Short-term outcomes in infants with mild neonatal encephalopathy: a retrospective, observational study.

BACKGROUND: Neonatal encephalopathy due to acute perinatal asphyxia is a major cause of perinatal brain damage. Moderate to severe neonatal encephalopathy is associated with high mortality and morbidity rates. However, the neurodevelopmental outcomes in neonates with mild neonatal encephalopathy are unclear. The primary aim of this single-center observational study was to assess the short-term outcomes in term neonates with mild neonatal encephalopathy due to perinatal asphyxia. A secondary aim was to identify predictors of poor prognosis by identifying the characteristics of these infants according to their short-term outcomes. METHODS: We retrospectively investigated all infants with perinatal asphyxia at Tokyo Metropolitan Children's Medical Center from January 2014 to December 2019. An abnormal short-term outcome was defined as any one of the following: seizures or abnormal electroencephalography, abnormal brain magnetic resonance imaging obtained within the first 4 weeks of life, and abnormal neurological examination findings at discharge. RESULTS: In total, 110 term infants with perinatal asphyxia during the study period were screened and 61 were diagnosed with mild neonatal encephalopathy. Eleven (18 %) of these infants had an abnormal short-term outcome. The median Thompson score at admission was significantly higher in infants with abnormal short-term outcomes than in those with normal short-term outcomes (5 [interquartile range, 4-5.5] vs. 2 [interquartile range, 1-3], p < 0.01). Receiver operating characteristic curve analysis showed that a cutoff value of 4 had high sensitivity and specificity (90.9 and 83.0 %, respectively) for prediction of an abnormal short-term outcome. CONCLUSIONS: 18 % of infants with mild encephalopathy had an abnormal short-term outcome, such as abnormal brain magnetic resonance imaging findings. The Thompson score at admission may be a useful predictor of an abnormal short-term outcome in infants with mild neonatal encephalopathy.

Observational study shows that it is feasible to provide neuroprotective treatment for neonatal encephalopathy in low-income countries.

AIM: Perinatal asphyxia is one of the most frequent causes of neonatal morbidity and mortality worldwide, and 96% of the burden of neonatal encephalopathy occurs in low-income countries. This study investigated the feasibility of providing neuroprotective treatment for neonatal encephalopathy in low-income countries. METHODS: Neonates with a gestational age of at least 36 weeks, with signs of perinatal asphyxia, were included in this 2015 observational study in three hospitals in Kinshasa, capital of the Democratic Republic of Congo. Their characteristics were described, including the time to admission and Thompson score on admission. RESULTS: We found that 42 of 134 patients (31.3%) reached the hospital within six hours of birth with a Thompson score of at least seven on admission. Another 15 patients (11.2%) had a five-minute Apgar score of up to five, without a Thompson score, and were eligible for treatment. Of the 57 (42.5%) eligible patients, 31 were discharged (54.4%), 25 died (43.9%) and one (1.8%) remained in hospital at the end of the study. CONCLUSION: Interventional studies are feasible and necessary, especially in countries where the burden of neonatal encephalopathy is largest. A Thompson score of 7-15 might be a useful entry criterion for neuroprotective treatment in low-income countries.

Evolution of the Thompson score during the first 6 h in infants with perinatal asphyxia.

AIM: This study aimed to determine the evolution of the Thompson score, which provides composite grading of encephalopathy signs, during the first 6 h of birth in neonates with perinatal asphyxia. METHODS: Twenty term infants with perinatal asphyxia were prospectively studied from the University Hospital of Kinshasa during a 12-month period. The Thompson score was performed after 1 h, then hourly until 6 h of birth. RESULTS: Fourteen infants had a Thompson score ≥7 and six had a score <7 after 1 h of birth. The Thompson score remained higher than 7 after 3 h in nine infants (64.3%) and in four infants (25.6%) after 6 h. After 3 h of birth, four infants moved from a score ≥7 to a score below 7. After 6 h, five infants had a score below 7. Seventy per cent of patients had a Thompson score higher than 7 after 1 h, 45% after 3 h and 20% after 6 h. CONCLUSION: The Thompson score changes over the time during the first 6 h of birth, and this should be taken into account when it is being used as an entry criterion for cooling.

Intrapartum cardiotocographic monitoring and its correlation with neonatal outcome.

Introduction: Despite the advancements in perinatal care in past decades, perinatal asphyxia remains a serious problem leading to significant perinatal morbidity and mortality. Therefore, foetal monitoring during the intrapartum period is of paramount importance. Among various methods of fetal monitoring, cardiotocography is a form of electronic foetal monitoring in which there is simultaneous recording of foetal heart rate and uterine contractions. Materials and Methods: This cross-sectional observational study was done in the labour room and neonatal intensive care unit (NICU) of a teaching Municipal Hospital in North India including 500 pregnant women of age group 18-45 years with singeleton fetus of gestation ≥36 weeks without any known congenital anomaly. Intrapartum cardiotocography (CTG) for 20 minutes was done within 12 hours prior to delivery and babies born to them were observed for birth asphyxia as Apgar score <7 at 1 minute as per using APGAR score less than 7 at 1 minute as per south east asia regional neonatal perinatal database (SEAR-NPD), world health organization (WHO) working definition. Results: CTG tracing was normal/reassuring in 92% of pregnant women, nonreassuring in 7% and was abnormal in only 1%. In patients with abnormal and nonreassuring CTG, delivery by lower segment cesarian section (LSCS) was significantly high (P < .0001). APGAR scoring was done at 1 minute and 5 minutes of life, it was found that 4% babies were having score less than 7 at 1 minute with incidence of birth asphyxia 40 per 1,000 live births Neonatal seizure was significantly more in nonreassuring and abnormal CTG group (P value <.0001). Conclusion: Abnormal CTG tracings result in higher incidence of operative interventions for deliveries. Abnormal CTG pattern during intrapartum CTG has high specificity and negative predictive value but has low sensitivity and positive predictive value for detection of birth asphyxia and need for NICU admission.

Correlation of Thompson Score in Predicting Early Outcome of Newborn with Birth Asphyxia.

BACKGROUND: Birth asphyxia is one of the important causes of neonatal morbidity and mortality, accounting up to 30% of neonatal death in Nepal. It is also an important cause of long term neurological disability and impairment. Thompson encephalopathy score is a clinical score which can be used to assess the newborn with hypoxic ischemic encephalopathy for the prognosis and their neurodevelopmental outcome. The aim of the study was to assess the role of Thompson score in predicting the early outcome of neonates with birth asphyxia. METHODS: A prospective study was conducted from May 2019 to April 2020 in Nepal Medical College. All the term babies during the period with Apgar score of less than seven at five minutes were considered to have birth asphyxia and included in the study. Neurological examination was done on first, second and third day using HIE score proposed by Thompson and severity of hypoxic ischemic encephalopathy was classified accordingly. Outcome was measured as normal, morbidity with encephalopathy, seizure, organ dysfunction and death. RESULTS: Out of 391 newborn admitted to neonatal unit, 84 (21.4%) had birth asphyxia. Mild Thompson score on day 1,2,3 were 49(58.3%), 49 (58.3%), 51(60.7%); moderate Thompson score on day 1,2,3 were 21 (25%), 21 (25%), 18(21.4%) and severe Thompson score on day 1, 2, 3 were 14 (16.7%), 14 (16.7%), 15(17.9%) respectively. Out of 14 babies who had severe Thompson score on day 1, 11(91.7%) expired and 3 (16.7%) developed encephalopathy. CONCLUSIONS: There was strong correlation of severity of Thompson score with the outcome.

Predictive Value of Thompson-Score for Long-Term Neurological and Cognitive Outcome in Term Newborns with Perinatal Asphyxia and Hypoxic-Ischemic Encephalopathy Undergoing Controlled Hypothermia Treatment.

BACKGROUND: The so-called Thompson-score (TS) for newborns with hypoxic-ischemic encephalopathy (HIE) was developed before the introduction of controlled hypothermia as clinical routine. Information on the predictive value of TS in newborns undergoing therapeutic hypothermia to estimate long-term outcome is limited. OBJECTIVES: To determine the predictive value of TS to estimate long-term cognitive and neurological outcome in newborns with perinatal asphyxia treated with controlled hypothermia. METHODS: Thirty-six term newborns with HIE undergoing controlled hypothermia were followed using Wechsler Preschool and Primary Scale of intelligence III test and standardized neurological examination. The primary outcome was survival without cognitive impairment, defined as an IQ ≥85. Secondary outcomes were motor outcomes, survival without relevant neurological impairment, death and epilepsy. RESULTS: Follow-up was done in 33 out of 36 (91.6%) infants at 53 ± 12 months (mean ± SD). For all investigated parameters, a statistically significant relationship with peak TS was demonstrated. A one-point increase in peak TS indicated an OR (95% CI) of 1.5 (1.1-2.0, p = 0.006) for death or cognitive impairment, an OR (95% CI) of 2.2 (1.3-3.8, p = 0.004) for death or relevant neurologic impairment, an OR (95% CI) of 2.1 (1.3-3.5, p = 0.005) for death or epilepsy and an OR (95% CI) of 1.5 (1.1-2.1, p = 0.02) for death. Although the TS for newborns with adverse outcome (death or cognitive impairment) compared to normal outcome tended to be higher (13 [4-16] vs. 9 [0-13], d1; 15 [5-19] vs. 9 [1-14], d2; 14 [5-21] vs. 8 [2-15], d3; median [range]), there was a considerable overlap during the first 3 days of life between both groups. CONCLUSIONS: The TS seems to be a prognostic tool for predicting the long-term outcome in asphyxiated term newborns undergoing controlled hypothermia after the third day of life. A higher score appears to be significantly associated with an adverse outcome.

A Comparison of the Thompson Encephalopathy Score and Amplitude-Integrated Electroencephalography in Infants with Perinatal Asphyxia and Therapeutic Hypothermia.

BACKGROUND: In previous studies clinical signs or amplitude-integrated electroencephalography (aEEG)-based signs of encephalopathy were used to select infants with perinatal asphyxia for treatment with hypothermia. AIM: The objective of this study was to compare Thompson encephalopathy scores and aEEG, and relate both to outcome. SUBJECTS AND METHODS: Thompson scores, aEEG, and outcome were compared in 122 infants with perinatal asphyxia and therapeutic hypothermia. Of these 122 infants, 41 died and 7 had an adverse neurodevelopmental outcome. A receiver operating characteristics (ROC) analysis was also performed. RESULTS: Thompson scores were higher in infants with more abnormal aEEG background patterns (ANOVA, p < 0.001). The ROC analysis demonstrated that a Thompson score of 11 or higher or an aEEG background pattern of continuous low voltage or worse was associated with an adverse outcome (AUC 0.84 for both). CONCLUSIONS: High Thompson scores and a suppressed aEEG background pattern are associated with an adverse outcome after perinatal asphyxia and therapeutic hypothermia. Further studies are needed to identify the best technique with which to select patients for therapeutic hypothermia.

Human Umbilical Cord Blood CD34-Positive Cells as Predictors of the Incidence and Short-Term Outcome of Neonatal Hypoxic-Ischemic Encephalopathy: A Pilot Study.

BACKGROUND AND PURPOSE: Neonatal hypoxic-ischemic encephalopathy (HIE) is one of the leading causes of neurological handicap in developing countries. Human umbilical cord blood (hUCB) CD34-positive (CD34⁺) stem cells exhibit the potential for neural repair. We tested the hypothesis that hUCB CD34⁺ stem cells and other cell types [leukocytes and nucleated red blood cells (NRBCs)] that are up-regulated during the acute stage of perinatal asphyxia (PA) could play a role in the early prediction of the occurrence, severity, and mortality of HIE. METHODS: This case-control pilot study investigated consecutive neonates exposed to PA. The hUCB CD34⁺ cell count in mononuclear layers was assayed using a flow cytometer. Twenty full-term neonates with PA and 25 healthy neonates were enrolled in the study. RESULTS: The absolute CD34⁺ cell count (p=0.02) and the relative CD34⁺ cell count (CD34⁺%) (p<0.001) in hUCB were higher in the HIE patients (n=20) than the healthy controls. The hUCB absolute CD34⁺ cell count (p=0.04), CD34⁺% (p<0.01), and Hobel risk scores (p=0.04) were higher in patients with moderate-to-severe HIE (n=9) than in those with mild HIE (n=11). The absolute CD34⁺ cell count was strongly correlated with CD34⁺% (p<0.001), Hobel risk score (p=0.04), total leukocyte count (TLC) (p<0.001), and NRBC count (p=0.01). CD34⁺% was correlated with TLC (p=0.02). CONCLUSIONS: hUCB CD34⁺ cells can be used to predict the occurrence, severity, and mortality of neonatal HIE after PA.

Study on MRI changes in phenylketonuria in patients referred to mofid hospital/iran.

OBJECTIVE: Phenylketonuria is one of the most common metabolic disorders and the first known cause of mental retardation in pediatrics. As Screening for phenylketonuria (PKU) is not a routine neurometabolic screening test for neonates in Iran, many PKU cases may be diagnosed after developing the clinical symptoms. One of the findings of PKU is myelination disorders, which is seen as hypersignal regions in T2-weighted (T2W) and FLAIR sequences of brain MRI. The aim of our study was to assess MRI changes in PKU patients referred to Mofid Children's Hospital, 2010-2011. MATERIALS & METHODS: We studied all PKU cases referred to our clinic as a referral neurometabolic center in Iran for brain MRI and assessed the phenylalanine level at the time of Imaging. The mean phenylalanine level (in one year), clinical manifestations, and MRI pattern based on Thompson scoring, were evaluated. RESULTS: The mean age of our study group was 155±99 months and the mean diagnosis age was 37±27.85 months. There were 15 patients with positive and 15 with negative family history. The mean phenylalanine level at the time of imaging was 9.75±6.28 and the mean 1 year phenylalanine level was 10.28±4.82. Seventy percent of our patients had MRI involvement, in whom 20% showed atrophic changes, in addition to white matter involvement. Based on modified Thompson scoring, the score for our study group was 4.84. The maximum involvement in MRI was in occipital region, followed by parietal, frontal, and temporal zones. There was not any correlation between MRI score and patients' age. But we found significant relationship between MRI score and the age of regimen cessation. No correlation was seen between phenylalanine level (at the time of Imaging) and MRI score. But there was a relationship between mean 1 year phenylalanine level and MRI score. CONCLUSION: According to the results of this study, brain MRI and white matter involvement can be used for evaluation of long-term control of phenylalanine level in PKU cases.