Neonatal Neurology: Clinical Research
Neonatal Neurology 4: Clinical 4
Rakesh Rao, MD (he/him/his)
Associate Professor of Pediatrics
Washington University in St. Louis School of Medicine
St. Louis, Missouri, United States
Kyong-Soon Lee, MD (she/her/hers)
The Hospital for Sick Children
Toronto, Ontario, Canada
Therapeutic hypothermia (TH) has become a standard of care for neonatal hypoxic encephalopathy (HIE) in high income countries.
Objective:
To evaluate variations in TH management grouped by region and volume of TH cases.
Design/Methods:
An electronic survey was sent to Children’s Hospitals Neonatal Consortium Site Sponsors, Canadian Neonatal Network Site Investigators, members of the Newborn Brain Society and American Academy of Pediatrics Neonatal Department Chairs in December 2021. One reminder was sent, and the survey closed in February 2022. Only one response per site was utilized. Questions included eligibility criteria for TH, practices during TH, MRI timing and neurodevelopmental follow up (NDFU).
Results:
105 sites responded with majority (n=95) from high income regions. Four modified United Nations region groups were created: United States (US, n=52); Canada (n=20); Western Europe and Other States excluding Canada and US (WEOG, n=18); and Latin America and Caribbean, Africa, Asia and Eastern Europe (Others, n=15). Figure 1 shows the volume of TH cases by region. Tables show results by region only. Regional variations were seen in minimum gestational age (GA) for TH; as well as HIE score, use of EEG, and severity of HIE used to determine TH eligibility. Active TH during transport varied among regions and was less likely in smaller volume centers (p < 0.01 for region, p=0.039 for volume). Amplitude integrated (aEEG) or continuous EEG (cEEG) to determine eligibility for TH was used by the majority of sites in WEOG and Others Groups, but not by the Canada and US Groups. However, the US Group had the highest rate of cEEG use during TH. Dexmedetomidine use as first choice for sedation during TH was high (33%) in the US Group. Timing of MRI and NDFU were heterogenous. MRI during the diffusion window (days 2 to 6 of life) was lowest in the Others Group. Overall, more practices were significantly different by region than by volume of TH cases.
Conclusion(s):
Significant regional variations in practices for HIE and TH exist. We identified opportunities for increasing evidence-based practices such as initiation of TH during transport. Areas of therapeutic drift beyond evidence-base such as minimum GA; oldest age to initiate TH; and management of mild HIE were seen that require further review. Insight into how specialized resources such as EEG, MRI and NDFU were utilized was obtained. Collation of these international data provides a unique opportunity to share practices and reduce variations; and may foster collaboration to develop consensus guidelines which may improve outcomes and resource utilization.