Availability of active therapeutic hypothermia at birth for neonatal hypoxic ischaemic encephalopathy: a UK population study from 2011 to 2018

Abstract

ObjectiveTherapeutic hypothermia (TH) commenced soon after birth for neonatal hypoxic ischaemic encephalopathy (HIE) improves survival and reduces neurodisability. Availability of active TH at the place of birth (Immediate-TH) in the UK is unknown.DesignPopulation-based observational study.SettingUK maternity centres.Patients5 975 056 births from 2011 to 2018.Intervention methodsFor each maternity centre, the year active Immediate-TH was available and the annual birth rates were established. Admission temperatures of infants with HIE transferred from non-tertiary centres with and without Immediate-TH were compared.Main outcome measuresQuantify the annual number of births with access to Immediate-TH. Secondary outcomes included temporal changes in Immediate-TH and admission temperatures for infants requiring transfer to tertiary centres.ResultsIn UK maternity centres, 75 of 194 (38.7%) provided Immediate-TH in 2011 rising to 95 of 192 (49.5%, p=0.003) in 2018 with marked regional variations. In 2011, 394 842 (51.2%) of 771 176 births had no access to Immediate-TH compared with 276 258 (39.3%) of 702 794 births in 2018 (p<0.001). More infants with HIE arrived in the therapeutic temperature range (76.5% vs 67.3%; OR 1.58, 95% CI 1.25 to 2.0, p<0.001) with less overcooling (10.6% vs 14.3%; OR 0.71, 95% CI 0.51 to 0.98, p=0.036) from centres with Immediate-TH compared with those without.ConclusionsAvailability of active Immediate-TH has slowly increased although many newborns still have no access and rely on transport team arrival to commence active TH. This is associated with delayed optimal hypothermic management. Provision of Immediate-TH across all units, with appropriate training and support, could improve care of infants with HIE.

Organizational factors associated with delayed therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: the LyTONEPAL cohort

“…Despite various criteria de ning optimal TH in the literature [16] (time to reach an optimal therapeutic temperature [12], or temperature at admission in therapeutic range [17]), and the extension of TH to less severe NE [18], our results of 70.2% of neonates reaching a rectal temperature within optimal range before 6 hr, is in line with data in the literature. In an early study from The Netherlands and Flanders, TH, indicated with "clear presence of perinatal asphyxia followed by neonatal encephalopathy", was started later than 6 hr after birth in 4.8% of infants [16].…”

“…Data using the UK national neonatal research database have allowed to describe more precisely factors associated with delayed timing [17]. The higher proportion of adequate delay among neonates born in a CC versus a non-CC observed in our study (79.7% vs 63.8%) was also reported in the United Kingdom with a higher rate of neonates achieving optimal therapeutic temperatures at admission among those with access to immediate TH in CC versus infants born in a non-CC (83.5% vs 73.7%) [12].…”

“…This was expected because access to care is much more di cult in these small health structures. Bene t of the initiation of TH during transport after adjustment for HIE severity was not enhanced, whereas access to TH during transport for almost all neonates in the United Kingdom allowed for a higher rate of infants in the therapeutic range and a reduction in overcooled babies at admission [12]. Finally, in our study, the rate of undesirable events during transport was high in both groups and they were signi cantly associated with an increased risk of having delayed TH.…”

“…In an early study from The Netherlands and Flanders, TH, indicated with "clear presence of perinatal asphyxia followed by neonatal encephalopathy", was started later than 6 hr after birth in 4.8% of infants [16]. In the United Kingdom, proportions of infants achieving optimal therapeutic temperatures at admission in a CC increased from 60.8% in 2011 to 76.0% in 2016 [12]. During the same period, 67.1% of UK neonates born in a non-CC arrived with a temperature between 33 and 34°C [17].…”

“…Recent studies suggest that current protocols for TH are near-optimal and that the key to better neurodevelopmental outcomes is earlier diagnosis and initiation of TH after birth [11]. However, cooling centres (CCs) are usually implemented in level-III neonatal units, and a recent study has shown that half of UK infants with HIE were born in non-CCs, which warranted providing active TH in non-CC hospitals before upward transfer [12].…”