Neonatal seizures and therapeutic hypothermia for hypoxic-ischemic encephalopathy.

Neonatal seizures are associated with morbidity and mortality. Hypoxic-ischemic encephalopathy (HIE) is the most common cause of seizures in newborns. Neonatal animal models suggest that therapeutic hypothermia can reduce seizures and epileptiform activity in the setting of hypoxia-ischemia, however data from human studies have conflicting results. In this research highlight, we will discuss the findings of our recent study that demonstrated a decreased seizure burden in term newborns with moderate HIE treated with hypothermia

Rate of head ultrasound abnormalities at one month in very premature and extremely premature infants with normal initial screening ultrasound

BackgroundPremature infants are at risk for multiple types of intracranial injury with potentially significant long-term neurological impact. The number of screening head ultrasounds needed to detect such injuries remains controversial.ObjectiveTo determine the rate of abnormal findings on routine follow-up head ultrasound (US) performed in infants born at ≤ 32 weeks' gestational age (GA) after initial normal screening US.Materials and methodsA retrospective study was performed on infants born at ≤ 32 weeks' GA with a head US at 3-5 weeks following a normal US at 3-10 days at a tertiary care pediatric hospital from 2014 to 2020. Exclusion criteria included significant congenital anomalies, such as congenital cardiac defects necessitating surgery, congenital diaphragmatic hernia or spinal dysraphism, and clinical indications for US other than routine screening, such as sepsis, other risk factors for intracranial injury besides prematurity, or clinical neurological abnormalities. Ultrasounds were classified as normal or abnormal based on original radiology reports. Images from initial examinations with abnormal follow-up were reviewed.ResultsThirty-three (14.2%) of 233 infants had 34 total abnormal findings on follow-up head US after normal initial US. Twenty-seven infants had grade 1 germinal matrix hemorrhage, and four had grade 2 intraventricular hemorrhage. Two had periventricular echogenicity and one had a focus of cerebellar echogenicity that resolved and was determined to be artifactual.ConclusionWhen initial screening head ultrasounds in premature infants are normal, follow-up screening ultrasounds are typically also normal. Abnormal findings are usually limited to grade 1 germinal matrix hemorrhage

Bronchopulmonary dysplasia precursors influence risk of white matter injury and adverse neurodevelopmental outcome in preterm infants.

BackgroundCumulative supplemental oxygen (CSO) and cumulative mean airway pressure (CMAP) are associated with bronchopulmonary dysplasia (BPD) in preterm infants, but their relationships to white matter injury (WMI) and neurodevelopment have not been evaluated.MethodsPreterm infants <32 weeks' gestation were prospectively imaged with 3 T MRI near term. CSO and CMAP were retrospectively summed over the first 14 and 28 days. Neurodevelopment was assessed at 30 months adjusted using the Bayley-III. ROC and linear regression were used to evaluate the relationship between CSO, CMAP, and BPD with WMI and neurodevelopmental performance, respectively.ResultsOf the 87 infants, 30 (34.5%) had moderate-severe BPD, which was associated with WMI (OR 5.5, 95% CI 1.1-34.9, p = 0.012). CSO and CMAP predicted WMI as well as BPD (AUC 0.68-0.77). CSO was independently associated with decreased language and cognitive performance (mean difference at 14 days: -11.0, 95% CI -19.8 to -2.2, p = 0.015 and -9.8, 95% CI -18.9 to -0.7, p = 0.035, respectively) at 30 months adjusted.ConclusionsBPD precursors predict WMI as well as BPD. Cumulative supplemental oxygen over the first 14 days of life is independently associated with lower language and cognitive performances. These data suggest that early respiratory status influences the risk of adverse neurodevelopment in preterm infants.ImpactRespiratory precursors to bronchopulmonary dysplasia (BPD), cumulative supplemental oxygen and mean airway pressure, over the first 14-28 days performed as well as BPD for the prediction of white matter injury on MRI in preterm infants. Cumulative supplemental oxygen was independently associated with lower language and cognitive performance on the Bayley-III at 30 months adjusted. These data suggest that early respiratory status may help explain why BPD is independently associated with adverse neurodevelopmental outcomes in the preterm population and highlights the importance of interventions targeting respiratory status as a potential avenue to improve neurodevelopmental outcomes

Disorders of Neuronal Migration/Organization Convey the Highest Risk of Neonatal Onset Epilepsy Compared With Other Congenital Brain Malformations.

Although seizures in neonates are common and often due to acute brain injury, 10-15% are unprovoked from congenital brain malformations. A better understanding of the risk of neonatal-onset epilepsy by the type of brain malformation is essential for counseling and monitoring. In this retrospective cohort study, we evaluated 132 neonates with congenital brain malformations and their risk of neonatal-onset epilepsy. Malformations were classified into one of five categories based on imaging patterns on prenatal or postnatal imaging. Infants were monitored with continuous video EEG (cEEG) for encephalopathy and paroxysmal events in addition to abnormal neuroimaging. Seventy-four of 132 (56%) neonates underwent EEG monitoring, and 18 of 132 (14%) were diagnosed with neonatal-onset epilepsy. The highest prevalence of epilepsy was in neonates with disorders of neuronal migration/organization (9/34, 26%; 95% confidence interval [CI] = 13-44%), followed by disorders of early prosencephalic development (6/38, 16%; 95% CI = 6-31%), complex total brain malformations (2/16, 13%; 95% CI = 2-38%), and disorders of midbrain/hindbrain malformations (1/30, 3%; 95% CI = 0-17%). Of neonates with epilepsy, 5 of 18 (28%) had only electrographic seizures, 13 of 18 (72%) required treatment with two or more antiseizure medicines (ASMs), and 7 of 18 (39%) died within the neonatal period. Our results demonstrate that disorders of neuronal migration/organization represent the highest-risk group for early-onset epilepsy. Seizures are frequently electrographic only, require treatment with multiple ASMs, and portend a high mortality rate. These results support American Clinical Neurophysiology Society recommendations for EEG monitoring during the neonatal period for infants with congenital brain malformations

Diminished white matter injury over time in a cohort of premature newborns.

ObjectivesTo determine the rate of magnetic resonance imaging (MRI)-detected noncystic white matter injury (WMI) in a prospective cohort of premature newborns, and to evaluate its associations with changes in clinical predictors of WMI over the study period.Study designA prospective cohort of premature newborns (<33 weeks gestational age) was studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T1-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. Subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI were excluded. Changes in clinical characteristics and predictors of WMI over the study period (1998-2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression.ResultsAmong 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P = .002, χ(2) test for trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased by 11% for each birth year of the cohort (OR, 0.89; 95% CI, 0.81-0.98; P = .02). Prolonged exposure to indomethacin also was independently associated with reduced odds of moderate/severe WMI.ConclusionThe decreasing burden of MRI-detected moderate/severe noncystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI

Relationship between social support and post-discharge mental health symptoms in mothers of preterm infants.

BackgroundSocial support is associated with decreased symptoms of postpartum mood and anxiety disorders (PMAD) in mothers of healthy infants, but less is known about social support and PMADs in mothers with preterm infants. The purpose of this study was to examine the relationship between social support and symptoms of PMADs reported by mothers in the months following hospital discharge of their preterm infant.MethodsMothers of infants less than 33 weeks gestational age were enrolled from neonatal intensive care units (NICU) at 6 sites. Mothers completed PMAD measures of depression, anxiety and post-traumatic stress approximately 3 months following their infant's discharge. Multivariable regression was used to evaluate relationships between social support and PMAD measures.ResultsOf 129 mothers, 1 in 5 reported clinically significant PMAD symptoms of: depression (24%), anxiety (19%), and post-traumatic stress (20%). Social support was strongly inversely associated with all 3 PMADs. Social support explained between 21% and 26% of the variance in depression, anxiety and post-traumatic stress symptoms.ConclusionIncreased social support may buffer PMAD symptoms in mothers of preterm infants after discharge. Research is needed to determine effective screening and interventions aimed at promoting social support for all parents during and following their infant's hospitalisation

Diminished White Matter Injury over Time in a Cohort of Premature Newborns

OBJECTIVES: To determine the rate of magnetic resonance imaging (MRI) detected non-cystic white matter injury (WMI) in a prospective cohort of premature newborns and to evaluate its associations with changes in clinical predictors of WMI over the study period. STUDY DESIGN: Prospective cohort of premature newborns (<33 weeks’ gestation) studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T(1)-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. We excluded subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI. Changes in clinical characteristics and predictors of WMI over the study period (1998–2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression. RESULTS: Among 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P=0.002, chi-squared test of trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased 11% for each birth year of the cohort (odds ratio 0.89, 95% confidence interval 0.81–0.98, P=0.04). Prolonged exposure to indomethacin was also independently associated with reduced odds of moderate/severe WMI. CONCLUSIONS: The decreasing burden of MRI-detected moderate/severe non-cystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI

Association of Histologic Chorioamnionitis with Perinatal Brain Injury and Early Childhood Neurodevelopmental Outcomes among Preterm Neonates

Acute chorioamnionitis refers to the neutrophilic inflammation of the placental tissues thought to result from an ascending bacterial infection. It is considered a major factor associated with pretermbirth and has been estimated to occur in 40%to 80% of preterm deliveries. Chorioamnionitis is associated with several adverse neonatal outcomes, including respiratory distress syndrome, sepsis, bronchopulmonary dysplasia, and death. Clinical studies examining brain injury and neurodevelopmental outcomes among infants with chorioamnionitis have yielded inconsistent results. Most of these studies have focused on intraventricular hemorrhage (IVH) and cystic periventricular leukomalacia. Because the incidence of cystic periventricular leukomalacia has greatly decreased during the past decades concurrent with improvements in neonatal intensive care, punctate white matter injury (WMI) is increasingly recognized as the most prevalent pattern of brain injury among preterm neonates. The researchers performed a prospective cohort study conducted across 3 academic centers in Canada, the Netherlands, and the United States. Children who were born preterm (24-32 weeks' gestation) and who had undergone a placental pathologic evaluation, magnetic resonance imaging (MRI) as soon as clinically stable, and Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley III) assessments between 18 and 24 months' corrected age (CA) were included. Magnetic resonance imaging scans were assessed for grade of IVH and volume of punctate WMI. Data analysis occurred between December 2016 and January 2018. Final multivariable analyses examining the association of chorioamnionitis with motor and cognitive outcomes accounted for academic center and perinatal and postnatal factors. PunctateWMI volume and IVH detected on neonatalMRI scans were used tomeasure the results,withmotor and cognitive outcomes defined using Bayley III assessments conducted among these children between 18 and 24 months' CA. There were 448 preterm infants (24-32 weeks' gestation) in the total cohort. Infants were included in the analysis if they had undergone placental pathologic assessments, early brainMRI, and 18 to 24 months of follow-up.Among the cohorts fromthe 3 academic centers, infants with evidence of a congenital infection, genetic syndrome, or large parenchymal hemorrhagic infarction (>2 cm) were excluded. Each placenta was sent fresh for macroscopic and microscopic analyses, which were conducted using the same clinical protocols at each center. Histologic chorioamnionitis was defined by clinical pathologists using strict criteria and the degree of placental inflammation was scored

Association of Histologic Chorioamnionitis with Perinatal Brain Injury and Early Childhood Neurodevelopmental Outcomes among Preterm Neonates

Acute chorioamnionitis refers to the neutrophilic inflammation of the placental tissues thought to result from an ascending bacterial infection. It is considered a major factor associated with pretermbirth and has been estimated to occur in 40%to 80% of preterm deliveries. Chorioamnionitis is associated with several adverse neonatal outcomes, including respiratory distress syndrome, sepsis, bronchopulmonary dysplasia, and death. Clinical studies examining brain injury and neurodevelopmental outcomes among infants with chorioamnionitis have yielded inconsistent results. Most of these studies have focused on intraventricular hemorrhage (IVH) and cystic periventricular leukomalacia. Because the incidence of cystic periventricular leukomalacia has greatly decreased during the past decades concurrent with improvements in neonatal intensive care, punctate white matter injury (WMI) is increasingly recognized as the most prevalent pattern of brain injury among preterm neonates. The researchers performed a prospective cohort study conducted across 3 academic centers in Canada, the Netherlands, and the United States. Children who were born preterm (24-32 weeks' gestation) and who had undergone a placental pathologic evaluation, magnetic resonance imaging (MRI) as soon as clinically stable, and Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley III) assessments between 18 and 24 months' corrected age (CA) were included. Magnetic resonance imaging scans were assessed for grade of IVH and volume of punctate WMI. Data analysis occurred between December 2016 and January 2018. Final multivariable analyses examining the association of chorioamnionitis with motor and cognitive outcomes accounted for academic center and perinatal and postnatal factors. PunctateWMI volume and IVH detected on neonatalMRI scans were used tomeasure the results,withmotor and cognitive outcomes defined using Bayley III assessments conducted among these children between 18 and 24 months' CA. There were 448 preterm infants (24-32 weeks' gestation) in the total cohort. Infants were included in the analysis if they had undergone placental pathologic assessments, early brainMRI, and 18 to 24 months of follow-up.Among the cohorts fromthe 3 academic centers, infants with evidence of a congenital infection, genetic syndrome, or large parenchymal hemorrhagic infarction (>2 cm) were excluded. Each placenta was sent fresh for macroscopic and microscopic analyses, which were conducted using the same clinical protocols at each center. Histologic chorioamnionitis was defined by clinical pathologists using strict criteria and the degree of placental inflammation was scored