Therapeutic Hypothermia for Neonatal Hypoxic Ischaemic Encephalopathy

IntroductionNeonatal hypoxic ischemic encephalopathy (HIE) presents a significant clinical burden with its high mortality and morbidity rates globally. Therapeutic hypothermia (TH) has been proven to provide neuroprotection for infants with moderate to severe HIE.ObjectivesTo evaluate translation of TH for neonatal HIE into clinical practice during initial years of implementation in NSW and ACT.MethodsThe project consists of a series of 4 retrospective cohort studies, conducted within NSW and ACT over a study period of 5 years. ResultsTwo hundred and seven infants received TH during study period.Study 1. Eligibility criteria for therapeutic hypothermia- 104 infants (50%) did not meet the eligibility criteria defined in NSW Policy Directive. Forty-eight infants (25%) had only mild encephalopathy. Mortality and adverse events were seen more frequently among infants who met eligibility criteria.Study 2. Temperature control during therapeutic hypothermia- A total of 12036 hourly temperature recordings were analyzed. Increase in adverse clinical events such as seizures and renal dysfunction were noted with persistent deviations from the target temperature.Study 3. Hospital outcomes and neurodiagnostics during therapeutic hypothermia- Overall mortality was 17% (36 out of 207). Premature infants with gestational age under 37 weeks had significantly higher mortality as compared to those born full term (p=0.04). Seventy (34%) infants had unfavourable outcome at discharge. Study 4. Outcomes of outborn infants undergoing therapeutic hypothermia- Cooling was initiated significantly later for outborn infants (p=0.04). Mortality and other hospital outcomes did not differ from inborn infants after correction for severity of encephalopathy.ConclusionsMany TH infants were treated based on clinician judgement, though not meeting the trial-design policy criteria. Potential risks and benefits need to be considered before initiating therapy. Mortality and other unfavourable outcomes at discharge (i.e. need for tube feeds or anticonvulsants as the surrogates for neural ability) were related to severity of encephalopathy. Although therapeutic hypothermia was widely was applied in the region, cooling was initiated significantly later for outborn infants. We recommend further studies on long term neurodevelopmental outcomes of all TH infants to examine the impact of some key diversions from hypothermia clinical trials

Does a high dietary intake of resistant starch affect glycaemic control and alter the gut microbiome in women with gestational diabetes? A randomised control trial protocol

Background: Gestational Diabetes Mellitus (GDM) is prevalent with lasting health implications for the mother and offspring. Medical nutrition therapy is the foundation of GDM management yet achieving optimal glycaemic control often requires treatment with medications, like insulin. New dietary strategies to improve GDM management and outcomes are required. Gut dysbiosis is a feature of GDM pregnancies, therefore, dietary manipulation of the gut microbiota may offer a new avenue for management. Resistant starch is a fermentable dietary fibre known to alter the gut microbiota and enhance production of short-chain fatty acids. Evidence suggests that short-chain fatty acids improve glycaemia via multiple mechanisms, however, this has not been evaluated in GDM. Methods: An open-label, parallel-group design study will investigate whether a high dietary resistant starch intake or resistant starch supplement improves glycaemic control and changes the gut microbiome compared with standard dietary advice in women with newly diagnosed GDM. Ninety women will be randomised to one of three groups - standard dietary treatment for GDM (Control), a high resistant starch diet or a high resistant starch diet plus a 16 g resistant starch supplement. Measurements taken at Baseline (24 to 30-weeks’ gestation), Day 10 and Day 56 (approximately 36 weeks’ gestation) will include fasting plasma glucose levels, microbial composition and short-chain fatty acid concentrations in stool, 3-day dietary intake records and bowel symptoms questionnaires. One-week post-natal data collection will include microbial composition and short-chain fatty acid concentrations of maternal and neonatal stools, microbial composition of breastmilk, birthweight, maternal and neonatal outcomes. Mixed model analysis of variance will assess change in glycaemia and permutation-based multivariate analysis of variance will assess changes in microbial composition within and between intervention groups. Distancebased linear modelling will identify correlation between change in stool microbiota, short-chain fatty acids and measures of glycaemia. Discussion: To improve outcomes for GDM dyads, evaluation of a high dietary intake of resistant starch to improve glycaemia through the gut microbiome needs to be established. This will expand the dietary interventions available to manage GDM without medication

The prevalence and significance of gestational cannabis use at an Australian tertiary hospital

Background: Cannabis is one of the most common non-prescribed psychoactive substances used in pregnancy. The prevalence of gestational cannabis use is increasing. Aim: The aim was to examine the prevalence of gestational cannabis use and associated pregnancy and neonate outcomes. Materials and Methods: A retrospective observational study involving pregnant women delivering in 2019 was conducted at a tertiary hospital in Perth, Western Australia. Gestational cannabis and other substance use records were based on maternal self-report. Pregnancy outcomes included neonatal gestational age, birthweight, birth length, head circumference, resuscitation measures, special care nursery admission, 5-min Apgar score and initial neonatal feeding method. Results: Among 3104 pregnant women (mean age: 31 years), gestational cannabis use was reported by 1.6% (n = 50). Cannabis users were younger, more likely to use other substances and experience mental illness or domestic violence compared with non-users. Neonates born to cannabis users had a lower mean gestational age, birthweight and birth length compared to those born to non-cannabis users. Gestational cannabis use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.6–6.7) and tobacco smoking (OR 2.2, 95% CI 1.5–3.6) were associated with increased odds of a low-birthweight neonate. Combined cannabis and tobacco use during pregnancy further increased the likelihood of low birthweight (LBW, adjusted OR 3.9, 95% CI 1.6–9.3). Multivariate logistic regression analysis adjusted for maternal socio-demographical characteristics, mental illness, alcohol, tobacco and other substance use demonstrated gestational cannabis use to be independently associated with LBW (OR 2.3, 95% CI 1.1–5.2). Conclusion: Gestational cannabis use was independently associated with low birthweight, synergistically affected by tobacco smoking