WHAT'S KNOWN ON THIS SUBJECT: Cooling infants with hypoxicischemic encephalopathy shortly after birth improves survival and neurodevelopmental outcome. The optimal way to cool infants during transfer to regional NICUs is unclear. WHAT THIS STUDY ADDS:Data from a regional neonatal transfer team, using first passive and subsequently active cooling for these infants, suggest that active cooling results in improved thermal control and a reduction in stabilization time.abstract BACKGROUND AND OBJECTIVE: Therapeutic hypothermia is now the standard of care for hypoxic-ischemic encephalopathy. Treatment should be started early, and it is often necessary to transfer the infant to a regional NICU for ongoing care. There are no large studies reporting outcomes from infants cooled passively compared with active (servo-controlled) cooling during transfer. Our goal was to review data from a regional transport service, comparing both methods of cooling. METHODS:This was a retrospective observational study of 143 infants referred to a regional NICU for ongoing therapeutic hypothermia. Of the 134 infants transferred, the first 64 were cooled passively, and 70 were subsequently cooled after purchase of a servo-controlled mattress. Key outcome measures were time to arrival at the regional unit, temperature at referral and arrival at the regional unit, and temperature stability during transfer. RESULTS:The age cooling was started was significantly shorter in the actively cooled group (46 [0-352] minutes vs 120 [0-502] minutes; P ,.01). The median (range) stabilization time (153 [60-385] minutes vs 133 minutes; P = .04) and age at arrival at the regional unit (504 minutes vs 452 ) minutes; P = .01) were significantly shorter in the actively cooled group. Only 39% of infants passively cooled were within the target temperature range at arrival to the regional unit compared with 100% actively cooled.CONCLUSIONS: Servo-controlled active cooling has been shown to improve temperature stability and is associated with a reduction in transfer time. All the major clinical trials randomized infants with intention to intervention by 6 hours of age. 6 Experimental studies have shown that the benefit of cooling is maximal the sooner it is commenced, 7 and the Total Body Hypothermia (TOBY) trial showed a trend to improved outcome in infants cooled within 4 hours of delivery. 8 There is limited evidence regarding the efficacy of cooling started beyond 12 hours of age. Therefore, current evidence would suggest that the sooner cooling is commenced, the more likely it is to be beneficial.Given that infants with HIE are born in all delivery settings, to minimize delay in initiating treatment, cooling should be commenced at the place of birth and continued during transfer to the regional NICU. In the East of England, the Acute Neonatal Transfer Service (ANTS) first transferred infants for therapeutic hypothermia to 1 of the 3 network NICUs in June 2009. In October 2009, the service began operating 24 hours, at which time cooling became the standard ...

Purpose To assess the tolerability and outcomes of laser treatment for retinopathy of prematurity (ROP) under sub-tenon anaesthetic with oral or rectal sedation using a reliable, multidimensional, and internationally accepted tool for assessment of neonatal pain. Methods Sixty-two babies have had ROP laser treatment in our neonatal unit in the 7-year interval between 1 March 2005 and 28 February 2012; 44% (27 of the 62) were performed using sub-tenon anaesthesia. Pain scores were routinely assessed using the Neonatal Pain Agitation and Sedation Scale (N-PASS) every 10 min during laser treatment. The outcome and requirement for re-treatment in this group was compared with that in the intravenous sedation group. Results Pain scores were available in 19 of the 27 babies treated under sub-tenon anaesthesia. The mean pain score during treatment was 2.7 (SD±1.7, range 0.5-6.2). There was no statistically significant correlation between the mean pain score and duration of treatment (Spearman correlation coefficient (q) = 0.31; P = 0.09), number of laser burns (r = 0.32; P = 0.09), or post-menstrual age of the baby at the time of treatment (r = 0.38; P = 0.052). Treatments performed under sub-tenon anaesthesia were as successful as those performed under intravenous sedation. The mean pain scores during laser treatment under sub-tenon anaesthesia in our study were lower than those previously reported during ROP screening or heel-stick procedure. ConclusionOur study demonstrated that sub-tenon anaesthesia with oral or rectal sedation provides sufficient pain control for laser treatment for ROP without the need or risks of intravenous sedation and intubation.

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There was no evidence of an increased rate of disability despite improved survival rates over the two time periods. The rate of blindness decreased, probably reflecting earlier treatment of retinopathy of prematurity. This study demonstrates that although follow-up remains a challenge, rates of over 90% are achievable.