Abstract:
BACKGROUND : In randomized clinical trials, therapeutic hypothermia (TH) has been shown to reduce death and/or
moderate-to-severe disability in neonates with hypoxic ischemic encephalopathy (HIE) in high-income countries,
while this has not consistently been the case in low-and middle-income countries (LMICs). Many studies reporting
on outcomes of neonates with HIE managed with TH are those conducted under controlled study conditions, and
few reporting in settings where this intervention is offered as part of standard of care, especially from LMICs. In this
study we report on short-term outcomes of neonates with moderate-to-severe HIE where TH was offered as part of
standard of care.
OBJECTIVE : To determine characteristics and mortality rate at hospital discharge in neonates with moderate-to-severe
HIE.
METHODS : Hospital records of neonates with intrapartum asphyxia were reviewed for clinical findings, management
with TH (cooled or non-cooled) and mortality at hospital discharge. Inclusion criteria were birthweight ≥ 1800 g, gestational
age ≥ 36 weeks and moderate-to-severe HIE. Comparisons were made between survivors and non–survivors
in cooled and/or non-cooled neonates.
RESULTS Intrapartum asphyxia was diagnosed in 856 neonates, with three having no recorded HIE status; 30%
(258/853) had mild HIE, and 595/853 (69%) with moderate-to-severe HIE. The overall incidence of intrapartum
asphyxia was 8.8/1000 live births. Of the 595 with moderate-to-severe HIE, three had no records on cooling and 67%
(399/592) were cooled. Amongst 193 non-cooled neonates, 126 (67%) had documented reasons for not being cooled
with common reasons being a moribund neonate (54.0%), equipment unavailability (11.1%), pulmonary hypertension
(9.5%), postnatal age > 6 h on admission (8.7%), and improvement in severity of encephalopathy (8.7%). Overall
mortality was 29.0%, being 17.0% and 53.4% in cooled and non-cooled infants respectively. On multivariate analysis,
the only factor associated with mortality was severe encephalopathy.
CONCLUSION : Overall mortality in neonates with moderate-to-severe HIE was 29.0% and 17.0% in those who were
cooled. Cooling was not offered to all neonates mainly because of severe clinical illness, equipment unavailability and
delayed presentation, making it difficult to assess overall impact of this intervention. Prospective clinical studies need
to be conducted in LMIC to further assess effect of TH in short and long-term outcomes.
