari F, Berardi A. Neonatal seizures treatment based on conventional multichannel EEG monitoring: an overview of therapeutic options. Expert Rev Neurother 2022; 22:623-638. [PMID: 35876114 DOI: 10.1080/14737175.2022.2105698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Seizures are the main neurological emergency during the neonatal period and are mostly acute and focal. The prognosis mainly depends on the underlying etiology. Conventional multichannel video-electroencephalographic (cEEG) monitoring is the gold standard for diagnosis, but treatment remains a challenge. AREAS COVERED : This review, based on PubMed search over the last 4 decades, focuses on the current treatment options for neonatal seizures based on cEEG monitoring. There is still no consensus on seizure therapy, owing to poor scientific evidence. Traditionally, the first-line treatments are phenobarbital and phenytoin, followed by midazolam and lidocaine, but their efficacy is limited. Therefore, current evidence strongly suggests the use of alternative antiseizure medications. Randomized controlled trials of new drugs are ongoing. EXPERT OPINION : Therapy for neonatal seizures should be prompt and tailored, based on semeiology, mirror of the underlying cause, and cEEG features. Further research should focus on antiseizure medications that directly act on the etiopathogenetic mechanism responsible for seizures and are therefore more effective in seizure control.
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Affiliation(s)
- Isotta Guidotti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Licia Lugli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Ori
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Maria Federica Roversi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Elisa Della Casa Muttini
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Bedetti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Marisa Pugliese
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, Modena, Italy
| | - Francesca Stefanelli
- Department of Medical and Surgical Sciences of the Mothers, Children and Adults, Post Graduate School of Pediatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Alberto Berardi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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12
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Leifsdottir K, Thelin EP, Lassarén P, Siljehav V, Nilsson P, Eksborg S, Herlenius E. Proteomic profiles in cerebrospinal fluid predicted death and disability in term infants with perinatal asphyxia: A pilot study. Acta Paediatr 2022; 111:961-970. [PMID: 35106835 PMCID: PMC9305740 DOI: 10.1111/apa.16277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/23/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
Abstract
Aim Perinatal asphyxia, resulting in hypoxic‐ischaemic encephalopathy (HIE), has been associated with high mortality rates and severe lifelong neurodevelopmental disabilities. Our aim was to study the association between the proteomic profile in cerebrospinal fluid (CSF) and the degree of HIE and long‐term outcomes. Methods We prospectively enrolled 18‐term born infants with HIE and 10‐term born controls between 2000 and 2004 from the Karolinska University Hospital. An antibody suspension bead array and FlexMap3D analysis was used to characterise 178 unique brain‐derived and inflammation associated proteins in their CSF. Results Increased CSF concentrations of several brain‐specific proteins were observed in the proteome of HIE patients compared with the controls. An upregulation of neuroinflammatory pathways was also noted and this was confirmed by pathway analysis. Principal component analysis revealed a gradient from favourable to unfavourable HIE grades and outcomes. The proteins that provided strong predictors were structural proteins, including myelin basic protein and alpha‐II spectrin. The functional proteins included energy‐related proteins like neuron‐specific enolase and synaptic regulatory proteins. Increased CSF levels of 51 proteins correlated with adverse outcomes in infants with HIE. Conclusion Brain‐specific proteins and neuroinflammatory mediators in CSF may predict HIE degrees and outcomes after perinatal asphyxia.
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Affiliation(s)
- Kristin Leifsdottir
- Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s Hospital Karolinska University Hospital Stockholm Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
- Department of Neurology Karolinska University Hospital Stockholm Sweden
| | - Philipp Lassarén
- Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
| | - Veronica Siljehav
- Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s Hospital Karolinska University Hospital Stockholm Sweden
| | - Peter Nilsson
- Department of Protein Science KTH Royal Institute of Technology SciLifeLab Stockholm Sweden
| | - Staffan Eksborg
- Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s Hospital Karolinska University Hospital Stockholm Sweden
| | - Eric Herlenius
- Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s Hospital Karolinska University Hospital Stockholm Sweden
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13
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Landucci E, Pellegrini-Giampietro DE, Facchinetti F. Experimental Models for Testing the Efficacy of Pharmacological Treatments for Neonatal Hypoxic-Ischemic Encephalopathy. Biomedicines 2022; 10:937. [PMID: 35625674 PMCID: PMC9138693 DOI: 10.3390/biomedicines10050937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023] Open
Abstract
Representing an important cause of long-term disability, term neonatal hypoxic-ischemic encephalopathy (HIE) urgently needs further research aimed at repurposing existing drug as well as developing new therapeutics. Since various experimental in vitro and in vivo models of HIE have been developed with distinct characteristics, it becomes important to select the appropriate preclinical screening cascade for testing the efficacy of novel pharmacological treatments. As therapeutic hypothermia is already a routine therapy for neonatal encephalopathy, it is essential that hypothermia be administered to the experimental model selected to allow translational testing of novel or repurposed drugs on top of the standard of care. Moreover, a translational approach requires that therapeutic interventions must be initiated after the induction of the insult, and the time window for intervention should be evaluated to translate to real world clinical practice. Hippocampal organotypic slice cultures, in particular, are an invaluable intermediate between simpler cell lines and in vivo models, as they largely maintain structural complexity of the original tissue and can be subjected to transient oxygen-glucose deprivation (OGD) and subsequent reoxygenation to simulate ischemic neuronal injury and reperfusion. Progressing to in vivo models, generally, rodent (mouse and rat) models could offer more flexibility and be more cost-effective for testing the efficacy of pharmacological agents with a dose-response approach. Large animal models, including piglets, sheep, and non-human primates, may be utilized as a third step for more focused and accurate translational studies, including also pharmacokinetic and safety pharmacology assessments. Thus, a preclinical proof of concept of efficacy of an emerging pharmacological treatment should be obtained firstly in vitro, including organotypic models, and, subsequently, in at least two different animal models, also in combination with hypothermia, before initiating clinical trials.
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Affiliation(s)
- Elisa Landucci
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, 50139 Florence, Italy;
| | | | - Fabrizio Facchinetti
- Department of Experimental Pharmacology and Translational Science, Corporate Pre-Clinical R&D, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy;
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14
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Mathew JL, Kaur N, Dsouza JM. Therapeutic hypothermia in neonatal hypoxic encephalopathy: A systematic review and meta-analysis. J Glob Health 2022; 12:04030. [PMID: 35444799 PMCID: PMC8994481 DOI: 10.7189/jogh.12.04030] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is regarded as the most efficacious therapy for neonatal hypoxic encephalopathy. However, limitations in previous systematic reviews and the publication of new data necessitate updating the evidence. We conducted this up-to-date systematic review to evaluate the effects of TH in neonatal encephalopathy on clinical outcomes. Methods In this systematic review and meta-analysis, we searched Medline, Cochrane Library, Embase, LIVIVO, Web of Science, Scopus, CINAHL, major trial registries, and grey literature (from inception to October 31, 2021), for randomized controlled trials (RCT) comparing TH vs normothermia in neonatal encephalopathy. We included RCTs enrolling neonates (gestation ≥35 weeks) with perinatal asphyxia and encephalopathy, who received either TH (temperature ≤34°C) initiated within 6 hours of birth for ≥48 hours, vs no cooling. We excluded non-RCTs, those with delayed cooling, or cooling to >34°C. Two authors independently appraised risk-of-bias and extracted data on mortality and neurologic disability at four time points: neonatal (from randomization to discharge/death), infancy (18-24 months), childhood (5-10 years), and long-term (>10 years). Other outcomes included seizures, EEG abnormalities, and MRI findings. Summary data from published RCTs were pooled through fixed-effect meta-analysis. Results We identified 36 863 citations and included 39 publications representing 29 RCTs with 2926 participants. Thirteen studies each had low, moderate, and high risk-of-bias. The pooled risk ratios (95% confidence interval, CI) were as follows: neonatal mortality: 0.87 (95% CI = 0.75, 1.00), n = 2434, I2 = 38%; mortality at 18-24 months: 0.88 (95% CI = 0.78, 1.01), n = 2042, I2 = 51%; mortality at 5-10 years: 0.81 (95% CI = 0.62, 1.04), n = 515, I2 = 59%; disability at 18-24 months: 0.62 (95% CI = 0.52, 0.75), n = 1440, I2 = 26%; disability at 5-10 years: 0.68 (95% CI = 0.52, 0.90), n = 442, I2 = 3%; mortality or disability at 18-24 months: 0.78 (95% CI = 0.72, 0.86), n = 1914, I2 = 54%; cerebral palsy at 18-24 months: 0.63 (95% CI = 0.50, 0.78), n = 1136, I2 = 39%; and childhood cerebral palsy: 0.63 (95% CI = 0.46, 0.85), n = 449, I2 = 0%. Some outcomes showed significant differences by study-setting; the risk ratio (95% CI) for mortality at 18-24 months was 0.79 (95% CI = 0.66,0.93), n = 1212, I2 = 7% in high-income countries, 0.67 (95% CI = 0.41, 1.09), n = 276, I2 = 0% in upper-middle-income countries, and 1.18 (95% CI = 0.94, 1.47), n = 554, I2 = 75% in lower-middle-income countries. The corresponding pooled risk ratios for ‘mortality or disability at 18-24 months’ were 0.77 (95% CI = 0.69, 0.86), n = 1089, I2 = 0%; 0.56 (95% CI = 0.41, 0.78), n = 276, I2 = 30%; and 0.92 (95% CI = 0.77, 1.09), n = 549, I2 = 86% respectively. Trials with low risk of bias showed risk ratio of 0.97 (95% CI = 0.80, 1.16, n = 1475, I2 = 62%) for neonatal mortality, whereas trials with higher risk of bias showed 0.71 (95% CI = 0.55, 0.91), n = 959, I2 = 0%. Likewise, risk ratio for mortality at 18-24 months was 0.96 (95% CI = 0.83, 1.13), n = 1336, I2 = 58% among low risk-of-bias trials, but 0.72 (95% CI = 0.56, 0.92), n = 706, I2 = 0%, among higher risk of bias trials. Conclusions Therapeutic hypothermia for neonatal encephalopathy reduces neurologic disability and cerebral palsy, but its effect on neonatal, infantile and childhood mortality is uncertain. The setting where it is implemented affects the outcomes. Low(er) quality trials overestimated the potential benefit of TH.
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Affiliation(s)
- Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Navneet Kaur
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
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15
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Kobayashi K, Liu C, Jonas RA, Ishibashi N. The Current Status of Neuroprotection in Congenital Heart Disease. CHILDREN 2021; 8:children8121116. [PMID: 34943311 PMCID: PMC8700367 DOI: 10.3390/children8121116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
Neurological deficits are a serious and common sequelae of congenital heart disease (CHD). While their underlying mechanisms have not been fully characterized, their manifestations are well-known and understood to persist through adulthood. Development of therapies to address or prevent these deficits are critical to attenuate future morbidity and improve quality of life. In this review, we aim to summarize the current status of neuroprotective therapy in CHD. Through an exploration of present research in the pre-operative, intra-operative, and post-operative phases of patient management, we will describe existing clinical and bench efforts as well as current endeavors underway within this research area.
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Affiliation(s)
- Kei Kobayashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - Christopher Liu
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Richard A. Jonas
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
- Correspondence:
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16
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Lee BL, Glass HC. Cognitive outcomes in late childhood and adolescence of neonatal hypoxic-ischemic encephalopathy. Clin Exp Pediatr 2021; 64:608-618. [PMID: 34044480 PMCID: PMC8650814 DOI: 10.3345/cep.2021.00164] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/18/2021] [Indexed: 12/04/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the most common cause of neonatal encephalopathy with a global incidence of approximately 1 to 8 per 1,000 live births. Neonatal encephalopathy can cause neurodevelopmental and cognitive impairments in survivors of hypoxic-ischemic insults with and without functional motor deficits. Normal neurodevelopmental outcomes in early childhood do not preclude cognitive and behavioral difficulties in late childhood and adolescence because cognitive functions are not yet fully developed at this early age. Therapeutic hypothermia has been shown to significantly reduced death and severe disabilities in term newborns with HIE. However, children treated with hypothermia therapy remain at risk for cognitive impairments and follow-up is necessary throughout late childhood and adolescence. Novel adjunctive neuroprotective therapies combined with therapeutic hypothermia may enhance the survival and neurodevelopmental outcomes of infants with HIE. The extent and severity of brain injury on magnetic resonance imaging might predict neurodevelopmental outcomes and lead to targeted interven tions in children with a history of neonatal encephalopathy. We provide a summary of the long-term cognitive outcomes in late childhood and adolescence in children with a history of HIE and the association between pattern of brain injury and neurodevelopmental outcomes.
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Affiliation(s)
- Bo Lyun Lee
- Department of Pediatrics, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.,Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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17
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Neuroprotective Agents for Neonates with Hypoxic-Ischemic Encephalopathy. Neonatal Netw 2021; 40:406-413. [PMID: 34845092 DOI: 10.1891/11-t-755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) remains a significant source of long-term neurodevelopmental impairment despite overall improvements in survival without disability in neonates who undergo therapeutic hypothermia. Each phase in the evolution of hypoxic-ischemic injury presents potential pharmacologic targets for neuroprotective agents. Melatonin is a promising emerging therapy for early phases of ischemic injury, but utility is currently limited by the lack of pharmaceutical-grade products. Magnesium has been extensively studied for its neuroprotective effects in the preterm population. Studies in neonates with HIE have produced mixed outcomes. Erythropoietin use in HIE with or without therapeutic hypothermia appears to be safe and may provide additional benefit. Dexmedetomidine, N-acetylcysteine, xenon, and topiramate all have promising animal data, but need additional human trials to elucidate what role they may play in HIE. Frequent review of existing literature is required to ensure provision of evidence-based pharmacologic agents for neuroprotection following HIE.
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18
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Metallinou D, Lazarou E, Lykeridou A. Pharmacological and Non-Pharmacological Brain-Focused Clinical Practices for Premature Neonates at High Risk of Neuronal Injury. MÆDICA 2021; 16:281-290. [PMID: 34621352 DOI: 10.26574/maedica.2020.16.2.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective:Disruption of smooth intrauterine brain development is a significant consequence of premature birth that may lead to adverse neurological outcomes. Although noteworthy progress has been made in the management of prematurity, the rates of neonatal morbidity and neurodevelopmental disorders remain high, underlining the need to find clinical practices that particularly protect the central nervous system. Aim:To identify recent articles regarding pharmacological and non-pharmacological brain-focused clinical practices (BFCP) for premature neonates at high risk of neuronal injury. Material and methods:We did an extensive search of PubMed and Google Scholar for relevant research published between 2000 and 2020. Results:Nineteen full-length original research papers fulfilled the inclusion criteria and were selected for the purpose of the present review. Non-pharmacological BFCP intend to improve the neonate's experience in the NICU environment and can be applied by a multidisciplinary team, while pharmacological ones are related to novel molecules that aim to quell apoptosis and inflammation or promote neurogenesis. Conclusion:In the future, a combination of pharmacological and non-pharmacological BFCP might be considered as the most promising protection and/or treatment provided in clinical practice to premature neonates at high risk of neuronal injury.
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Affiliation(s)
- Dimitra Metallinou
- Department of Midwifery, Faculty of Health and Caring Sciences, University of West Attica, Greece
| | | | - Aikaterini Lykeridou
- Department of Midwifery, Faculty of Health and Caring Sciences, University of West Attica, Greece
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19
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Ziobro JM, Eschbach K, Shellhaas RA. Novel Therapeutics for Neonatal Seizures. Neurotherapeutics 2021; 18:1564-1581. [PMID: 34386906 PMCID: PMC8608938 DOI: 10.1007/s13311-021-01085-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 02/04/2023] Open
Abstract
Neonatal seizures are a common neurologic emergency for which therapies have not significantly changed in decades. Improvements in diagnosis and pathophysiologic understanding of the distinct features of acute symptomatic seizures and neonatal-onset epilepsies present exceptional opportunities for development of precision therapies with potential to improve outcomes. Herein, we discuss the pathophysiology of neonatal seizures and review the evidence for currently available treatment. We present emerging therapies in clinical and preclinical development for the treatment of acute symptomatic neonatal seizures. Lastly, we discuss the role of precision therapies for genetic neonatal-onset epilepsies and address barriers and goals for developing new therapies for clinical care.
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Affiliation(s)
- Julie M Ziobro
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA.
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, Denver Anschutz School of Medicine, Children's Hospital Colorado, University of Colorado, Aurora, CO, 80045, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA
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20
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Validity Prediction of Amplitude-Integrated EEG in Early Neuromotor Development Outcomes in High-Risk Neonates. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2020:9438248. [PMID: 32256684 PMCID: PMC7086433 DOI: 10.1155/2020/9438248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/02/2022]
Abstract
With the continuous advancement of medical technology, the survival rate of high-risk children is increasing year by year, but the developmental problems that have gradually become apparent in the later stages have a serious impact on the quality of life of children. Amplitude-integrated EEG is an EEG monitoring technology developed for clinical use in newborns in recent years. Therefore, to better detect neuromata development in high-risk children, this study explores the validity prediction of amplitude-integrated EEG in early neuromata development in high-risk children. For 100 high-risk children, amplitude-integrated EEG was used for monitoring, and the exercise scale and validity predictors in the Bailey Infant Development Scale were used to assess whether high-risk children had neurobehavioral abnormalities. The experimental results show that the application of amplitude-integrated EEG can make accurate and effective predictions of early neuromata development outcomes in high-risk children. Compared with traditional neurological examination methods, it has higher sensitivity, specificity, positive predictive value, and consistency in predicting the early neuromata development outcomes of high-risk children. It is suitable for application and promotion in China and has a good application value.
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21
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McAdams RM, Berube MW. Emerging therapies and management for neonatal encephalopathy-controversies and current approaches. J Perinatol 2021; 41:661-674. [PMID: 33712717 DOI: 10.1038/s41372-021-01022-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 01/31/2023]
Abstract
Neonatal encephalopathy (NE) continues to have a major impact on newborn survival and neurodevelopmental outcomes worldwide. In high-income settings, therapeutic hypothermia is the only established standard treatment for neonates with moderate-to-severe NE, with compelling evidence that cooling reduces mortality and major neurodevelopmental impairment in survivors. Despite therapeutic hypothermia, a significant proportion of cooled infants continue to suffer long-term disability from brain injury. Innovative therapies offer the possibility of further improving neurodevelopmental outcomes by working synergistically with therapeutic hypothermia to decrease hypoxia-ischemia-induced excitotoxicity, prevent progression to secondary energy failure, and in some cases, promote neuroregeneration in the developing neonatal brain. This review discusses emerging NE therapies currently under investigation, offers insight into controversies surrounding various approaches to clinical care during therapeutic hypothermia, and identifies ongoing knowledge deficits that hinder attainment of optimal outcomes for neonates with NE.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Megan W Berube
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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22
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Michniewicz B, Wroblewska-Seniuk K, Amara JA, Al-Saad SR, Szyfter W, Karbowski LM, Gadzinowski J, Szymankiewicz M, Szpecht D. Hearing Impairment in Infants with Hypoxic Ischemic Encephalopathy Treated with Hypothermia. Ther Hypothermia Temp Manag 2021; 12:8-15. [PMID: 33512300 DOI: 10.1089/ther.2020.0043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Therapeutic hypothermia acts as the standard of care for infants with moderate to severe hypoxic ischemic encephalopathy (HIE). A proportion of neonates who undergo hypothermia due to HIE have shown to develop various degrees of hearing impairment. Analyzing and identifying infants at high risk of developing hearing difficulties is fundamental for early intervention of such auditory complications. The aim was to assess clinical factors in the development of hearing impairment following therapeutic hypothermia in HIE infants. A retrospective analysis was performed on infants hospitalized in our neonatology department in Poznan University of Medical Sciences, Poland. All infants experienced moderate to severe HIE, and were treated with therapeutic hypothermia. Risk factors for hearing impairment were identified in all infants included in the study. Clinical data during hospital stay and follow-up hearing status were analyzed. A total of 87 HIE infants were included in the study. Seventy-six infants (40 male and 36 female) had otoacoustic emission (OAE) examination following birth, of which 14 (18.4%) demonstrated abnormal (positive) results. Infants with abnormal OAE results had significantly lower blood pH (6.86 ± 0.16, p = 0.001) and base excess (BE) (-22.46 ± 2.59, p = 0.006). Of the 49 infants who returned for follow-up assessment, 4 (8.2%) were diagnosed with sensorineural bilateral hearing impairment (1 infant, mild [<40 dB], 2 moderate [41-70 dB], and 1 profound [>90 dB]). The biochemical analysis following birth revealed significantly lower umbilical BE levels (-23.90 ± 4.99, p = 0.041) and higher lactate levels (160.67 ± 4.93, p = 0.019) in the infants with eventual sensorineural hearing deficit. Infants with moderate or severe HIE are at risk of delayed onset hearing loss. Diligent efforts to monitor auditory status are required, even if early screening results for hearing are insignificant. Exploring biochemical parameters, such as lactate, BE, and blood pH, can prove beneficial in identifying HIE infants at risk of developing a hearing impairment.
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Affiliation(s)
- Barbara Michniewicz
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Jasmine A Amara
- Students' Research Group at the Department of Neonatology, and Poznan University of Medical Sciences, Poznań, Poland
| | - Salwan R Al-Saad
- Students' Research Group at the Department of Neonatology, and Poznan University of Medical Sciences, Poznań, Poland
| | - Witold Szyfter
- Department of Otolaryngology and Oncological Laryngology, Poznan University of Medical Sciences, Poznań, Poland
| | - Lukasz M Karbowski
- Students' Research Group at the Department of Neonatology, and Poznan University of Medical Sciences, Poznań, Poland
| | - Janusz Gadzinowski
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Szymankiewicz
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Dawid Szpecht
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
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23
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Benninger KL, Inder TE, Goodman AM, Cotten CM, Nordli DR, Shah TA, Slaughter JC, Maitre NL. Perspectives from the Society for Pediatric Research. Neonatal encephalopathy clinical trials: developing the future. Pediatr Res 2021; 89:74-84. [PMID: 32221474 PMCID: PMC7529683 DOI: 10.1038/s41390-020-0859-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022]
Abstract
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.
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MESH Headings
- Biomarkers/blood
- Biomedical Research/trends
- Brain Diseases/diagnostic imaging
- Brain Diseases/etiology
- Brain Diseases/physiopathology
- Brain Diseases/therapy
- Clinical Trials as Topic
- Consensus
- Delphi Technique
- Diffusion of Innovation
- Forecasting
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnostic imaging
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/physiopathology
- Infant, Newborn, Diseases/therapy
- Neonatology/trends
- Neuroimaging
- Research Design/trends
- Societies, Medical
- Societies, Scientific
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Kristen L Benninger
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Amy M Goodman
- Division of Child Neurology, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Douglas R Nordli
- Section of Child Neurology, Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Tushar A Shah
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk, VA, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathalie L Maitre
- Division of Neonatology and Center for Perinatal Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
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24
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Frajewicki A, Laštůvka Z, Borbélyová V, Khan S, Jandová K, Janišová K, Otáhal J, Mysliveček J, Riljak V. Perinatal hypoxic-ischemic damage: review of the current treatment possibilities. Physiol Res 2020; 69:S379-S401. [PMID: 33464921 DOI: 10.33549/physiolres.934595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Neonatal hypoxic-ischemic encephalopathy is a disorder with heterogeneous manifestation due to asphyxia during perinatal period. It affects approximately 3-12 children per 1000 live births and cause death of 1 million neonates worldwide per year. Besides, motor disabilities, seizures, impaired muscle tone and epilepsy are few of the consequences of hypoxic-ischemic encephalopathy. Despite an extensive research effort regarding various treatment strategies, therapeutic hypothermia with intensive care unit supportive treatment remains the only approved method for neonates who have suffered from moderate to severe hypoxic-ischemic encephalopathy. However, these protocols are only partially effective given that many infants still suffer from severe brain damage. Thus, further research to systematically test promising neuroprotective treatments in combination with hypothermia is essential. In this review, we discussed the pathophysiology of hypoxic-ischemic encephalopathy and delved into different promising treatment modalities, such as melatonin and erythropoietin. However, preclinical studies and clinical trials are still needed to further elucidate the mechanisms of action of these modalities.
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Affiliation(s)
- A Frajewicki
- Institute of Physiology, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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25
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Pisani F, Fusco C, Nagarajan L, Spagnoli C. Acute symptomatic neonatal seizures, brain injury, and long-term outcome: The role of neuroprotective strategies. Expert Rev Neurother 2020; 21:189-203. [PMID: 33176104 DOI: 10.1080/14737175.2021.1848547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal seizures are frequent but underdiagnosed manifestations of acute brain dysfunction and an important contributor to unfavorable outcomes. Etiology and severity of brain injury are the single strongest outcome determinants. AREAS COVERED The authors will discuss the prognostic role of acute symptomatic seizures versus brain injury and the main neuroprotective and neurorestorative strategies for full-term and preterm infants. EXPERT OPINION Prolonged acute symptomatic seizures likely contribute to long-term outcomes by independently adding further brain injury to initial insults. Correct timing and dosing of therapeutic interventions, depending on etiology and gestational ages, need careful evaluation. Although promising strategies are under study, the only standard of care is whole-body therapeutic hypothermia in full-term newborns with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine and Surgery Department, University of Parma , Parma, Italy
| | - Carlo Fusco
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, University of Western Australia , Perth, Australia
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
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26
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Adjunctive Neuroprotective Therapies for Treatment of Hypoxic-Ischemic Encephalopathy (HIE). CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00231-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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27
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Zhang S, Li B, Zhang X, Zhu C, Wang X. Birth Asphyxia Is Associated With Increased Risk of Cerebral Palsy: A Meta-Analysis. Front Neurol 2020; 11:704. [PMID: 32765409 PMCID: PMC7381116 DOI: 10.3389/fneur.2020.00704] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/09/2020] [Indexed: 01/04/2023] Open
Abstract
Objective: To assess the association between birth asphyxia—as defined by the pH of umbilical cord blood—and cerebral palsy in asphyxiated neonates ≥35 weeks' gestation. Methods: Two reviewers independently selected English-language studies that included data on the incidence of cerebral palsy in asphyxiated neonates ≥35 weeks' gestation. Studies were searched from the Embase, Google Scholar, PubMed, and Cochrane Library databases up to 31 December 2019, and the references in the retrieved articles were screened. Results: We identified 10 studies that met the inclusion criteria for our meta-analysis, including 8 randomized controlled trials and 2 observational studies. According to a random effects model, the pooled rate of cerebral palsy in the randomized controlled trials was 20.3% (95% CI: 16.0–24.5) and the incidence of cerebral palsy in the observational studies was 22.2% (95% CI: 8.5–35.8). Subgroup analysis by treatment for hypoxic ischemic encephalopathy in asphyxiated neonates showed that the pooled rates of cerebral palsy were 17.3% (95% CI: 13.3–21.2) and 23.9% (95% CI: 18.1–29.7) for the intervention group and non-intervention group, respectively. Conclusion: Our findings suggest that the incidence of cerebral palsy in neonates (≥35 weeks' gestation) with perinatal asphyxia is significantly higher compared to that in the healthy neonate population. With the growing emphasis on improving neonatal neurodevelopment and reducing neurological sequelae, we conclude that the prevention and treatment of perinatal asphyxia is essential for preventing the development of cerebral palsy.
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Affiliation(s)
- Shan Zhang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Bingbing Li
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China.,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Third Affiliated Hospital and Institute of Neuroscience of Zhengzhou University, Zhengzhou, China.,Center of Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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28
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Yang L, Zhao H, Cui H. Treatment and new progress of neonatal hypoxic-ischemic brain damage. Histol Histopathol 2020; 35:929-936. [PMID: 32167570 DOI: 10.14670/hh-18-214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neonatal hypoxic ischemia (HI) results in different extents of brain damage, and immature brain tissue is particularly sensitive to the stimulation of HI. Hypoxic-ischemic brain damage (HIBD) is a common and serious nervous system disease in neonates, for both full-term infants and preterm infants, and is one of the main causes of neonatal death. The surviving infants are often associated with cerebral palsy, mental retardation, and other sequelae, which severely affect quality of life. For term infants, hypoxia and ischemia mainly affect gray matter, whereas in preterm infants, the white matter. However, up to now, inadequate standards and specific measures that can be used to treat hypoxic-ischemic brain injury are available. Recently, in addition to supportive therapy and symptomatic treatment, research on the treatment of hypoxic-ischemic brain injury has focused on the following aspects: hypothermia therapy, stem cell therapy, neuroprotective agents, ibuprofen, and combination therapy. In this review, we will summarize the treatment of HIBD and make suggestions for the future treatment direction.
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Affiliation(s)
- Lijun Yang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Hehua Zhao
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong Cui
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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Marques MR, Garcia‐Robles A, Usach I, Vento M, Poveda JL, Peris JE, Mangas‐Sanjuan V. Topiramate pharmacokinetics in neonates undergoing therapeutic hypothermia and proposal of an optimised dosing schedule. Acta Paediatr 2020; 109:300-308. [PMID: 31336401 DOI: 10.1111/apa.14944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 11/28/2022]
Abstract
AIM The adequate dosing of topiramate in neonates undergoing therapeutic hypothermia has not been established. The aim of this study was to design a dosing schedule capable of providing topiramate serum concentrations within the accepted therapeutic range. METHODS Neonates (n = 52) with hypoxic ischaemic encephalopathy and subjected to therapeutic hypothermia were dosed with topiramate, 5 mg/kg on day one and 3 mg/kg on days two to five, to decrease seizure events. A total of 451 topiramate serum concentrations obtained in the patients were used to develop a population pharmacokinetic model using a non-linear mixed-effects modelling approach. RESULTS A one-compartment model with first-order absorption and two different clearance terms, one for the cooling period and another for the post-warming period, were used to describe the concentration-time topiramate data. The probability of no-seizure events could not be related to topiramate concentrations, which was attributed to excessively low topiramate concentrations. A modified dosage schedule was designed with the aim of obtaining more than 90% of patients with topiramate concentrations within the therapeutic range after the first dose. CONCLUSION The dosage schedule of topiramate in these patients should be modified with the aim of decreasing the frequency of seizure events.
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Affiliation(s)
- María Remedios Marques
- Department of Pharmacy Services University and Polytechnic Hospital La Fe Valencia Spain
| | - Ana Garcia‐Robles
- Division of Neonatology University and Polytechnic Hospital La Fe Valencia Spain
| | - Iris Usach
- Department of Pharmacy and Pharmaceutical Technology and Parasitology University of Valencia Valencia Spain
| | - Maximo Vento
- Division of Neonatology University and Polytechnic Hospital La Fe Valencia Spain
| | - José Luis Poveda
- Department of Pharmacy Services University and Polytechnic Hospital La Fe Valencia Spain
| | - José Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology and Parasitology University of Valencia Valencia Spain
| | - Victor Mangas‐Sanjuan
- Department of Pharmacy and Pharmaceutical Technology and Parasitology University of Valencia Valencia Spain
- Interuniversity Research Institute for Molecular Recognition and Technological Development Polytechnic University of Valencia‐University of Valencia Valencia Spain
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30
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Abstract
Brain injury in the full-term and near-term neonates is a significant cause of mortality and long-term morbidity, resulting in injury patterns distinct from that seen in premature infants and older patients. Therapeutic hypothermia improves long-term outcomes for many of these infants, but there is a continued search for therapies to enhance the plasticity of the newborn brain, resulting in long-term repair. It is likely that a combination strategy utilizing both early and late interventions may have the most benefit, capitalizing on endogenous mechanisms triggered by hypoxia or ischemia. Optimizing care of these critically ill newborns in the acute setting is also vital for improving both short- and long-term outcomes.
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31
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Abstract
Perinatal brain injury is a major cause of neurological disability in both premature and term infants. In this review, we summarize the evidence behind some established neuroprotective practices such as administration of antenatal steroids, intrapartum magnesium for preterm delivery, and therapeutic hypothermia. In addition, we examine emerging practices such as delayed cord clamping, postnatal magnesium administration, recombinant erythropoietin, and non-steroidal anti-inflammatory agents and finally inform the reader about novel interventions, some of which are currently in trials, such as xenon, melatonin, topiramate, allopurinol, creatine, and autologous cord cell therapy.
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Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA.,Department of Pediatric Neurology, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
| | - Michael Johnston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
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32
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Lee CYZ, Chakranon P, Lee SWH. Comparative Efficacy and Safety of Neuroprotective Therapies for Neonates With Hypoxic Ischemic Encephalopathy: A Network Meta-Analysis. Front Pharmacol 2019; 10:1221. [PMID: 31708771 PMCID: PMC6824259 DOI: 10.3389/fphar.2019.01221] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
Context: Several interventions are available for the management of hypoxic ischemic encephalopathy (HIE), but no studies have compared their relative efficacy in a single analysis. This study aims to compare and determine the effectiveness of available interventions for HIE using direct and indirect data. Methods: Large randomized trials were identified from PubMed, EMBASE, CINAHL Plus, AMED, and Cochrane Library of Clinical Trials database from inception until June 30, 2018. Two independent reviewers extracted study data and performed quality assessment. Direct and network meta-analysis of randomized controlled trials was performed to obtained pooled results comparing the effectiveness of different therapies used in HIE on mortality, neurodevelopmental delay at 18 months, as well as adverse events. Their probability of having the highest efficacy and safety was estimated and ranked. The certainty of evidence for the primary outcomes of mortality and mortality or neurodevelopmental delay at 18 months was evaluated using GRADE criteria. Results: Fifteen studies comparing five interventions were included in the network meta-analysis. Whole body cooling [Odds ratio: 0.62 (95% credible interval: 0.46–0.83); 8 trials, high certainty of evidence] was the most effective treatment in reducing the risk of mortality, followed by selective head cooling (0.73; 0.48–1.11; 2 trials, moderate certainty of evidence) and use of magnesium sulfate (0.79; 0.20–3.06; 2 trials, low certainty of evidence). Whole body hypothermia (0.48; 0.33–0.71; 5 trials), selective head hypothermia (0.54; 0.32–0.89; 2 trials), and erythropoietin (0.36; 0.19–0.66; 2 trials) were more effective for reducing the risk of mortality and neurodevelopmental delay at 18 months (moderate to high certainty). Among neonates treated for HIE, the use of erythropoietin (0.36; 0.18–0.74, 2 trials) and whole body hypothermia (0.61; 0.45–0.83; 7 trials) were associated with lower rates of cerebral palsy. Similarly, there were lower rates of seizures among neonates treated with erythropoietin (0.35; 0.13–0.94; 1 trial) and whole body hypothermia (0.64; 0.46–0.87, 7 trials). Conclusion: The findings support current guidelines using therapeutic hypothermia in neonates with HIE. However, more trials are needed to determine the role of adjuvant therapy to hypothermia in reducing the risk of mortality and/or neurodevelopmental delay.
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Affiliation(s)
| | | | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia.,School of Pharmacy, Taylor's University, Subang Jaya, Malaysia
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33
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Solevåg AL, Schmölzer GM, Cheung PY. Novel interventions to reduce oxidative-stress related brain injury in neonatal asphyxia. Free Radic Biol Med 2019; 142:113-122. [PMID: 31039399 DOI: 10.1016/j.freeradbiomed.2019.04.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 01/10/2023]
Abstract
Perinatal asphyxia-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and disability including cerebral palsy in the long term. The brain injury is secondary to both the hypoxic-ischemic event and the reoxygenation-reperfusion following resuscitation. Early events in the cascade of brain injury can be classified as either inflammation or oxidative stress through the generation of free radicals. The objective of this paper is to present efforts that have been made to limit the oxidative stress associated with hypoxic-ischemic encephalopathy. In the acute phase of ischemia/hypoxia and reperfusion/reoxygenation, the outcomes of asphyxiated infants can be improved by optimizing the initial delivery room stabilization. Interventions include limiting oxygen exposure, and shortening the time to return of spontaneous circulation through improved methods for supporting hemodynamics and ventilation. Allopurinol, melatonin, noble gases such as xenon and argon, and magnesium administration also target the acute injury phase. Therapeutic hypothermia, N-acetylcysteine2-iminobiotin, remote ischemic postconditioning, cannabinoids and doxycycline target the subacute phase. Erythropoietin, mesenchymal stem cells, topiramate and memantine could potentially limit injury in the repair phase after asphyxia. To limit the injurious biochemical processes during the different stages of brain injury, determination of the stage of injury in any particular infant remains essential. Currently, therapeutic hypothermia is the only established treatment in the subacute phase of asphyxia-induced brain injury. The effects and side effects of oxidative stress reducing/limiting medications may however be difficult to predict in infants during therapeutic hypothermia. Future neuroprotection in asphyxiated infants may indeed include a combination of therapies. Challenges include timing, dosing and administration route for each neuroprotectant.
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Affiliation(s)
- A L Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - P-Y Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Albrecht M, Zitta K, Groenendaal F, van Bel F, Peeters-Scholte C. Neuroprotective strategies following perinatal hypoxia-ischemia: Taking aim at NOS. Free Radic Biol Med 2019; 142:123-131. [PMID: 30818057 DOI: 10.1016/j.freeradbiomed.2019.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/07/2019] [Accepted: 02/19/2019] [Indexed: 12/13/2022]
Abstract
Perinatal asphyxia is characterized by oxygen deprivation and lack of perfusion in the perinatal period, leading to hypoxic-ischemic encephalopathy and sequelae such as cerebral palsy, mental retardation, cerebral visual impairment, epilepsy and learning disabilities. On cellular level PA is associated with a decrease in oxygen and glucose leading to ATP depletion and a compromised mitochondrial function. Upon reoxygenation and reperfusion, the renewed availability of oxygen gives rise to not only restoration of cell function, but also to the activation of multiple detrimental biochemical pathways, leading to secondary energy failure and ultimately, cell death. The formation of reactive oxygen species, nitric oxide and peroxynitrite plays a central role in the development of subsequent neurological damage. In this review we give insight into the pathophysiology of perinatal asphyxia, discuss its clinical relevance and summarize current neuroprotective strategies related to therapeutic hypothermia, ischemic postconditioning and pharmacological interventions. The review will also focus on the possible neuroprotective actions and molecular mechanisms of the selective neuronal and inducible nitric oxide synthase inhibitor 2-iminobiotin that may represent a novel therapeutic agent for the treatment of hypoxic-ischemic encephalopathy, both in combination with therapeutic hypothermia in middle- and high-income countries, as well as stand-alone treatment in low-income countries.
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Affiliation(s)
- Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cacha Peeters-Scholte
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Neurophyxia BV, 's Hertogenbosch, the Netherlands.
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Abstract
Neonatal brain injury (NBI) remains a major contributor to neonatal mortality and long-term neurodevelopmental morbidity. Although therapeutic hypothermia is the only proven treatment to minimize brain injury caused by neonatal encephalopathy in term neonates, it provides incomplete neuroprotection. There are no specific drugs yet proven to prevent NBI in preterm neonates. This review discusses the scientific and emerging clinical trial data for several neuroprotective drugs in development, examining potential efficacy and safety concerns. Drugs with the highest likelihood of success and closest to clinical application include erythropoietin for term and preterm neonates and antenatal magnesium for preterm neonates.
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Affiliation(s)
- Melanie A McNally
- Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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36
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Soul JS, Pressler R, Allen M, Boylan G, Rabe H, Portman R, Hardy P, Zohar S, Romero K, Tseng B, Bhatt-Mehta V, Hahn C, Denne S, Auvin S, Vinks A, Lantos J, Marlow N, Davis JM. Recommendations for the design of therapeutic trials for neonatal seizures. Pediatr Res 2019; 85:943-954. [PMID: 30584262 PMCID: PMC6760680 DOI: 10.1038/s41390-018-0242-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 12/01/2022]
Abstract
Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.
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Affiliation(s)
- Janet S Soul
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.
| | - Ronit Pressler
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Heike Rabe
- Brighton and Sussex Medical School, Brighton, England
| | | | | | - Sarah Zohar
- INSERM, UMRS1138, University Paris V and University Paris VI, Paris, France
| | | | | | - Varsha Bhatt-Mehta
- C.S.Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Cecil Hahn
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Scott Denne
- Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Stephane Auvin
- Pediatric Neurology Department & INSERM U1141, APHP, Robert Debré University Hospital, Paris, France
| | - Alexander Vinks
- College of Medicine & Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - John Lantos
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Neil Marlow
- UCL Institute for Women's Health, University College London, London, UK
| | - Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
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Current Overview of Neonatal Convulsions. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:1-6. [PMID: 33536818 PMCID: PMC7847733 DOI: 10.14744/semb.2018.22844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/06/2018] [Indexed: 11/30/2022]
Abstract
Neonatal convulsions are one of the most common emergency neurological events in the early period after birth. The frequency has been reported to be 1.5 to 3 in 1000 live births. It has been established that the convulsion threshold is lower in infants due to immature neonatal neurons and differences in neurotransmitters. Hypoxic ischemic encephalopathy is the most common etiology in neonatal convulsions. Other causes vary, and may be related to the level of development of the country. Convulsions are classified into 4 different types according to the clinical findings. The most common is the subtle (undefined) type of seizure; the other types are defined as clonic, tonic, and myoclonic seizures. Non-epileptic paroxysmal movements frequently seen in the neonatal period, should not be confused with seizures. The most common non-epileptic paroxysmal movements are jitteriness, benign neonatal sleep myoclonus, and hyperekplexia. A newborn that experiences convulsions should be hospitalized and monitored with continuous video electroencephalogram, if possible. If an initial rapid evaluation detects an acute metabolic disorder, treatment is provided, and, if warranted, it will be followed by a plan for further treatment with anticonvulsant drugs. Phenobarbital is still currently recommended as first-line therapy, though there are studies of other anticonvulsant drugs. Levetiracetam and phenytoin are commonly used as second-step anticonvulsant drugs. The aim of treatment should be not only to stop acute symptomatic seizures, but also to reduce the risk of brain damage and to minimize the possible negative effects of epilepsy and neurological deficits.
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38
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Ahrens S, Ream MA, Slaughter LA. Status Epilepticus in the Neonate: Updates in Treatment Strategies. Curr Treat Options Neurol 2019; 21:8. [PMID: 30773607 DOI: 10.1007/s11940-019-0546-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to report recent advances in treatment of neonatal seizures, with a specific focus on new literature since a 2013 systematic review performed by this author (Slaughter) and others. There is a paucity of data with regard to well-defined status epilepticus (SE) in neonates, so treatment of recurrent seizures was also included in this inquiry. We aimed to summarize the efficacy and safety profiles of current therapeutic options as well as describe trends in medication selection in the neonatal intensive care unit (NICU) setting. RECENT FINDINGS Phenobarbital remains first-line therapy in practice, though there is increasing evidence of its neurotoxicity and long-term sequelae. Bumetanide failed an open-label trial for efficacy, demonstrated an increased risk for hearing loss, and has since fallen out of favor for use in this population. New agents, such as levetiracetam and topiramate, still have very limited data but appear to be as efficacious as older medications, with more favorable side effect profiles. There are limited high-level evidence-based data to guide treatment of neonatal seizures. Emerging research focusing on drug mechanisms and safety profiles may provide additional information to guide decisions; however, further research is needed.
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Affiliation(s)
- Stephanie Ahrens
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, 611 E Livingston Avenue FB4, Columbus, OH, 43205, USA.
| | - Margie A Ream
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, 611 E Livingston Avenue FB4, Columbus, OH, 43205, USA
| | - Laurel A Slaughter
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, 611 E Livingston Avenue FB4, Columbus, OH, 43205, USA
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News of the Academy of Neonatal Nursing. Neonatal Netw 2019; 37:186-192. [PMID: 29789061 DOI: 10.1891/0730-0832.37.3.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wassink G, Davidson JO, Dhillon SK, Zhou K, Bennet L, Thoresen M, Gunn AJ. Therapeutic Hypothermia in Neonatal Hypoxic-Ischemic Encephalopathy. Curr Neurol Neurosci Rep 2019; 19:2. [PMID: 30637551 DOI: 10.1007/s11910-019-0916-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Therapeutic hypothermia reduces death or disability in term and near-term infants with moderate-severe hypoxic-ischemic encephalopathy. Nevertheless, many infants still survive with disability, despite hypothermia, supporting further research in to ways to further improve neurologic outcomes. RECENT FINDINGS Recent clinical and experimental studies have refined our understanding of the key parameters for hypothermic neuroprotection, including timing of initiation, depth, and duration of hypothermia, and subsequent rewarming rate. However, important knowledge gaps remain. There is encouraging clinical evidence from a small phase II trial that combined treatment of hypothermia with recombinant erythropoietin further reduces risk of disability but definitive studies are still needed. In conclusion, recent studies suggest that current protocols for therapeutic hypothermia are near-optimal, and that the key to better neurodevelopmental outcomes is earlier diagnosis and initiation of hypothermia after birth. Further research is essential to find and evaluate ways to further improve outcomes after hypoxic-ischemic encephalopathy, including add-on therapies for therapeutic hypothermia and preventing pyrexia during labor and delivery.
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Affiliation(s)
- Guido Wassink
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Joanne O Davidson
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Simerdeep K Dhillon
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Kelly Zhou
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Laura Bennet
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Alistair J Gunn
- Department of Physiology, School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, Auckland, 92019, New Zealand.
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Nair J, Kumar VHS. Current and Emerging Therapies in the Management of Hypoxic Ischemic Encephalopathy in Neonates. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E99. [PMID: 30029531 PMCID: PMC6069156 DOI: 10.3390/children5070099] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023]
Abstract
Neonatal hypoxic ischemic encephalopathy (HIE) presents a significant clinical burden with its high mortality and morbidity rates globally. Therapeutic hypothermia (TH) is now standard of care for infants with moderate to severe HIE, but has not definitively changed outcomes in severe HIE. In this review, we discuss newer promising markers that may help the clinician identify severity of HIE. Therapies that are beneficial and agents that hold promise for neuroprotection are described, both for use either alone or as adjuncts to TH. These include endogenous pathway modifiers such as erythropoietin and analogues, melatonin, and remote ischemic post conditioning. Stem cells have therapeutic potential in this condition, as in many other neonatal conditions. Of the agents listed, only erythropoietin and analogues are currently being evaluated in large randomized controlled trials (RCTs). Exogenous therapies such as argon and xenon, allopurinol, monosialogangliosides, and magnesium sulfate continue to be investigated. The recognition of tertiary mechanisms of brain damage has opened up new research into therapies not only to attenuate brain damage but also to promote cell repair and regeneration in a developmentally disorganized brain long after the perinatal insult. These alternative modalities may be especially important in mild HIE and in areas of the world where there is limited access to expensive hypothermia equipment and services.
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Affiliation(s)
- Jayasree Nair
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
| | - Vasantha H S Kumar
- Division of Neonatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA.
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Abstract
Acute symptomatic seizures caused by either diffuse or focal perinatal hypoxic-ischemic insults and intracranial hemorrhage in term newborns make up the large majority of all neonatal seizures. Acute seizures are one of the most common neurological disorders in term newborns who require admission to the neonatal intensive care unit. Despite elucidation of seizure pathogenesis in this population using animal models, treatment is limited by a lack of good evidence-based guidelines because of a paucity of rigorously conducted clinical trials or prospective studies in human newborns. A result of this knowledge gap is that management, particularly drug choice, is guided by clinical experience rather than by data informing drug efficacy and safety. This review summarizes the common etiologies and pathogenesis of acute symptomatic seizures, and the current data informing their treatment, including potential novel drugs, together with a suggested treatment algorithm.
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Affiliation(s)
- Janet S. Soul
- Fetal–Neonatal Neurology Program, Boston Children’s Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Address: Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. Tel.: +1 617-355-8994; fax: +1 617-730-0279. (J.S. Soul)
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Wassink G, Davidson JO, Lear CA, Juul SE, Northington F, Bennet L, Gunn AJ. A working model for hypothermic neuroprotection. J Physiol 2018; 596:5641-5654. [PMID: 29660115 DOI: 10.1113/jp274928] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/28/2018] [Indexed: 01/04/2023] Open
Abstract
Therapeutic hypothermia significantly improves survival without disability in near-term and full-term newborns with moderate to severe hypoxic-ischaemic encephalopathy. However, hypothermic neuroprotection is incomplete. The challenge now is to find ways to further improve outcomes. One major limitation to progress is that the specific mechanisms of hypothermia are only partly understood. Evidence supports the concept that therapeutic cooling suppresses multiple extracellular death signals, including intracellular pathways of apoptotic and necrotic cell death and inappropriate microglial activation. Thus, the optimal depth of induced hypothermia is that which effectively suppresses the cell death pathways after hypoxia-ischaemia, but without inhibiting recovery of the cellular environment. Thus mild hypothermia needs to be continued until the cell environment has recovered until it can actively support cell survival. This review highlights that key survival cues likely include the inter-related restoration of neuronal activity and growth factor release. This working model suggests that interventions that target overlapping mechanisms, such as anticonvulsants, are unlikely to materially augment hypothermic neuroprotection. We suggest that further improvements are most likely to be achieved with late interventions that maximise restoration of the normal cell environment after therapeutic hypothermia, such as recombinant human erythropoietin or stem cell therapy.
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Affiliation(s)
- Guido Wassink
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Frances Northington
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
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Yozawitz E, Stacey A, Pressler RM. Pharmacotherapy for Seizures in Neonates with Hypoxic Ischemic Encephalopathy. Paediatr Drugs 2017; 19:553-567. [PMID: 28770451 DOI: 10.1007/s40272-017-0250-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Seizures are common in neonates with moderate and severe hypoxic ischemic encephalopathy (HIE) and are associated with worse outcomes, independent of HIE severity. In contrast to adults and older children, no new drugs have been licensed for treatment of neonatal seizures over the last 50 years, because of a lack of controlled clinical trials. Hence, many antiseizure medications licensed in older children and adults are used off-label for neonatal seizure, which is associated with potential risks of adverse effects during a period when the brain is particularly vulnerable. Phenobarbital is worldwide the first-line drug and is considered standard of care, although there is a limited evidence base for its efficacy. Second-line agents include phenytoin, benzodiazepines, levetiracetam, and lidocaine. These drugs are discussed in more detail along with two emerging drugs (bumetanide and topiramate). More safety, pharmacokinetic, and efficacy data are needed from well-designed clinical trials to develop safe and effective antiseizure regimes for the treatment of neonatal seizures in HIE.
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Affiliation(s)
- Elissa Yozawitz
- Department of Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arthur Stacey
- UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, Great Ormond Street, London, WC1N 3JH, UK. .,Clinical Neurosciences, UCL- Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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