Presented at the Neonatal Society 2017 Autumn Meeting.
Martinello K1,3, Enweronu-Laryea C2,4, Rose M3, Manu S4, Tann CJ3,5, Meek J3, Kraus D6, Ahor-Essel K4, Boylan G7, Robertson NJ1,8
1 Institute for Women’s Health, University College London, UK
2 Department of Child Health, College of Health Sciences, University of Ghana
3 Department of Neonatology, UCLH, UK
4 Korle Bu Teaching hospital, Accra, Ghana
5 MARCH Centre, LSHTM, UK
6 PRISM Training and Consultancy Ltd, UK
7 Neonatal Brain Research Group, INFANT Centre, University College Cork, Republic of Ireland.
8 Sidra Medical and Research Centre, Doha, Qatar
Background: Neonatal encephalopathy (NE) secondary to intrapartum hypoxic events is a significant problem across the world with the highest rates in sub Saharan Africa (1). Few low and middle-income countries implement therapeutic hypothermia (TH) for 72h due to lack of equipment and evidence of TH safety in this setting (2). There is as yet no standard for cooling affected infants in Ghana although some centres practice “facilitated endogenous cooling”(3). Little is known about endogenous temperature responses in NE in relation to outcome in these settings. We hypothesize that affected infants will demonstrate endogenous hypothermia following birth, correlating with NE severity.
Methods: Ethical approval was granted from the KBTH ethics review board. This prospective pilot observational cohort study was conducted at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana, in June/July 2017. Infants ≥36 weeks with suspected intrapartum asphyxia (Apgar <6 at 5 minutes) and evidence of moderate-to-severe NE based on Thompson’s score or clinical seizures were enrolled as soon as possible after birth following informed parental consent. Rectal, axillary and ambient temperatures were continuously measured and stored until 80h of age, using a 4-channel data logger (Squirrel SQ 2020, Keison Products, Chelmford, UK). Neurological assessments were performed for the first 4 days, and infants were followed till discharge.
Results: 13 infants (69% male) were recruited, with a mean gestation of 39+5 weeks (SD 12d) and birth weight 3138g (SD 463g). 3 infants died before discharge home. The mean ambient temperature in SCBU was 28.3ºC (SD 0.7ºC) (over 80h). The mean baby core temperature over the first 24h was 34.2ºC (SD 1.2ºC) and over 80h was 35ºC (SD 1ºC). All infants had one core temperature reading ≤35.5ºC, in the first 24h with the nadir mean core temperature at 15h. The mean core temperature for infants surviving to discharge was 35.3ºC (SD 0.81ºC), significantly greater than 33.96ºC (SD 1.07ºC) for those that died (p = 0.043). Similarly, the mean nadir core temperature recorded in first 80h for infants surviving to discharge was 33.27ºC, compared with 31.67ºC for those that died (p = 0.022). Temperature profile was negatively correlated with day 4 Thompson score (R2 = 0.63): infants with Thompson score of 0-6 had significantly higher mean core temperatures (despite a lower ambient temperature p = 0.038) than those with a score of 7-15 (p = 0.021) and 16+/deceased (p = 0.007).
Conclusion: All infants with moderate to severe NE demonstrated endogenous hypothermia in the first 24 h after birth. There was a clear difference in the 80h temperature profiles of those with low, mid and high Thompson scores on day 4. The optimal temperature management for NE in this setting remains unknown and warrants investigation.
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1. Lee AC, et al. Pediatric Research 2013, 74, Suppl 1:50-72
2. Pauliah S, et al. PLoS One 2013;8:e58834
3. Burnard E, Cross K. BMJ 1958;ii:1197-1199.