ObjectiveHypoxic-ischaemic encephalopathy (HIE) remains a leading cause of neonatal mortality and neurodisability. We aimed to determine the incidence of HIE and management patterns against national guidelines.DesignRetrospective cohort study using the National Neonatal Research Database.SettingNeonatal units in England and Wales.PatientsInfants 34–42 weeks gestational age (GA) with a recorded diagnosis of HIE.Main outcomesIncidence of HIE, mortality and treatment with therapeutic hypothermia (TH) were the main outcomes. Temporal changes were compared across two epochs (2011–2013 and 2014–2016).ResultsAmong 407 462 infants admitted for neonatal care, 12 195 were diagnosed with HIE. 8166 infants ≥36 weeks GA had moderate/severe HIE, 62.1% (n=5069) underwent TH and mortality was 9.3% (n=762). Of infants with mild HIE (n=3394), 30.3% (n=1027) underwent TH and 6 died. In late preterm infants (34–35 weeks GA) with HIE (n=635, 5.2%), 33.1% (n=210) received TH and 13.1% (n=83) died. Between epochs (2011–2013 vs 2014–2016), mortality decreased for infants ≥36 weeks GA with moderate/severe HIE (17.5% vs 12.3%; OR 0.69, 95% CI 0.59 to 0.81, p<0.001). Treatment with TH increased significantly between epochs in infants with mild HIE (24.9% vs 35.8%, p<0.001) and those born late preterm (34.3% vs 46.6%, p=0.002).ConclusionsMortality of infants ≥36 weeks GA with moderate/severe HIE has reduced over time, although many infants diagnosed with moderate/severe HIE do not undergo TH. Increasingly, mild HIE and late preterm infants with HIE are undergoing TH, where the evidence base is lacking, highlighting the need for prospective studies to evaluate safety and efficacy in these populations.

Barrie Hayes-Gill 2 | Don Sharkey 1 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Evaluate the risk of severe intraventricular haemorrhage (IVH), in the first week of life, in preterm infants undergoing early inter-hospital transport. Design Retrospective cohort study SettingTertiary neonatal centres of the Trent Perinatal Network in the UK. PatientsPreterm infants <32 weeks gestation, who were either born within and remained at the tertiary neonatal centre (inborn), or were transferred (transported) between centres in the first 72 hours of life. MethodsMultivariable logistic regression models adjusting for key confounders were used to calculate odds ratios (OR) for IVH with 95% confidence intervals (CI) for comparison of inborn and transported infants. Interventions None MeasurementsCranial ultrasound findings on day 7 of life. Secondary analyses were performed for antenatal steroid course and gestational age subgroups. Main ResultsA total of 1047 preterm infants were included in the main analysis. Transported infants (n=391) had a significantly higher risk of severe (grade III/IV) IVH compared with inborns (n=656) (9.7% vs 5.8%, aOR 1.69, 95%CI 1.04-2.76), especially for infants born at <28 weeks gestation (aOR 1.83, 95%CI 1.03-3.21). Transported infants were less likely to receive a full antenatal steroid course (47.8% vs 64.3%, p<0.001). A full antenatal steroid course significantly decreased the risk of severe IVH irrespective of transport status (OR 0.33, 95%CI 0.2-0.55). However, transported infants <28 weeks gestation remained significantly more likely to develop a severe IVH despite a full antenatal steroid course (aOR 2.84, 95%CI 1.08-7.47). ConclusionPreterm infants transported in the first 72 hours of life have an increased risk of early-life severe IVH even when maternal antenatal steroids are given. The additional burden of postnatal transport could be an important component in the pathway to severe IVH. As timely in-utero transfer isn't always possible, we need to focus research on improving the transport pathway to reduce this additional risk.

ObjectiveTherapeutic hypothermia (TH) for neonatal hypoxic-ischaemic encephalopathy (HIE), delivered mainly in tertiary cooling centres (CCs), reduces mortality and neurodisability. It is unknown if birth in a non-cooling centre (non-CC), without active TH, impacts short-term outcomes.DesignRetrospective cohort study using National Neonatal Research Database and propensity score-matching.SettingUK neonatal units.PatientsInfants ≥36 weeks gestational age with moderate or severe HIE admitted 2011–2016.InterventionsBirth in non-CC compared with CC.Main outcome measuresPrimary outcome was survival to discharge without recorded seizures. Secondary outcomes were recorded seizures, mortality and temperature on arrival at CCs following transfer.Results5059 infants were included with 2364 (46.7%) born in non-CCs. Birth in a CC was associated with improved survival without seizures (35.1% vs 31.8%; OR 1.15, 95% CI 1.02 to 1.31; p=0.02), fewer seizures (60.7% vs 64.6%; OR 0.84, 95% CI 0.75 to 0.95, p=0.007) and similar mortality (15.8% vs 14.4%; OR 1.11, 95% CI 0.93 to 1.31, p=0.20) compared with birth in a non-CC. Matched infants from level 2 centres only had similar results, and birth in CCs was associated with greater seizure-free survival compared with non-CCs. Following transfer from a non-CC to a CC (n=2027), 1362 (67.1%) infants arrived with a recorded optimal therapeutic temperature but only 259 (12.7%) of these arrived within 6 hours of birth.ConclusionsAlmost half of UK infants with HIE were born in a non-CC, which was associated with suboptimal hypothermic treatment and reduced seizure-free survival. Provision of active TH in non-CC hospitals prior to upward transfer warrants consideration.

The centralisation of neonatal intensive care in recent years has improved mortality, particularly of extremely preterm infants, but similar improvements in morbidity, such as neurodevelopmental impairment, have not been seen. Integral to the success of centralisation are specialised neonatal transport teams who provide intensive care prior to and during retrieval of high‐risk neonates when in‐utero transfer has not been possible. Neonatal retrieval aims to stabilise the clinical condition and then transfer the neonate during a high‐risk period for patient. Transport introduces the hazards of noise and vibration; acceleration and deceleration forces; additional handling and temperature fluctuations. The transport team must stabilise the infant fully prior to transport as when on the move they are limited by space and movement to effectively attend to clinical deterioration. Inborn infants have better neurodevelopmental outcome compared with the outborn and aetiology of this seems to be multifactorial with the impact of transport itself during critical illness, remaining unclear. To improve the neurological outcomes for transported infants, it seems imperative to integrate the advancing intensive care neuromonitoring tools into the transport milieu. This review examines current inter‐hospital transport neuromonitoring and how new modalities might be applied to the neurocritical care delivered by specialist transport teams.