Neurodevelopmental outcome in neonates with hypoxic-ischaemic encephalopathy managed with therapeutic hypothermia in a tertiary-level public hospital outside an intensive care unit setting

Abstract

Background: Management of hypoxic-ischaemic encephalopathy (HIE) by therapeutic hypothermia (TH) is a major challenge in low-and middle-income countries (LMIC) because of the limited resources. Clinicians in LMIC offer this intervention outside neonatal intensive care units (NICU). The effect of this practice on neurodevelopmental outcome is not well known. Aim: To determine neurodevelopmental outcome in neonates with HIE managed with TH outside NICU settings. Methods: : This was a retrospective descriptive study of neonates with HIE managed with TH and followed up for neurodevelopmental assessment at 12 and 18-24 months postnatal age. Patients were reviewed over a 24-month period. Outcome at 12 and 18-24 months was compared. Results: Of 178 neonates with HIE attending the clinic, there was information on TH for 155 (87.1%), 113 of whom (72.9%) received TH. HIE was moderate in 88% and severe in 10%. Twenty-seven (23.9%) and 16 (14.1%) were assessed at one time-point at 12 or 18-24 months, respectively, 40 (35.3%) at both time-points, and 30 (26.6%) were not assessed. At 18-24 months, 32% had moderate-to-severe disability compared with 6% at 12 months, with the sensitivity and specificity of assessment at 12 months being 50% and 100%, respectively. The disability attrition rate at 18-24 months was 50%. Conclusions:The relatively low prevalence of disability (32%) at 18-24 months suggests that use of TH in a Level 2 nursery is feasible and possibly beneficial. More studies are needed to confirm these findings

Characteristics and Outcomes of Neonates With Intrapartum Asphyxia Managed With Therapeutic Hypothermia in a Public Tertiary Hospital in South Africa

“…In a separate study in our setting, we reported an abnormal outcome in 32% of neonates who were cooled when assessed at 18-24 months. (15) Another study from South Africa reported severe neurodevelopmental outcomes in 18% of infants assessed at 1 year of age. (20) Limitation of this retrospective observational study include the fact that there was incomplete information especially on the reasons for not cooling neonates who were considered to have moderate-tosevere encephalopathy and were not cooled.…”

“…Recently, a multicenter randomized clinical trial (HELIX trial) from LMICs reported that TH was associated with increased mortality, resulting in authors of this paper calling for an immediate cessation of cooling in LMICs (12). TH continues to be used as an intervention to reduce the incidence of abnormal neurodevelopmental outcomes in neonates with intrapartum asphyxia in many centers in LMIC (13)(14)(15)(16). With concerns raised by the HELIX trial, it is important that continued use of TH in LMIC be monitored with a special focus on mortality.…”

“…A number of observational studies from South Africa where TH was implemented as part of standard care, reported mortality rates of 13-20%. (15,16,(19)(20)(21) Many of these South African studies reporting these relative lower mortality rates were from relative small cohorts of neonates with HIE. Routine use of TH in LMIC needs to be monitored as impact of TH on mortality, based on randomized clinical trials is questionable (12,18).…”

Characteristics and outcomes of neonates with intrapartum asphyxia managed with therapeutic hypothermia in a public tertiary hospital in South Africa

“…While this current study reports short-term outcomes of neonates who were cooled but it is important that long-term outcomes be assessed so that the relative low mortality rate at hospital discharge is not outweighed by high mortality post-discharge and increased risk for abnormal neurodevelopmental outcomes. In a separate study in our setting, we reported an abnormal outcome in 32% of neonates who were cooled when assessed at 18–24 months [ 15 ]. Another study from South Africa reported severe neurodevelopmental outcomes in 18% of infants assessed at 1 year of age [ 20 ].…”

Therapeutic hypothermia for neonatal hypoxic ischaemic encephalopathy should not be discontinued in low- and middle-income countries

“…We have been offering TH in neonates with HIE in SA for more than a decade, with apparently reasonable outcomes, with in-hospital mortality of 13 -14% [2,5] and normal neurological outcome or mild impairment in 82% at 12 months [2] and 68% at 18 -24 months. [8] We therefore have a major concern with this 'all or none' approach recommended by the HELIX authors. In addition, contrary to what the HELIX authors have recommended, a recent meta-analysis on TH for asphyxiated neonates with encephalopathy recommends that TH should be offered as part of the standard of care, as the reduction in mortality was found to be greatest in LMICs.…”