Therapeutic hypothermia (TH), shown in developed countries to improve outcome in infants with hypoxic-ischaemic encephalopathy (HIE), was introduced into standard care at Tygerberg Children's Hospital in 2008. We aimed to describe the management and characteristics of infants treated with TH at this tertiary centre as well as the logistical challenges encountered.Infants admitted for TH between 2008 and 2011 were included. They fulfilled TOBY study entry criteria and were cooled using a whole-body cooling system. A retrospective analysis of the cooling process and clinical findings was made using data collected during treatment.100 infants with mild (32%), moderate (45%) and severe (23%) HIE were treated over 3 years. Mean time to admission was 4.87 (±1.63) hours, median time from delivery to target temperature was 7.5 h (range 2.5-15.5 h). Mean temperature on admission was 35.5°C (±1.5°C). Overall, rectal temperature was within target temperature for 82.8% of the time. Complications noted were clinically suspected/proven infection (45%), abnormal coagulation tests (48%), thrombocytopenia (34%), need for inotropic support (17%), hypoglycaemia (4%) and hyperglycaemia (10%). Rate of follow-up at 1 year among survivors was 57%. Infants not attending 1-year follow-up were more likely to have HIV-infected mothers, but there were no other demographic or clinical differences when compared with those who attended follow-up.Cooling is feasible in a resource-limited setting, within a strict protocol. With close monitoring, the known and common complications occur as frequently as in less resource-limited settings. Surrogate markers of later outcome need to be explored where follow-up is problematic.
Abstract Perinatal arterial ischemic stroke is a relatively common and serious neurological disorder. It can carry significant long-term disabilities. Here we describe the current understanding of its etiology, pathophysiology, and classification, its different presentations, and optimal early management. We discuss the role of brain imaging in defining the extent of lesions and the impact this has on the prediction of outcomes. An overview is given of the range of possible outcomes and optimal approaches to follow-up and support for the child and their family. Large focal lobar hemorrhage occurs less often than perinatal arterial ischemic stroke and does not follow arterial territories. The presentation can be very similar. The hemorrhage is usually well seen on initial cranial ultrasound scan, unlike stroke, and the sites are often frontal or temporal. Brain imaging is diagnostic and prognostic of outcomes.
Objective To evaluate the association between neuroimaging and outcome in infants with congenital cytomegalovirus (cCMV), focusing on qualitative MRI and quantitative diffusion-weighted imaging of white matter abnormalities (WMAs). Methods Multicentre retrospective cohort study of 160 infants with cCMV (103 symptomatic). A four-grade neuroimaging scoring system was applied to cranial ultrasonography and MRI acquired at ≤3 months. WMAs were categorised as multifocal or diffuse. Temporal-pole WMAs (TPWMAs) consisted of swollen or cystic appearance. Apparent diffusion coefficient (ADC) values were obtained from frontal, parieto-occipital and temporal white matter regions. Available follow-up MRI at ≥6 months (N=14) was additionally reviewed. Neurodevelopmental assessment included motor function, cognition, behaviour, hearing, vision and epilepsy. Adverse outcome was defined as death or moderate/severe disability. Results Neuroimaging scoring was associated with outcome (p < 0.001, area under the curve 0.89±0.03). Isolated WMAs (IWMAs) were present in 61 infants, and WMAs associated with other lesions in 30. Although TPWMAs and diffuse pattern often coexisted in infants with IWMAs (p < 0.001), only TPWMAs were associated with adverse outcomes (OR 7.8; 95% CI 1.4 to 42.8), including severe hearing loss in 20% and hearing loss combined with other moderate/severe disabilities in 15%. Increased ADC values were associated with higher neuroimaging scores, WMAs based on visual assessment and IWMAs with TPWMAs. ADC values were not associated with outcome in infants with IWMAs. Findings suggestive of progression of WMAs on follow-up MRI included gliosis and malacia. Conclusions Categorisation of neuroimaging severity correlates with outcome in cCMV. In infants with IWMAs, TPWMAs provide a guide to prognosis.
BackgroundNeonatal encephalopathy (NE) is a leading cause of global child mortality. Survivor outcomes in low-resource settings are poorly described. We present early childhood outcomes after NE in Uganda.MethodsWe conducted a prospective cohort study of term-born infants with NE (n = 210) and a comparison group of term non-encephalopathic (non-NE) infants (n = 409), assessing neurodevelopmental impairment (NDI) and growth at 27–30 months. Relationships between early clinical parameters and later outcomes were summarised using risk ratios (RR).FindingsMortality by 27–30 months was 40·3% after NE and 3·8% in non-NE infants. Impairment-free survival occurred in 41·6% after NE and 98·7% of non-NE infants. Amongst NE survivors, 29·3% had NDI including 19·0% with cerebral palsy (CP), commonly bilateral spastic CP (64%); 10·3% had global developmental delay (GDD) without CP. CP was frequently associated with childhood seizures, vision and hearing loss and mortality. NDI was commonly associated with undernutrition (44·1% Z-score < −2) and microcephaly (32·4% Z-score < −2). Motor function scores were reduced in NE survivors without CP/GDD compared to non-NE infants (median difference −8·2 (95% confidence interval; −13·0, −3·7)). Neonatal clinical seizures (RR 4.1(2.0–8.7)), abnormalities on cranial ultrasound, (RR 7.0(3.8–16.3), nasogastric feeding at discharge (RR 3·6(2·1–6·1)), and small head circumference at one year (Z-score < −2, RR 4·9(2·9–5·6)) increased the risk of NDI.InterpretationIn this sub-Saharan African population, death and neurodevelopmental disability after NE were common. CP was associated with sensorineural impairment, malnutrition, seizures and high mortality by 2 years. Early clinical parameters predicted impairment outcomes.
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