Identifying Ways to Fix Outcome Disparities among Outborns Needing Therapeutic Hypothermia.

OBJECTIVE: This study examined patterns of care after birth in newborns treated with therapeutic hypothermia to identify remediable causes for the poorer outcomes observed in outborn infants. STUDY DESIGN: This was a secondary analysis of 150 newborns (68 outborn) prospectively enrolled at our center in the Vermont Oxford Neonatal Encephalopathy Registry from January 2008 to October 2016. RESULTS: The 5-minute Apgar's score and cord pH value did not differ, but cord blood gases were obtained far less frequently in outborns (p = 0.002). Outborns needed more chest compressions (p = 0.01) and epinephrine (p = 0.04), and had more brain injury on neuroimaging (p = 0.05). Outborns took longer to reach target hypothermia temperature (p < 0.0001). CONCLUSION: The lack of cord gas values and longer time to reach target temperature observed in the outborns are two observed differences in care that can be potentially remedied by providing education and resources at delivering hospitals in rapid identification of hypothermia candidates, though further research is needed to define the effects of such measures. Possible solutions are also discussed here.

Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: There are no US Food and Drug Administration-approved therapies for neonatal seizures. Phenobarbital and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam has proven efficacy and an excellent safety profile in older patients; therefore, there is great interest in its use in neonates. However, randomized studies have not been performed. Our objectives were to study the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment of neonatal seizures. METHODS: The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment for neonatal seizures of any cause. The primary outcome measure was complete seizure freedom for 24 hours, assessed by independent review of the EEGs by 2 neurophysiologists. RESULTS: Eighty percent of patients (24 of 30) randomly assigned to phenobarbital remained seizure free for 24 hours, compared with 28% of patients (15 of 53) randomly assigned to levetiracetam (P < .001; relative risk 0.35 [95% confidence interval: 0.22-0.56]; modified intention-to-treat population). A 7.5% improvement in efficacy was achieved with a dose escalation of levetiracetam from 40 to 60 mg/kg. More adverse effects were seen in subjects randomly assigned to phenobarbital (not statistically significant). CONCLUSIONS: In this phase IIb study, phenobarbital was more effective than levetiracetam for the treatment of neonatal seizures. Higher rates of adverse effects were seen with phenobarbital treatment. Higher-dose studies of levetiracetam are warranted, and definitive studies with long-term outcome measures are needed.

Late onset autistic symptoms and other fluctuating behaviors.

CASE: Suzanna was born to a 26-year-old woman who used cocaine, alcohol, and cigarettes and experienced domestic violence throughout her pregnancy. Suzanna was placed in foster care with her current adoptive family after her birth. Her initial evaluation at 4 years revealed a global developmental delay (physical: 6 months; social and communication: 12 months). Improvements in development seemed to be in response to subsequent interventions. At 5 years, she had borderline intellectual functioning, an expressive or receptive language disorder, and attention-deficit hyperactivity disorder. Suzanna experienced an abrupt developmental decline at 6 1/2 years old. She lost cognitive abilities, and she no longer carried on conversations. Although she was no longer interactive with most people, she remained affectionate with her parents. Her mother thought that Suzanna had visual and auditory hallucinations. In addition, she developed encopresis and hand flapping. A neurological evaluation, including a test for Rett Syndrome, was negative. Her Full Scale IQ dropped from 73 to 50 with decreased adaptive functioning and clinically significant problems with hyperactivity, attention, and functional communication. Suzanna's development stabilized temporarily during an 18-month period. A second period of declining function included "zombie-like" behavior, anxiety, and hallucinations. Weekly sessions in child psychiatry included treatment with risperidone, methylphenidate, and supportive therapy for mother and child. After some clinical improvements in behavior, attention, and functioning, a psychological assessment confirmed the persistence of moderate mental retardation. A multidisciplinary team considered a diagnosis of childhood disintegrative disorder.

Late onset autistic symptoms and other fluctuating behaviors.

Suzanna was born to a 26-year-old woman who used cocaine, alcohol, and cigarettes and experienced domestic violence throughout her pregnancy. Suzanna was placed in foster care with her current adoptive family after her birth. Her initial evaluation at 4 years revealed a global developmental delay (physical: 6 months; social and communication: 12 months). Improvements in development seemed to be in response to subsequent interventions. At 5 years, she had borderline intellectual functioning, an expressive or receptive language disorder, and attention-deficit hyperactivity disorder.Suzanna experienced an abrupt developmental decline at 6 1/2 years old. She lost cognitive abilities, and she no longer carried on conversations. Although she was no longer interactive with most people, she remained affectionate with her parents. Her mother thought that Suzanna had visual and auditory hallucinations. In addition, she developed encopresis and hand flapping. A neurological evaluation, including a test for Rett Syndrome, was negative. Her Full Scale IQ dropped from 73 to 50 with decreased adaptive functioning and clinically significant problems with hyperactivity, attention, and functional communication.Suzanna's development stabilized temporarily during an 18-month period. A second period of declining function included "zombie-like" behavior, anxiety, and hallucinations. Weekly sessions in child psychiatry included treatment with risperidone, methylphenidate, and supportive therapy for mother and child. After some clinical improvements in behavior, attention, and functioning, a psychological assessment confirmed the persistence of moderate mental retardation. A multidisciplinary team considered a diagnosis of childhood disintegrative disorder.